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29917 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMITNO. � ,.a��//X BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 'L) 9 BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE 11-32 ,5 4AIA21qz5 \6-q6 OAME: PHO WN 'S E: C NIRACR SN LIC NO: �/nnVV99 NIC CONTROLM �ARCHITECT/ENG1 EER: LIC NO: A RESS: ❑ 611 CONTACT: PHONE: - HUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT PLUMB M17 11 ❑ ❑ ❑ LICENSED tNSEDCONTRd under SDECLARATION QTY ELECFRIC PERMIT FEE 1 hereby arrmt that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION WIZ with Section 7") fl)fDivisiotC]o(rh business and Professions Code,and my licenuis RESIDENTIAL: co O hS tome an /DOi`/ PERMIT ISSUANCE V�1�-] License CI L Lic,p �� ❑SFDWL ❑KITCHEN REMODEL . NZLLI Dare Contrucmr APPLIANCES-RESIDENTIAL ❑ADDITION EI PLUMBING RIi-PIPE, rn<4 ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL PANELS Z O E24 1 understand my plans shall be used as puhlic recoils h ODIFICATION OZ O UP TO 200 AMPS 1:1 INTERIOR HANEY RE IR r 01"'LL1 Licensed Rofessinnal - 201.1000AMPS IMPROVEMENT ((((((��`` S4 ppp OWNER-BUILDER DECLARATION yy �se I hereby aRrm that I am cVwF,form the Contmxors License Law for the OVER 1 WOAMPS ❑HATH REMODEI/REPAIR DEMOLITION Otiose Ly following reason.(Section 7031.5,Business and Professions Code:Any city orcoumy SIGNS ELECTRICAL ❑OTHER kk11 u O which requires a Permit to construct,alter,improve,demolish,or repair any stmeture y prior toits issuance,also requires the applicamforsuch on.,[to file asigned smremem SPECIAL CIRCUITNISC. y that he is licensed moscalt on he provisimnsof the ConOaemds License Law(Chapter 9 � p0 (commencing with Seel ion]000)ofEM,imn3mf the Murine,,and tiro c,alnnx Cold)in '112 ME METER OR POLE I NST, COMMERCIAL: - 4 es oC thin he is empt xetherefrom and the basis for the alleged exemption.Any violmicn C1Elof NEW BLDG/ADDITION DEMOLITION sp(, u• n Section by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES W^m C1 TENANT ❑FOODSERVICE hZY run more man Fee hundred dollars($SI)). IMPROVEMENT F6 wi Lo o,ooraf the pemmid rr myemntended with wages as talei(See*e,mpcnsmion, SWIMMING POOL ELECTRIC Cr0 will do work,and the.dmcwrtis not intended ornffemtl(.,sale(SecA(W,Business ❑0 ER 6 3 and professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who docs such work himself or through his own employees,provided than such improventnns we net intended or oiered for N17W RES1DF,NTIA1,ELECTR ,FT. sale.IL however.the building or improvement i s sold within one year of completion the4FE � .F..FLOOR AREA S/SQ.IT. bui owner- lder will have the burden of prating that he did not build or improve for put- pose of sale.). - I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: A cnnnrita the project(Se.]0EL Business and Pofeasions Code:)The Contractors Li- �C c se Law does not apply to an owner of property who builds or improves thereon,and Q'IY. PLUMBING PERMIT who contracts for such projects with a contootor(s)licensed porsuam to the Contractor's JI�� License,Law, PERMIT ISSUANCE A I(In [-] I am exempt under set. ,B&P C for this reason (s f JX7 AL'I'EN-DRAIN&VENT-WATER(EA) f VAIAJAI'ION Owner WORKER'S COMPENSATION DECLARATION BACK FLOWPROTECT.DEVICE EU,,Gn I IIVU I hereby affirm under Penalty of perjury,one of the follox ing declarations: ❑ I have and will maintain aCertiOcate of Consetn to self-insure for Workers Compen- DRAINS-FLOOR.ROORAREA,COND. STORIES