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00010084APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY ©`J 0 I 0 ,9p 4 CITY OF CUPERTINO BUILDING - ELECTRICAL. BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL, BUILDING PROJECT IDF\TIFICATION PERMITNO. BUILDING ADDRESS: SANITARY NO. APPLICAT TAL DATE 1 937 6 S�c kNwYs &OA 1A — 0C o NERB AME: Atil 4 PHONE: A, 1 A,;- CONT&ACI'OR'S tNAME. LTC NO: 9/IV, �x ,ow N/C ❑ CONfROLp . fiCHITECIDENGINE R: LIC NO: ADDRESS. �� �`-n O vC CONTACT: PHONE: BUILDING PERMIT INFO. , ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT PLUMB MECH Tr ❑ ❑ ❑ LICENSED CONTRACTORS DECLARATION 1 hereby affirm that 1 am Iicenmd under provisions of Chapter 9 (commencing ,in Sean.... 20(0)of Division 3 of the Broad easand Professions Code,andmy license is full force and alien 'n ,31A%9 ¢ License CI Lic.p Use 111 or QTY. ELECTRIC PERMIT FEE y�0Z .,- - Y U <ZU n Q a pan --Z Z�0 YIa1 •.1 Y Q 6 U L O y Q� G� CO JOB DESCRIPTION RESIDENTIAL ❑ SFT)WL KITCHIiN REMODEL ❑ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL MODIFICATION El INTERIOR [I CHIMNEY REPAIR IMPROVEMENT E] SWIMMING POOLS ❑BATH RF:MODEIJItEPAIR ❑DEMOLITION ❑ OTHER PERMIT ISSI3ANCF. APPLIANCES - RESIDENTIAL I S DE ARCIIIT[C'T "S UECLARAI'ION I understand my has shall be had as public records PANELS UP T0200 AMPS Licensed Prnfbssional OWNER- BUILDUR DECLARATION I hereby affirm that 1 am exempt from the Common nr'a License Law for the fallowing reason. (Section 7031.5. Business and Professions Code: Any city or county which regnlres n permit to crmtrac6 Idmr, iorlood. demolish. or ramp, any structure prior to its issuance, also requires the applicant for such permit to file a signed snmment that he is licensed pursuant to the provisions ofthe Cotnmcmr's License Law (Chapter 9 (commencing with Scedon 7000) of Division 3 ofthe Business and Professions Code) or 201.100DAMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. SIFTER OR POLE INST. COMMERCIAL: e eG (hot he Is exempt therefrom vnA the basis for the alleged unnptino. Any violvl ion of ❑ NEW BLDG /ADDITION ❑ DEMOLITION 4• �m Q FQ Section 7031.5 by any applicanl for a permit subjects the applicant to a civil Penally of r more than five hundred dollars y employers ❑I, as owner of the property, or myenrployoeswith wages as rhairmlecompemntion, will do the work, and the swerve is not intended rroRetW formic (Sec. 91,14, Business POWER DEVICES ❑TENANT [I TOO[) SERVICE IMPROVEMENT 11 OTHER SWIMMING ('001, ELECTRI r' 3 m° and Professions Code: The Contractor's License Law does not apply to an owner of formerly who builds or impnrves thereon, and who does such work himself or Ihmugh OUTLETS - SWITCHES - FIXTURES f—n7V_ his own ctnployeeI. provided (hat such in, rh scon, arc ant owndul or nRmul for BW RESIDENTIAL ELLCTR SO Pf. sale. TL however, the building or improvement is sold within oneyem of completion ,the SQ. I, r FLOOR AREA S /SQ. IT. owneobuilder will have the burden of proving that he indoor build m improve for put - grse of >alcJ. []1. as owner of the pmfeny, um eXCIU%ivcly Cranr40ing with hceonW contractors a TOTAL consumer the project (Sec. 7044, Bminess and Pofe,dam, Cale:) The Contractors Li- -- easeLawdoesnotapplyto anownerofpropertywhobuildxorimpooesRamon ,and QTY. Pi, BIND. PERMIT FEE who contracts for such projects with a crntmc ur(s) licensed parson at to that Commc or's PERMIT ISSUANCE Lioense Low. ❑ I am exempt under Sec. B & P C fonhi.s ¢axon , ALTER - DRAIN &VENT - WATER TEAT r Deto VALUATION COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICH ♦ J��yT -� affirm 1 hereby arm under penally of perjury one of the fallowing declarations: lM/ DRAINS - FLOOR, ROOF, AREA, COND. ❑ I have and will maimai a u Certificate of Concern to sel Gimure fir Worker's Camper- saber, us provided for by Sario irtmauc n 3]00 of the Labor Code, for the psi e ol'the STORIES TYPE CONSTRUCT ION work for which this Permit is issued. FIX] GRES -PER TRAP R 1 have and will maintain Worker's Compensation Insurance, as requital by Section . (Xl of the Labor Code, for the performance of the work for which this Omit is is sued. My Work lion ra"c T'aq'e Policcyo revery\ U-14-Its GAS - EA. SYSTEM -I INC. 4 OUTLETS OCC. GROUP LPN/ L% OnIpS Pand Cameo /+ H• W GAS - EA. SYSTIiM OVER 4IEA) CIiRf1FIC TIi OF EXEMPTION FROM WORKERS' COMPF.NSAI']ON INSURANCE difthe pert is for nc hundred dollars lSl00) (3'hissarion need not Ise completed mi nr less) GREASMNDUS'I RL WASTE INTERCEPTOR BUILDING DIVISION PEI'i5 - a GREASE TRAP PLANCHECK FEE SEWER - SANI'T'ARY- S'TORMEA.20OFI'. Iccni[y that in that perlbrmm�ce oftM1C work for wM1iehthlxpennir is issued,lsM1UII not employ any person in any manner so an to beacon subject to the Workers' Cnmpen- ENHRGY FEE WATER HEATER W/VENT /BLECfR WATER SYSTI3M/TRPA'TING WggLN SERVICE - IC IL O,� O H y W cation Lrwsof C.Iigmri..D.m Applicant NaricE l0 APPLICANT: V afar, making this Ccndicam of Exemplam, you ahonld femme subject m the Worker's Compensation provisions of the Labor Code, you must fonhwirh comply with such provisions nnhis ferric shall be deem deemed revoked. l GRADING FEE, I In 1 v _ \ 'SOILSFEF. 7zCONSTRUCTION Ufa fJy LENDING (hereby affirm that them is a construction lending agency for the Performance of the work for which th is permit is issued (See 4(19], Co. C.) I,IpN 1 NEW RESIDENTIAL PI,MH. SQ. FT. IPA( Date Raeiptp U TOTAL: "- r [U rF-I N V Z Lender's Name Lender's Add.,, - TOTAL: - - - 1 unify Iha 1 hove read this apPlintion and atom (hat the aMrve information is comet. l agree to comply with all ciryand county ordinances and state lows reWling to building,omnuctirn, and hereby umhndz.e mpmsenwdves nfthis city In enter ufnn the BUIEDING'MIT.- �`- QTY, MECHANICAL PERMIT FEE SEISMIC FEE PERMIT ISSUANCE ELECTRIC FEE aMve- mentioned property for inspection purposes. (We) agree mince, indemnify and keep M1umdess the City of Cupertino against ACI'IJ2 OR ADD TO MECI I. PLUMBING FEE labilines,judgments.acts and expenses whaLothyia any way accrue agai hold City co nc in nsequee.1 the graming of this permit. AIR HANDLING UNIT (TO 10,001) CENT) MECHANICAL FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGU VIONS. .a�. o4 114,1W AIR HANDLING UNI'I(OVER 10,000 CFM) CONSTRUCTION TAX Signature of ApplicanUComractor Data HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD (W /DUCT) HOUSING MITIGATION FEE HEA'L'ING UNI FU 0100.000 B' I' U) Will the appllcmn or future ding rrtcupunt store In handle haittlosmnteriul as defined by the Cupertino Municipal Code, Chapter 9.12, and the licahh and Safety Cale. Section 25532(a)P Yes No Will the applicant or future building occupant use equipment or devices which emit hnmrdoas air cnmaminants as defined by the Be, Arco Air Quality Manngemcm Disvict!❑Yes -Iq No HEATING UNIT (OVER 100,00) IT ITH PAID - VEN '1'l1.AT10N PAN SINGLE RIiSIU) Data Receipt# BUTLER - COMP (3HP OR MOTOR BTU) TOTAL If A BOILER - COMP (OVER I W." B' I' U) AIR CONDITIONER I have read the docranus materials is under Cir tar 6.95 of thin Cull- re,25533n p Too Id II I & Sulmy Code. Sammy 25505, 25533 and 25534.1 understand Nat if the To Id mar tlyhaveber r.rhal.Imymspfaihmfic roof theoecupum of the rcquirem t vcnh muxlMnueninr�n issuanw of Ccnifcarq A0 1 IDaie ISSUANCE DATE / �( (( NEW RGSIDIiNT1AL MIiCH. SQ. FT. 1/p Owner or authorized agent TOTAL: ISSUEDBY: OFFICE