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S 0377 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.ELECT RICA rE II No ^J BUILDING DIVISION APPLICATION/PERNIrr PLUMBING-MECHANICAL � 037 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY PC APPLICA'1lON SUBMI'1'IAL DNIE ©S7N' h10C.7� gD Cu- IeTi 3 OW ER'S N ) HONE CON'I'RAC'IURIS NAME: I.IC NO: �. . hctccrl 8;<p S NIC S-1110 L# • AkCHITE T/IiNGINEE LIC NO: AU 1 iS. J �{ , EJ CONTACT: 11IIONE ` BUILDING PERMIT INFO /Ii./ � "o 9 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MD Hov, LICENSED CONTRACTORS DECLARATION Q'i ELECTRIC PERMIT FEE 1 hereby arum that l am licensed under pmvlxioa%of chapter v(commencing JOB 'SCRIPTION c'�w0 wise Sation n1fX01 of UividOn3of me lousiness and Pntfcsxioos Gale,anJ myltaensc is RFSIDENTIAI' W Q PIiRMI I ISSUANCE x�F nfull Tome and el t. r S"�20(!7 ❑SFDWL ❑KITCHEN RFXlODEh QVV License Clazs — Lie# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIi F Z U Dam Commcue Q04 2M/1 rnQW ❑MULTI-UNIT ❑STkUCTURAI. RCHITECTS DECLARATION PANELS FmZ IunderstaW my plans shell Sleeved.,mbirreemids MODIFICATION OZ—� Up TO 201 AMUS El INTERIOR ❑CHIMNF:YRITAIR tw f, F-yaj Licensed Professional 2111-I(XXI,kMPS IMPROVEMENT 0SWIMMINGPDOIS C Y�� OWNER BUILDER DECLARATION OVIiR 10X0AMCS ❑BATH REMODEUREPAIR El DEMOLITION C 5 Q I hereby limn thin 1 am exempt from the Commcmr's License Law far the X aU following reason.(Section 7031.5.Business and professions Code Any city nr county SIGNS ELIiCfRICAL ❑OTHER y which calcines a permit to ron%wet alter,improve,demolish,no repair any stmcturc FNO_1 prim"' o iu ixsuance,also regldn"Oapplicam for weM1 permiun file aligned xtmntwnt SPIiCIAI.CIRCUIT/A1ISC. Ery hat he is licensed PursuannO the provisions of the Cnmvador%Licene Low(Chapter 9 COMMERCIAL YSI���O (commencing with Section 7")of Division J of the Business and Pn)fcaion%Code)Or TEMP.METER OR POLE INST. a 2 e C mat he is exempt thcrtfmm and,he basis for the alleged exemption.Any violation of C1NEW BLDG/ADDITION ❑DEMOLITION X-m Section 7031.5 by any applicamforu pemtit%ubjegsthe aFPlicunun acivil penalty of POWER DEVICES ❑TENANT DEMOLITION-1 SIiRVICE not more than five hundred dollars(85(01). IMPROVEMEN El L m owner of the Foolery,or my employees with wages as their sole compensation. / SWIMMING M>ULIiLE IC F. will do the work.and the%tractor,is not intended or offered formic(Sec.]MJ.Eusinesv OTHER ¢j m and Pmfexsions Cole:The Contmcar's License Lw does not avi to an towner of OUTLETS-SWITCHES 'TURES l It.3 proPany who builds or impmvcs thereon,and who does such work himself or through u his own employees,provided that such improvcmentx am not intended or offered for NEW RESIDENTIAL ELECTR SQ tel'. sale.If.however.the building or improvement is sold within one yap of mntFldI the SQ.Fr.FLOOR AREA $ISQ IT. w eetruilder will have the burden of proving that he did not huilJ nil intprovc for pull JULFj['n poseofsale.l OTAL: L O II�{I{� 1] I.as owner of the prnpery,am exclavvely contracting with licensed contractors to construct the project(Sce.7014.Business and Professions Cash:)The Contmdors I.i else Law does not apply to an owner of property who build%or improve%thereon.and QTY. PLUMBING PH FEE �II j �,. V�rtNCINO_ whocontracts forsuch pmjecu with a commucha l licensed pursuant tothe Contractors _ License I... P17RMIT ISSUANCE 1 am exempt under Sec. .1t&P C for this reason ALT ER-DRAIN as VENT-WATER(EAI VALUATION Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW PaidFCi'.DEVICE 1 hereby affect under penalty of perjury one of