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29364 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION I . 14EWATIONIPERMIT PLUMBING-MECHANICAL 1 BUILDING PROJECT IDENTIFICATION 9364 BUILDING ADDRESS: vi,#!& y� n / 3a SANITARY NO. APPLICATION SUBMITTAL DATE Alam n mete n Cee �:ao' �/10�79 ,lo7' , OW ERS NAMM ., PHONE/ CONTH DR'S NAME �'AT 6-9� : LIC NO r S63S 0 c% N/C CONTROL# ARCHITECT/ENGINEER: LIC O: ADDRESS: ❑ CONTACT: u PHONE: BUILDING PERMIT INFO •B �=666� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELD arerD4 X LICENSED CONTRACTORS DECLARATION gQTY. ELECTRIC PERMIT FEE 1 hereby affirm that 1 am licensed under orokiens of Chapter 9(commencing JOB DESCRIPTION 0ZO with Section 700d)of Division 3 ofthe Business and Professions Code.and my license is RFCIDFNTIAI: lyF in full force and effect. PERMIT ISSUANCE a U((,,JJ License Class Lica ❑SFDWL ❑KITCHEN REMODEL yQL Date Contractor' APPLIANCES-RESIDENTIAL ❑ADDITION. [I PLUMBING RE-PIPE I„ q t2o ARCHITECTS DECLARATION f; Z O E2q I understand my plans shall be used as public records PANELS ❑MULTI-UNIT ff (]STRUCNRAL OZ-- UPT02W AMPS RR MODIFICATION (-(�.tL¢enseJ Professional ❑IMPROVE N -j[S cO CHIMNEY REPAIR 201.1000 AMPS _ N 2 V y OWNER-BUILDER DECLARATION IMPROVEME T Q[� 6 I hereby mfmn that 1 am exempt from the Contractor's License Law,for the OVER 1 WBAMPS ❑BATHIREMODEL/REPAIR�r`A?D1IOLITION 0,U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER k r I— which 3O F which requires a permit m construct,alter,improve,demolish or repair any structure �n/1fYI I prior to its issuance,also nopares the applicant for such Permit o rile a signed statement SPECIAL CIRCUIT/MISC. y that he is licensed pursuant In the provisions afthe Commons-License Law(Chapter 9 G� (commencing with Sec'na"i bof Division 3 ofthe Business and Professions Crude) - COMMERCIAL q0 TEMP.METER OR POLE INST. El NEW BLDG/ADDITION ❑DEMOLITION d y m y that he Is exempt therefrom and the basis for Na cta the exemption.Any violation of Www 'lot Section m than by hundred liana rs($50 rmit.cuhjeck the applicant to a civil Penalty of POWER DEVICES -' Z tot marc then rive hundred dollars y employees TENANT [I FOOD SERVICE �7a I]Lasowner work, dtepe Frty or soluble yemntended oithfered liatei(Set.compensation, SWIMMING POLL ELECTRIC IMPROVEMENT q will do the coons and the he Cont a not immense Law doesor of apply to an Business ❑OTHER k�l andProfessionswho Code TheContractor'sthereo License Lowdoesnotapply to owner of OUTLETS-SWITCHES-FIXTURES .y property who builds or improves thereon,and who does such work himself or through his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ FT. sale.If.however the building or improvement is slid within c neyearoftempletiov,the SQ.FC FLOOR AREA $/SQ.ET overno-builder will have the burden of pmving that he did not build improve for par- pose ar- poseofe E]1.as owner of the property, exclusively contracting with licensed contractors - TOTAL: consntret Ne project(Sec 71144,,Business end Professions Coder)The Convnnor's Li- censeLawdoesnotapplytoanownerofpmpertywhobuildsorimprovesthereon,and QTY, PLUMBINGPERMIT FEE J who contracts for such projects with a contractor(s)licensed pursuant to the Contmetoe',, ^. License Law. PERMIT ISSUANCE Y ❑lamexemptunder Sec. ,B&PCfmthi.sreason ALTER-DRAIN&VENT-WATER(EA) Owner Date eSe /91yIS—IS-4r VALUATION WORKER'S COMPENSATIONDECLARATION BACK FLOW PROTECT.DEVICE' �Dr I hereby affirm under penalty of perdjuryor,one of the following declarations: ❑I have and will maintain aCemificale of Consenne self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA COND. Salton,as provided for by Section 37W of the Labor Code,for the parhnrnence of the STORIES TYPE CONSTRUCTION work for which this permit is issued. FIXTURES-PER TRAP ❑I have and will orm.min Worker's Compensaion Insurance,ua required by Section 37W ofthe Labor Code,for the performance ofthe work for which this p/errymitpis issued. GAS-EA.SYSTEM-I INC.4 OUTLETS - OCC.GROUP APN C`Worker's teens jiu Ir ural¢j��fytWW--QQjj''hI��0he,No.Pill Yn [7�"tZp-� GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE Op EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEBS (Thio union need nor Fz completed if the permit is fornne hundred dollars(SIM) GREASE TRAP • or less.) PLAN CHECK FEE Loy any that int an performance of the work forwhicM1this thefilocallissued,I SEWER-SANITARY-STORM EA.2W FP. or employ any person i aany manner( to ng r nthe Workers'Compen- ENERGY FEE ,� copal laws of Calif o.Date � "- WATER HEATER WNENT/ELECI'R - Applicant �j.�[sl. GRADING FEE y NOTICE TO W LICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMTREATING become subject to the Worker's Compensation provisions of the Labor Code,you most .SOILS FEE C; Fr forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE � Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUMP. SQ.FT. PAID IJ O I hereby affirm that there iso conswction lending agency for the perf rampol.f Dam ReceiptIf W. LP the work for which this permit Is Issued(See 3097,Cl,C.) Q V Lender's Name TOTAL L>a Lender's Address TOTAL: y I certify that I have read this application and state that the above information is BUILDING FEE V1 correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE / U building construction,and hereby authorize rcpmsentatives ofthis city to enter upon the SEISMIC FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE , (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE Iiabilities,judgmenis,costs and expenses which may in any way accrue against said City in consequenceALTER OR ADD TO MECH. PLUMBING FEE /73 y� of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IgWO CFM) /�� SOURCEREGULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX 60 Signature of Agplieant/Contmclor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will theepplicaut nr future building eacupanr smrc or handle hamolmo,material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertlne Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(0)? HEATING UNIT(OVER IHE,"BTU) - ❑Yes ❑No ♦ VENTILATION FAN(SINGLE RESID) ,PAID' Will the applicant m future building buse equipment or devices which Dom Receipt p BOILER-COMP(3HP OR 1 W,OW BTU) q emit hazardous air contaminenm as defined byy the the Bay Arca Air Quality Management District? BOILER-COME(OVER I W.OW BTU) TOTA ❑Yes r-1 No 1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE forma Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Ff building does not currently have a tenant,that it is my responsibility to notify the occupant . / ofthe require ,which;%mprior issuanceofu ffifi:�OfDectmancy. Owner or authorized agent TOTAL ISSUED BY: OFFICE