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B 0192APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY CITY CUPVISION BUILDING - PERMIT NO, MECHA ICACAL BUILDING DIVISION APPLICATION/PF.RMIT PLUM1IBING. MECHANICAL DI ,BUILDING PROJECT IDENTIFICATION S000I 0192 BUILDING ADDRESS'. 2-1:X55- 5fevewf C/. -c% 131 Dai • 64 (ry.'-N % S/o-Ge6-o4 SANI'T'ARY NO: APPLICATION SUBMITTAL DATE 6PI'Vyg OWNER' E: a PHONE: � Tiff ClL(I" � 'SII-iOIM1 i; �,/ 1 NlC 7 CONTROL 7 ARCHITI?LT/• INEER: , LIC NO: e r� ADDRISX4 M335t Srvlx✓f( of coNT'nc'R q0 PH oa BUILDING PERMIT INFO 3 y / ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT' PLUMB/ MECH U_ LICENS ) CONTRACTOR'S DECLARATION I hereby affirm that I a... Ibesed under, provisions of Chapter 9lasmmeneh.g with Section MOO) of Division 3 of the Business and Professions Code, and my acease is in full mrec and efice], License Clavas Lar.# QTY ELECTRICPERMIT PEE JO ESCRIPTION . ❑SFDWL ❑ KITCHEN REMODEL PERMIT ISSUANC13 ] Dam Contractor APPLIANCES —RGSIDF,NTIAL ❑ADDITI El PLUMBING RE -PIPE ❑(ULT NIT EI STRUCTURAL MODIFICATION ❑1 ;RIOR ❑CHIMNEY REPAIR 1 PROV17MENT E]SWIMMINGI'UOLS j ARCHITECTS DECLARATION IunJemand my plans shall he used as public records PANELS UP TO 2W AMPS Licensed Professional t OWNHR-BUILDER DECLARATION I 201-1000AMPS OVER 1000AMPS I hereby affimt that I am exempt from the Contractor's License Law for the following reason Seca art 7001.5, Business and Prolesi.ns Core: Any city or county which require a Permit ]o e m local, alma improve, demolish, or repair a, swemre priorno its issuance, also requires the applicant for such Permit o file a signed statement That le is licensed Transition to the provisions of the Contractor, License Law (Chapter 9 ATH REMODEUREPAIR ❑ DEMOLITION OTHER SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC. TEMP. MET ER OR IDLE INST. COMMERCIAL, ❑ NEW I11,DG/ADDITION ❑ DEMOLUION ❑TENANT' ❑FOOD SERVICE (commedeing with Section 71X(1) of Division 3 of the Nosiness and Pndedsionx Code) or that he is exempt therefrom amai the basis for tire al lcgN memelma, Any vlolalion of Section 7131.5 by any applicant lire a permit amoss the applicannor civilpenully of man are 'him five hundred dollars ($500). POWER DEVICES SWIMMING POOL ELECTRIC - ❑ Lus swncr of me pmpcny..r my employm with wages as mein xnk co.]pe..sution. will do the work, and the structure is not intended or offered formdo, (Sec. 71H4. Business IMPROVEMENT ❑ OTHER, and Professions Code: The Contractor's License Law does not apply to an owner of OUTLETS,—SWI'fCHIS—FIXTURES properly, who builds or improves thereon, and who does such work himself or tbmugh his own anph,.,, provided shut such improvements ore not intended or olfemd fur NEW RESIDEN DAI. ELECTR SQ F. 2 I sale. Il, however, the building or hapmvemedt is sold sd Bhinone year ofeontpletion,the ,wantondlift, will have the burden of proving that he did oat build or improve fimpm- SQ. PI'. PLOORAIti?A $/SQ. FI,. poseofaaleJ. ' 'ICTAL: ❑ 1, as snvner of the pmpeny, am v,wImively cramming with licensed commetors t. concoct the pmjmt (Sec. 70,J, Business and Professions Cade:) The Contractor's Li- QTY. PLUMBING PERM FEE cense Law does not apply to an owner of properly who builds or improves ]hereon, and who contracts forsueh projects with a conteaetodo licensed pumuam to the Cod]metors TERM IT ISSUANCE, License Law, 0 l am exempt under SeeB&PClin This reason Owner Dam