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S 0310 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ' • CCTYOFCIJPERTINO BUILDING-ELECTRICAL - PE51T NO, 0310 w'J{ 10 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL l\1 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: - � SANITARY NO. APPLICATION SUBMITTAL DATE 0 'S ti / Wv ON V a 1 leo NAME .I�$, � NER'S NAM':f - PHONE: Cn(]5fTRACTOR'S NAME: IC NO: CIS S q a 6. ,4O z I NIC CONTROL M ARCHITECUENGINEER: N 'LI NO: A RESS: ^I ❑ a -.Y: lhJ' CONTACT: PHONE: BUILDING PERMIT INFO 9_0_01 ��•� © El Consultant Fees Paid by Applicant(Initial) BL E r PLUMB MECH LICENSED CONTRACTOR'S ECLARATION QTY ELECTRIC PERMIT FEE El EJhereby affirm thm I am licensed under provisions of Chapter 9(commencingJOA DESCRIPTION FUMWZwith Section 7")ofDivision 3 ofthe Business and Prodesion.s Code,and my license is —" RESIDENTIAL U in full%forClesand effect• Lic.k -391499 _ PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL H6 ate ' Comms (F APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE E,Sm ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL Y 1 understand m lens shall be used as blit records PANELS ZOO YP public MODIFICATION O Z UP TO 200 AMPS FYd,k7toi Licensed Professional El INTERIOR ❑CHIMNEY REPAIR OWNER-BUILDER DECLARATION El SWIMMING POOLS 6 201- 1000AMPS IMPROVEMENT I hereby affirm that 1 am exempt from the Commdors License Law for the OVER 1000 AMPS El BATH REMODEVREPAIR El DEMOLITION following reason.(Section 7031.5,Business and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER ly 3 y Fv¢a which requires v permh to construct,alto,improve,demolish,or,spur any structure0.1 prior to its issuance,also requires the applicant for such permiuo file a signed statement SPECIAL CIRCUIT/MISC. Fey that he is licensed pamormt to the previsions of do Cmrtracmr's License Law(Chapter 9 ��'a (commencing with Section 911W)of Division 3 afthe Business and Profeasions Code)mr TEMP.METER OR PULE DIST. COMMERCIAL 4 C.m a that be is exempt therefrom and the basis for the alleged exemption.Any violation of BLDG/ADDITION ❑DEMOLITION W..m Section 70315 by say applicant fora permit subjects the applicant.a civil penalty of POWER DEVICES NANT t more than five hundred dollun($500). - ❑FOOD SERVICE: F 6 ❑ Las owner offiepmpery,or my employees with wages as theirsole compensation, SWIMMING POOL ELECTRIC I OVEMENT O will do the work,and the structure is not intended orreffered for sale(See.'/W,Business DOTTER 6 3 m end Pmfessions Cade:The Contractor's License Law does not apply to sm owner of OUTLETS-SWITCHES-FIXTURES ^ prapery who builds,,,improves thereon,tad wbo does such work himself or through his own employees,provided that such improvements are not intended or offered far NEW RESIDENTIAL ELECfR SQ FE sale.If,however the building or improvement is sold within one year afcompletion,the SQ.FT FLOOR AREA $/SQ.PC. oavvncr-buildcr will have the burden of proving that he did nut build or. r improve for Aur- . poseoL.sale.). ❑ 1,as owner of the properly,am exclusively contacting with licensed command.to TOTAL: - construct the project(Sec.9044,Business and Professions Code)The Contractors Li- P A cense Low does not apply to an owner ofFroperty,who more or improves thereon,and QTY PLUM INRMIT FEE who contracts for such projects with a conmacmCorrosivesgs)licensed pursuant to theCorrosives ��� �� License Law. - ❑ 1 am exempt under Sec. ,B&P C fnr this reason PERMIT ISSUANCEas - 'Oj•aa 71 Owner Date ALTER-DRAIN&VEN ER(,A(__/ Ur' VALUATION WORKER'S COMPENSATION DECLARATION BACK I7LOW PROTECT.DE I � SIO 1 hemby affirm under penalty of perjury one of the following declarations: I have and will maintain a Certificam of Consent toself-insure for Worker's Camper- DRAINS-FLOOR,RODE AR ND. STORIES ECONSTRUCPION satin,es provided for by Section 3900 of the Labor Code,for the perfornance,,f the work for which Nis permit is issued. FIXTURES-PER TRAP "have and will maintain Worker's Compensation Insurance,as required by Section 900 of the Labor Code,for the perfamnance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40 L OCC. O APN My Warner's Carq�'�tio�^srrQa isrand Policy ryrMe�gtq;2� GAS-EA.SYSTEM-OVER 4IE Cartier.KfOYb E Lp'p�( -l5 9(R Al CERTIFl� ON FROM WORKERS' GREASEANDUSTRL WASTE INTERCE 'O COMPENSATION INSURANCE DING DIV] t ES (This section need not becompleteplcmdif the permit is forone hundrAdollaa($IW) OR TRAP or less) PLAN B certify that in the any of the work for whichthis permitislured,Ishall - not en Law any person in any manner sec asmbecome subject the Workers'Compen- SEWER-SANITARY-STORM P,A.200 Fr'. ENER F z ,� .amine Laws of California.Dare O Applicant 1 WATER HEATER WNENT/ELCCTR GRAVING fE VI NOTICE TO APPLICANT:If,after making this Cetifici to of Exemption,you should WATER SYSTEMOREATING abecome subject to the Worker'.%Compensation provisions of the Labor Code,you must SOILS FE W foMwith comply with such provisions or this permit shall he deemed revoked. WATERSERVICE Q CONSTRUCTION LENUINGAGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID U Q l for by which int Real there is sued(See. 097,Cis.agency for the performance of Dam Receipt N (A e� the work for which this permit is issue)(Sea 3099,Civ.CJ U Lenders Name TOTAL: {4J Lenders Address 'TOTAL: a I certify that 1 have read this application and state that the above information is MPAI , EE Vl .comect.l agree tocomply with all city and county ordiumbes and state laws relating to QTY. MECHANICAL PERMIT FE UZ building construction,and hereby authorize representatives of this city to enter upon the E above-mentioned pmpetty for inspection purposes. (Wit)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE EE � liabilitics,judgmenu,costs and expenses which may in any way accrue egninst said City -ALTER OR ADD TO MECH. in consequence of the granting of this permit. FEC APW TA S ND WILL COMPLY WITH ALL NON-POINT I AIR HANDLING UNIT(OVER 100 CPM) SO � 1 ]CAL FEE �{..(J/y AIR HANDLING UNIT(OVER III,IKKI CFM) TION TAX mm ofA I 7• $igra pp f vnVCom4§! Dam EXHAUST HOOD(W/DUCT) I ATION PCE SMATERIAIS DISCLOSURE. Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)1 HEATING UNIT(OVER 100,000 BTU). ❑Yes ON. VENTILATION FAN(SINGLE RESID) Will me applicant or future building accupant use equipmentor devices which Date iIn M mil hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR Ifar"BTU) Dismict? OTAL: ❑Yes ❑No BOILER-COMP(OVER 100,000 BTU) _ I have read the Enormous mamrials requirements under Chapter 695,,f the Cali- AIRCONUITIONER ISSUANCE DATE forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.F-C building chested currently have a tenant,Nat it i.a my resprmsibility minify the occupant of the retirements which must be met prior to issuance of a Certificate of Oocupamcy. Owneroralifismzed agent Date - TOTAL: ISSUED OFFICE