the following declarations: LQ l have and will maintain a Certificate of Consent to self-insure for Workers Compel- DRAINS-FLIX)R,HOUR All BA.GOND. STORIES TY PECONSTRUCTION steins,as provided for by Section 3900 of the Lobe Cole,for the pudurnionce of the work for which this permit is issued PI%TURKS-I'ER'1'kAl' 1 have and wIt maintain Worker's Compensation Insurance,its mquircd by Section 3700of,he labor Code,f..r the wool....anceof the work fail whichmis lvmti,is Issued. GAS-F.A.SYS'1'EM.I INC.I OUTLET. OCC GROUP MIN My WOrkcrs�Cy��q�e ylin 'u WPoficy uQ¢t Carrier: S4MiLf � rPnI eY Nn,:�o /_' h GAS-EA.SYSTEM�OVER 4 IRA) CP.RTIPICATC OF EXEMPTION FROM WORKERS GREASEDINDUS'I RL WAS TE INTERCEPTOR COMpENSNI'SON INSURANCE BUILDING DIVISION FEHS fThissection need not be nnmpletd it the Coconut is for tine hundred dalLm($ICHI) GREASE'S RAP PLANCHECK hili or less) Icedifythat ,,,a car"om:mceofthe wmg Crr which it Indwniiisill'Condon- SCWIIk-SAFE'T'ARY-STORM I?A.2fX0 FI'. nm cntpiny uny lwnan in any inunncr so tax to baunm subject bt the Wnrkcrs'Compcn, ENERGY FtiF. Z satin.Low,Of Gdifornin Done WATER DEXTER W/VEN'ITLECTR GRADING FIA? z O Applicant NOTICE.TO APPLICAN"1':Ifaoernmking this Cenifanmof llrccnrption,you should WAFER SVS'I'IiMn RICA]INC.m ons FEE F� become subject m the Worker's C..iryenwtll, annot had h the Labor Code,you inose fnrthwiif comply with mob pmvixinnv in'ill,pcnni,nhnll be dcmncd ray..Aul. WR'I'ER$IiRY1Cli a' Q CONSTRUCI]ON LINDING AGENCY NEW R ISIOHNI'[A],PLMB. SQ.lel'. PAID '7 'ZIhereby air that there,,a cenxovetiun leading ncySothe iFurnloo,ol Dom UOkeccipi# ,hework For which this pnrmit is issued(Seas 3(X)7,Civ.C.) F' Lender's Name TO'T'AL: U Lenders Address '1'OI'AL: r a 1 certify that 1 have read this application and enc that me abwc intinmation iv BUILDING 17EE .F.. h correct.l agree tit comply will all city and County...matinees and.sate lawn eclatingm QTY. MECHANICAL PERMIT FEE SEISMIC FEE U Z building con.swerian.and hereby authorize nePrescontees of this city,(,voter uman mho above mon tired propcny for inslwNnn purposes. PRISMS ISSUANCE ELECTRIC FEE (Wr (Wes)agree to save,indemnify and keep harmless the City()I Cupertino again, liabilities,judgments,costs and expenses which may in any way acerae against slid City AI,TERORADDTOMECH. PLUMBING FEE in conseluence Of the granting of this Ni APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLI NO UNIT(1010010 CFM) MECHANICAL.FEE SOURCE 'GU�ATION.' AIR HANDLING UNIT(OVER I(LIXM)CFM) CONSTRUCTION TAX tg u e n AppliceMC ester Dine EXHAUST HOOD(W/DUCry HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or fuwm gave...at sone or handle haeallous nmcen,ol IJUsITING UNIT(TO 1(.00t)BTU) ac defined by the Canadian Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 101.0X1 RTU) Colds.Section 255320)'! E3 Yes El No VENTILATION PAN(SINGLE RESID) PAID Dam Receipt# 8511 the applicant or future building Occupant use equipment or device%which BOILER-COMP GHPOR 101,0X0 BTU) mit baemd(,os air contaminant%as defined by,he Bay Area Air Quality Management TOTAL: District? BOILER-COMP(OVER IWJXIO BTU) G Yes 0 N I have read the ham.aus materials re,irenents under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE forma Health&Safety Code,Sections 25505,25533 ad 11531.1 understand that if the, NEW RESIDENT[At,MECIL SQ.ET. building don not currently have a tenant,that i,is my res,Nmsibi,ity to notify the rwcuprat of the requirement which mor be met prim to iuuance of o Cre ifco a Of tkcoPancy. Owser ter emhoriroJ a.ent Data TOTAL: ISSUCD BY: OFFICE