ALTER — DRAIN M VENT— ATER IEA) VALUATION WORKERS COMPENSATION DECLARATION I hereby atTirmunder penalty of p jury morafthe following declarations: HACK FLOW PROTECT' EVICE DRAINS — FLOOR, Oh, AREA, COND. I haveand will maintain aCenifcateof Comcm mself-insumforWmkcr's Comped- a on, as provided for by Section 37M of the Labor Code, for the perlunname of the STURIIS 'TYPE CONSI'RUC'I'ION FIX' I' ot work Ibr which this permit Is issued. ❑ I have and will maintain Workers Compensation Insurance, as required by Section - 3700.1 ]he lalm,Code, for the perlonaameof Ne work for which mi.a perm;] is issued. My WorkeA'a Cpmpensetier� mncec er and lbli Carrier. %1 f = //nsu 'ro Policy.": GAS— .SY '•M -I Io4C. 4 OUTLET'S ® GAS— 4 ) eC comp R .: aCCep GFA _ QQ Glt A, ��G toga sµr• Pjaumne Drspen- .s WAf OCC. GROUP tion Nl11fDING DIVISION APPS FEES CERTIFICATE? OF EXEMPTION FROM W RKERg' . COMPENSATION INSURANCE (ellinstai rlwxI'hissecom need not heamtpleted lfthepermit is foronehnndreddollms($100) in the penimmance ofine work for which this permit is issued,I shall rot employ any person in any manner so as to become subject o me Warkers'Cum satin. Laws of California. Date Applicant HECK PERIcentuythat ENERGY PER GRADING FEE NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you must WAT SOILS FEE ftmhwith comply withsuch Insieiodsor this permit Shull be deemed revoked. WA'1" •RVICB CONSTRUCTION LENDING AGENCY I hereby M. that is a consauction lending agency for the perfonnan of NEWR PAN Dae Receipt# the work for which this permit is ismed (Sec. 3097. Ci, C.) 'T(TI'AL: BUILDING FEE o act Lenders Nanta Lender's Address 1 certify that 1 have read this application and state ]hat the above inti nation is - reset. I agme to comply with all city and county on inances and emtn low Tdutin to g cons you p buildin traction, and hereb mmize remoot,mlves of thisci]y to terupm me _ t / o QT'Y� HRMI'P ispl:"( CFPD abowc-memiond propcny far inspersion purposes. (We) agree m save, indemnify and -keep hurmle" the Ciry of Amino againsr liabilitie.a,judgments. costs and expenses which may in any way are ainst said City suento g in eq ce of the granting of this permit. PERMIT ISSUANCE ELECTRIC ITiE ALTER OR ADU TO MECH. PLUMBING FEE APPLICAN"IUNDERSTANDS AND WILL COMPLY WITH 1.1, NON -POINT SOURCI7 REGULATIONS. AIR HANDLING Good I'(TO 10,000 CFM) MECHANICAL FEE AIR HANDLING ON[ 'I'(OVER 10,000CF1) CONST' RUCTION TAX Signature of ApplicamiCommacrorDate HAZARDOUS NIATERIALS DISCLO RE EXHAUST IIM])(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT 00100.1100 BTU) William applicant., future building.ccomen marc handle harraft. mamma 9.1 , and the Health and Safety as defined by the Cupertino Municipal Cad/,incints Code. Section 25532(.)7 HEATING UNIT (OVER 100,000 BTU) C] Yea ❑No Will the applicant or furore buildinguse equipment .r devices which emit hamrJous air c.nmminams m definedy AreaAirQualityManagementC DIs1I]C17 ❑Yes ❑Nohave PAID Dom Brescia0 VENTILATION PAN (SINGLE RESID) BOILER-GOM11P (3III'QR IOO,IXIO BTU) d BOILER — COMP(OVER 100.(100 BTU) AIRCONDDIONER read me harantoux nwterals runder Chapter h.95 o1' the Cali- ISSUANCE DATE NEW RESNEN'IIALMECH.r—�building d 25534.1understandthatIf]he docs noteutrently have a tensa, Thatponsibilitymnotifytheoccupant ( ofmcreuirementswhichmumhmc]primofa Cciificam.f Occupancy. A ISSUED B17:3 �f� •' ^ ' t O Owner r authorized agent Date TOTAL: OFFICE