TYPECONSTRUCTION sation,as provided for by Section 37W of the Unfair Cot for the performance mine work for which this permit is issued. FIXTURES-PER TRAP ❑ 1 have and will maintain Workers Compensation Insurance,as required by Section - 970)ofthe Labor Code,for life performance of the work for which this permit is issued. GAS-EA,SYSTEM-I INC.4 OUTLETS OCC.GROUP APN My Worke's tion 11 naecmrier and policy nu9'¢Fr�fe tee/ Currier: ''-a�-T� /-L/.U/1 policy IS GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXENIMON FROM WORKERS' COMPENSATION INSURANCE GRI!ASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES section need not N completed lithe permit is forms,hundmddollars(S100) GRF.ASE'fRAP or less.) PIANCHECK FEE I certify thin in the performance nRhe work for which this permit is issued,L shall SEWER-SANITARY-STORM EA.200 FT. Poison employ any Pem In any manner sin as In become sato ttome Workers Compen- ENERGY FEE stolon Lawsof Collfor iia I),rm — O O A X/ WATER HEATER W/VHNTIHLEC'I'R Applicant - p{ GRADING PEE .~N-t NOTICE TO APPLICANT:IL after making this Cetypidin,of Exemption,you should WATER SYSTEM/TREATING a , become subject m the Winkles Compensation provisions of the prove Gyle,you must SOILS FEE forthwith Comply with such provisions or his pornit shall be,decimal invoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL)LMB. SQ.EL PAID UO 'IhertM1y afErm that there isaconstruction lending agency for the performance of Date Receipt) tt. the work for which this permit is issued(See,3097,Civ.CJ U Landers Name TOTAL: >i 4t7 lenders Address TOTAL: p„ 1 certify thin I have read Ihis application and stale that me above information is BUILDING FEE LH.t h comctlagree to comply with all city wd county ordinances and sate laws relmingm QTY. MECHANICAL PERMIT FEE U Z buildingconmactismand herebyoumodm reprtsenmtives o(oris cirymenter upon the SEISMIC FEE shove-mentioned privny for inspection purposes. PERMITISSUANCE(We)agave save, e to indemnify and keep harmless the City of Cupertino against ELECTRIC FEE liahilities,judgmems,costs and expenses which may in any wayeccrce againstsaid City AIXERORADDTOMECH, in consequence of the granting of this permit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ADR HANDLING UNIT(]I()ILg10 CFM) SOURCE REC",A'I'IONS. MIiCHANICALFEE p AIR HANDLING UNIT(OVER 10d"CFM) CONSTRUCTION TAX Signature of APPlicant/Commcmr Dore IiXNAUS'i'LOCH(W/DUCf) HOUSING MITIGATION FEE HAZARDOUS MATERIA DISCLOSURE Will theapplicamorfinure buildingoceupent store mhaodle haroomm material HEATING UNIT(TO 100,0da)BTU) as defined by the Cupertino Municipal Code.Chapme 9.12,and the Health and Safety Cade,Section 25532(a)7 HEATING UNIT(OVER 100,100 BTU) E3 Yes E]No PAID VEMI'11,ATION FAN(SINGLERF_SID) Date Recei ptN Will the ircnapplicant or future building byoccupant use equipment or devices which District' TOTAL airxmmminunts as defined by the bey Area Air Quality Management BOILER-COMP(3HPOR 100,000BTU) , Distrix? TOTAL: - ❑Yes ❑No BOILER-COMP(OVER 100,000 BTU) I have read the hmmrdons materials a is under Cha ter 6.95 of the Cali- AIR CONDITIONER g25.533n p ISSUANCED Torula Heetrh&Sol'ety Out,Sections 25505,25,53)and 25534.1 underxwdd that it he NEW RESIDENTIAL MECH. SQ.FF. building does not currently host:a tenant,that h Ix my respnmsCeniy m notify the mccupnm of the requirementsbe m requirements which must er prionoisxuantt nfe Certif me of(kcupancy. Owner mr amhodud ogcel Date TOTAL: ISSUED BY: OFFICE