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S 0171 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ,CITY OF CUPFRTINO - _ BUILDING-ELECTRICAL. 1'IikMl"['NO. BUILDING DIVISION APPLICATION/PERMIT rLuntBiNr..Ml:cunNlr,AL S 0171 ",BUILDING PROJECT IDENTIFICATION SANI FARY NO. APPLICATION SUBMITTAL[)A'['I BUILDING ADDRESS: Blab Slww &-u.iU 611, �15ioo - euv�Ko Cal g6D4 G lq q O N%R'SNAME:AI PH(INE: CONTItACTR:S NAME: LIC NO: NIC CONTROL# e1/L Y4 ARCHITEC'I'IINGIN. - LIC NO: ADDIt DSS: ❑ CONTACT: PHONIi: B111LDING PCItMIT INFO ❑ Consultant Feng Paid by Applicant(initial) HLpCy ELELTPLGMR MEc , LICENSED CONTRACTOR S DECLARATION QTY , fl i.ELECTRIC PERMIT �, - .:+�•�FEE JOB ESCRIPT❑ION I hereby of re that 1 n licensed under pcv s ons of Chapter')(comate ing OCy with Section]WO)ol'Divisinn 9ofthe l3usincax and Profession.Csde.trod mylicense is RESIDFNTIAL' WOO PERMIT ISSUANCE 2�� in full force and eRuk ❑SFDWf. ❑KITCHEN REMODEL�UU 4eenec Class _ LICkAPPLIANCES-RESIDENTIAh ❑ADIIITION [I PLUMBING RE-PIPIT m Q 1 Dale Coal memr ARCHITECTS DECLARATION PANELS ❑MUI:I'I-0NI'1' ❑SriµllCTUl1AL F=N Inndcrstand my plans sh' - MODIFICATION ml tee aaea,ta pamm reaorda OZ-o PTO20OAMl'S ❑INIIiIt10R ❑CIIIMNIiYItEPAIH 2144'61 Licenced Professional 241-1000AMPS IMPROVEMENT ❑SWIMMING FOOTS QhdJ OWNER"BUILDFR DECLARATION , OVER IOIlOAMI'S ❑BX[11 REMODEWREPAIR El DEMOLITION C I hereby afftmt that I um exempt from Ne Ciott is Licenu Law hsr the ❑IYf11ER �6 O d U following reason.(Section 70]1.5,Business and Professions Code:Any city or county SIGNS FLECfRICAL 613 a y which mature,a Penni(to construct.alter,iinprove,demolish,or repair any xlmemre 0g prior( !Is indomm.ats requires th,applicantf h verign,fl udid incoual SPECIA L CIHCU'TIM ISC. y that M1 licensed p r a they f theC (con :L m 1 (Chapter 9 COMMERCIAL; �a�0a (coat 6 with Sect ]11(X) I])!visioni IN II JP Cxlc)or TCM 1'.METIi1t OR P(11,E INS'('. ti Xm 4 that he is exempt therefrom and the basis for the alleged exmnpuon.Any vr01atimu'd ❑ W BLDG/ADDI'T'ION ❑DEMOLITION W�1 y Section 7021.5 by any applicant fora peril aabjees the applicant m.civil penalty of POWER DEVICES /I'�]NF,NANT ❑FOOD SERVICE 001 inure than live hundred foods Q.90()d. - f IMPROVEMEiNT f � ❑'Las owner of(he pmpeny.ter my emplsyees with wages car(heir sole cnmrymmion, SWIMMING POOL ELECTRIC " El OTHER Is Jo he wink,mail the structure is not intended or offered for sale(Sm.7YTL Business cf UUfS SWITCHES MIXTURE t n : h W39 nTh Core t L 1 J : t l papeny I b id' - S p N J h J h stock If ,Ihroagh NE .SIDIi AL PLECTH SQ 14. hi,a ply p dad that. himprovements Iintended Bred for SQ.FT.PLO R AREA I $ISQ.1'1'. come 11 M1 t[hM1 Id 6 p pro t Id id Y I pluton the owner bat Id ll have the burden of proving that M1 Td I Wild prof purr. 1 � Pon foal L TOTAL:l V Ica f proper property,,Business excess ly ( f g (I 1 t'� t I II cnI Itheprj ((Sec t)an wnerofandProfession nCode:)The C Inco i' - cen: Law .not hptymun with a carproperty whoh Ip pursuant he Cr and QT'Y + 1 ',PL RMIT f P{N', who contracts for:such projects wnhnnommemgs)ntcnsed purxuannolhe Convecnvs ! e" License Law. PERMIT ISSUANCE ❑ I in.exempt under e . .H&P C fort kmetan Data .7-11_ ALIER-DRAIN&VIiN'f-WATERHiA) A U / Owner \ pRK�' COMPF.NSA'I'ION DECLARATION BACK FLOW PROTECT.DEVICEHTINO Ih a""from undL penalty of pe jury one tel the fnlhnvin6 Jcclara(ions:, 0 ,0[h and will maintain a Krublede of Cnnwnno self-insure for Warked's Compnm DRAINS-FL(IOR,ROOF,AREA.COND. STORIES TY PE CONS'I'RUCFI01 