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29076 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMITNO.'29076 ., 0 w k1••1; BUILDING DIVISION APPLICATIONXERMIT PLUMBING.MECHANICAL Ju BUILDING PROJECT IDENTIFICATION BUILDINGADDRESSI �� SANITARY NO. APPLICATION SUBMITTAL DATE (�(jJ(f� 9'Z3H� OWNER'S NAM[' Y�p'rii �PHON-:' I COKfRAC )R' N MP.: CNO� NIC CONTROLg RCHITECDENGINEER: LIC NO: A R S is / _is ❑ CONTACE PHONE: �/•!i !/YiKf/J BUILDING PERMIT INFO ,/�J,� _ ❑ COnSultant Fe"Paid by Applicant(Initial) BLDG F.E PLUMB CH - LICENSED CONTRACTOR'S DECLARRATIOON''-VJ/(O QTY ELECTRIC PERMIT FEE ❑ E:11 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION D with Sedate,70(so Of Division 3 ofthe Business and Professions Cade,and my license is O PERMIT ISSUANCE D RESIDENTIAL: in full fume end elle w^ �W L.' !ea/ ❑SPDWL. C1 KITCHEN REMODEL UZU LiccnseC - Lic'p APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RF--PIPE W Oma TSDeC! ARCffi'fECT'S DECLARATION � ❑MULTIANIT [I STRUCTURAL 4 i'ANELS Z O f a 1 undcrntanJ my piano.hall he usal as Public records MODIFICATION OZ UP'1'031g1AMPti. ❑INTERIOR ❑CHIMNEY REPAIR [+� {y Licensed Professional 201.10INIAMPS IMPROV17MENT !aj OWNER-BUILDER DECLARATION 1 hereby affirm that I am escmpi from the Contractor's License naw for the OVER Hill)AMPS, 0 BATH REMODELIREPAIR D DEMOLITION F 3 06 U fallowing reason.(Section 7031.3.Business and Pofeseions Code:Any city or county SIGNS ELECTRICAL OOTHER W y which.,.I.it permit to cnnatract,alter,Improve,demolish.or Rpalr any stNetnR ^�- h� prior to its issuance,also requires the applicant forsuch permit to file a signed statement SPECIALCIRCUITIMISC. Q InInothat he is licensed pursuant the provisions of the Contractor's License law(Chapter 9 oq (commencing with Section 71011)of Division Sof the Business and Pmfessinns Codc)in TEMP.METER OR POLE INST COMMERCIAL: L c LL that he is exempt therefrom mal the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION + may Section T031.5 by anyapplicint for a permit subjects the applicant o a civil penalty of POWER DEVICES l []TENANT ❑FOOD SERVICE SGnm more than Bve handfed dollars($50x0'FIMPROV 01.as ownerof the property,or my employees with wages as their sole compensation, SWIMMING POOL .E C F will do the work,and the structure is not imendedoroBetN forsale(Sec.T0a4,Businen ❑OTHER and Professions Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCS property who builds or improves thereon,and who does such work himself or through .. his own employees,provided that such improvements are not intended or offered for NEW RESIOI3MIAL ELECTN FT. sale.If,however,the building or improvement is sold within ane yearofcomplepiomthe SQ.FT.FLOOR AREA S/SQ.FT. owner builder will have the burden of proving that he did not build or improve for pur- is poseofsalw). • 0 Lie ownerof the prnpeny um exclusively mmoccurg with licensed contractors in IOTA construct the poject(Sec.TM4,Business and Protestants Code:)The Contractors Li- move,Law does not apply to an owner(if property who builds or improves thereon,and QTY PLUMBINOPE VK/ Z FEE who contracts far such projects with it maintains)licensed pursuanuo Nc Cotrunors CNCgN [y Licenve Low. PERMITISSUANCE SEP J 1fl(TLn 0Iamv,u, pounder Sec. .B&PCfurthisroma s7�7(j AI:P.1 -DRAIN&VEKI'-WA'THR(EA) VALUATION owner I Dem s / ' WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penalty of perjury one of the following declarations: O l have and will maintain a Certificate ofComent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION scion,us provided for by Section 37W of the Label Code,for the perforranec of the w for which thea pernit is issued. FIXTURES-PER TRAP Ihave and will maintain.Worker'a Compensation Imu ounce,as required by Section 3100oRhelator Code,6rthe perfonnanc<ofthe work for which this permit is is sue d. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN Cu Wmkcr�sC�at9�cps ac camera#Policy nyy99''�,��,,J,J My We_(liLrV Policylicya •�••011a`;kfo GAS-F.A.SYSTEM OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRPASI%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION HIS This section treed net be completed if the Pa t is for one hundred dollars($IM) or less.) GREASETRAP PLANCHECK FEE I scanty Nat in the performance ofnhe work forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any........n es to become subject to the Wm1o.*Compact- ENERGY FEE radon".set California.Date WATER HEATER O WNEM/ELECfR O Applicant GRADING FEE h NOTICE TO APPLICANT,11 after making this Certificate of Exemption,you should WATER SYST'13MnRE, TING abecome subject In the Workers Compensation provisions of the Labor Code,you must SOILS FEE W forthwith comply withauch p...iskso.,this permitshall be deemed revoked. WATER SERVICE. CONSTRUCTION LENDING AGENCY NEW RESIDEN'f1AL PLMB. SQ.FT. PAID UO I hereby affirm that there is a construction lending agency for the peRornance of Dare Receipt# Lis Ir the work lot which ibis pennon is issued(Sec.3099,Civ,C.) H Lender's Name TOTAL.: O,W Leader',Address TOTAL: I unify that 1 have read this application and state Nat theabuve information is BUILDING PER N correct.l agree to comply with all city and county ordinances and mate laws relating to QTY. MECHANICAL PERMIT FEF - U Z building construction,and hereby awhodze reprosemativeso!this city tomer upon the SEISMIC Fill. above-mentioned ma pony far inspection purposes. (We) Sam to save.indemnify and keep hamdess the City of Calsomno against PERMIT ISSUANCE ELF.CI'RIC FEE liabilities,judgments,cons and expenses which may inanywayaccrueagamst said City ALTER OR ADD TO MECH. in consequence of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) SOURCE REGULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10,000 Clil CONSTRUCTIONTAX Signature of Appliant/Contracmr Date EXHAUST HUGH) W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT ITO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Cade,Section 25532(0)7 / BEATING UNIT(OVER 100,600 BTU) ElYet, Nn VEMI WTION PAN(SINGLE RfSID) PAID Will the applicant or future building occupant use maipmem or devices which Dat° Ra°rpt# mit hazardous air commitments as def tied by the Bay Area Air Quality Management BOILER-COMP(311P OR IW,OOB BTU) TOTAL: OntnetF Fly"Fly" "' 100.00)BOILER-COMP(OVER 100,NBTU) 1 have read the htmnNous materials minircments under Clapper 6.95 of the Culi- AIR CONDITIONER ISSUANCE DATE moult Health&Sa(dy Code,Sections 255115,25533 am125534.I understand that if that NEW 1113SIIA3NTIA1.#PRH. StFr.buildingd s not currentlyhve.(en:m6 than itis my nespnabilityo tify flacom....IofNe;quire is who t t be met Prior to Issuance of a CenlfiateI Ocrcuup y. O rtf� hal �� S� (T--- T ISSUED BY: OFFICE a3f