anion,as provided for by SmIam 3700 of the Labor Code,for the pmformande more work for.I ich this permit is issued. IIX]T R_ES-11178 TRAP ❑I have and will maintain Worker's Compensation lnsumnce.as require]by Section 9700 of the Labor Code,for the performance of wremark the work for hich this peit in issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCCG 'P AI'N My Workees Cominnmdon Insurance carrier and Policy coroner are: Carrier: Policy No.: GAS-LA.SYS'TEM-OVER 4IEA) CEM IFICATE O[:EXEMPTION FROM WORKERS' CREASIIINIli1S'1'RI.WAS'1'H IMfF.RCEI'fOH COMPENSATION INSURANCE + UILI 0DIVISION FERS Ondausedien need no,be a aple(ed life Permit is f0rnne hundred dollars($1001 GREASE TRAP ter PLANCH PEE; Ices.) I cerify that lathe perfnranee.fthe work fen whichlhE permit ie issued.[,hall SEWER-SANITARY-STORM EA.200 Ff. not employ any person in any manner so as to become subject m the Worker;Compen, L'NEHG Z edion Lows of Clifmnia.Dam WA'I'BR HEN[Idt WIVBNTIE6ECTR Z2 Applicant ORAE 1PEli - ti c4 Not ICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should WATER SYS'I EMOItHATING h ' became suhjecn the Wmkmis Compensalinn Provisions of the Labor Code,you most -. SOILS BE n a' tti Ommoolh comply with Each provisions or this pednit shall W deemed revoked. WAG IiR SERVICE - Gi Q t1 . CONSTRUCTION LENDING AGENCY NEW RF.SIDI;N'1'IAL I'LMIi. SQ.Trp PAID I hereby afOra that thahem is a construction lending agency for perfonuance of [)[,,a Haecip(M W H the work dirt which this peril is Issued(See.3097.Cie.C.) TOTAL: - ' ULander s Name {la Lenders Address IOIAL: certify(hal I h d this app( 'I d ,am(h he,the hinformation -.,y t I BUILD G FEE . UZ corral lagrecus comply hemby ehYi evuntyoN'mne!this cel li yi+ QTY.' Y MEC({ANICAI PERMIT? '/) FEE U Z building construction,and hereby amhofee representatives r f Ihrs any it)eater spm the i � SEISA C FEE. uhovo-mcmioned properly for imxpeclion purposes. -.PERMIT ISSUANCE P.LE( CF:. (We)agree m save,indemnify unit keep harmless the City of Cu'doo amino _ liabilities.judgments,costs and expenses which may in any way scame against said City ALTER OR ADD TO MECH. PLO MBING FEE in censeptcoca or the grueling of this peon. - - APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTAIR DANDLING ON["I'(TO 111,100 CFM) MECHANICAL FEE SOURCE REGULATIONS,n AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUCfION"I'AX . gra( ren pI mmeror - f0 [Ihat� EXHAUST FOOD(W/DUC) HOUSING MITIGATION FEE 1A'AIt DOUS MATERIALS DISCLOSURE - Villlheupl 'c orfumthuildingoveupmaid eorhandlehazallousmme+Tal 1{EA'1'INC UNI'I'(TO I(Xhlxq NTU7 as defined by the Cupertino Municipal Coda,Chapter 9.12,and the Health and Safely HEATING UNIT(OVER Iob,opp B'fof - Cile,Section 25532(a)4 C]Yes El No VENTILATION FAN(SINGLE RESID) PAlll Da¢ µcceip(X Will the upplieant or fumm building occupant use equipment or devices which BOILER-COMP(31111 OR 100,000 BTU) emaeNit haous mina air conantx as defined by the any Area Air Quality Management( TOTAL: Dinner? BOILER-COME(OVER 100,000 BTU) ❑Yes No I have rend the hantrdems marefiala reyuircmm�e under Chapter 6.95 of the Cali- AIH CONIII'1'ION13H ISSUANCE DNI I, Lucia Health&Safety Code,Sections 25505,25539 and 25534.1 understenJ Ihm 11"the NEW RFSIDEN'UAL MECH. SQ.ET. ' building does nocurrently have a tenant,that it is my responsibility as notify the amomm _ of the reyuirementa which mush mel prior m ixsunnce aLr Certifcme of Occupancy. Owner or vulhmi)<d agent Dale 'TOTAL: ISSUE])BY: OFFICE "