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S 3851 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL O PERMIT NO. BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 3851 ' n BUILDING PROJECT,IDRNTHICATION' " "t; . BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 0310 1,4uk C' Z - q OWNER'S NAME: PHONE: CONIRACTOR'SNAME: LIC NO: i kl� �Q NIC //�� CONTROLM CHIT r /ENGINEER:VV LI NO: ADDRESS ❑ � D ( J CONTACT: PHONE -;j,'HUILDINO PERMITINFO 0- 1,11 j C+Q zD r^ E] Consultant Fees Paid by Applicant(Initial) +BLELEQ PLUMB MEQ LICENSED CONTRACTOR'S DECLARATIONQTY. P• , ' "ELECTRIC PERMIT xt'i,r I t" FENS T. 1 hereby amort mal 1 am Bconed under pmviaiona of chapter 9(a.mmenaimg , - .. . JOB DESCRIPTION OqZ with Section 10007 of DivisionJo[the Business omd lMdessi.nsCMa anti mylicenw is Fw+Op in full force and effect. License Class Lia. PERMIT ISSUANCE SND M TE, ❑KITCHEN REMODEL yG o Date Contractor APPLIANCES—RESIDENTIAL E:1 ADDITION C1 PLUMBING RE-PIPE ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL Z O l understand my plans shall be used as public records MODIFICATION 024— UP TO 200AMPS F eol,l,_11Jai Licensed Professional El INTERIOR ❑CHIMNEY REPAIR +� OWNER-BUILDFR DECLARATION 201-IlXtOAMPS IMPROVEMENT El SWIMMING POOLS t, C w 6 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER Iona AMPS El REMODEVREPAIR Q DEMOLITION x6xOiV following must(Switch 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL C3 OTHER u131y F which regnlres a permit to construct,alter,improve,demolish,or repair any sweture prior,.its ismaace,ulsotegaires the applicant forsueh permit toflea si,adamtemcm SPECIAL CIRCUIUMISC, that he is licensed pursuant to the provisionsufthe Contractors license Law(Chapter 9 .pal.,A� (commencing with Section TIES)of Division 3 ofthe Business and Professions Code)or TEMRMETERORPOLEINSL COMMERCIAL' it ,bat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BIAGIADDITION ❑DEMOLITION ) LLXl u• Section 7131.5 by any applicant for a permit subjects the applicant to a civil penalty POWER DEVICES ❑TENANT ❑FOODSERVICE F.,Z} not more than five hundred dollars(5500). �QO I,as owner n(@e property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT Ir will do the ax.al nd olU,umeturc in notlMandedornlfeed vitiate(Set.7044,Buslncss ❑OTHER 3 m and Prices tons Cala The Contractors License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES { property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not iamaded or mRered for NEW RESIDENTIAL ELF.CB SQ FT. sale.If,however,the building in impr.venncnt is sold wable one year of completua,de SQ.FT,FLOOR AR EA $ISQ.FL ISL ale 7 will have me burden of moving that he did not build or improve for pur- D Y '"�a. ` p.L. t a •,�� pose {r ` (A AMF.D 7 !IO r the poopert,,am exclusively anandracting with ficersed contractors to construct the project(Se,70,44,B .,oil Prefie,aid,Code)The Cmitmau ' 1 i cense Law does not applyt a of property who builds or improves immune and QTY. PLUMBING PERMIT FEE• aW who t t South rojectswthaeontraetngs)licensed pursuant the C.mmet s L cense Lew PERMIT ISSUANCE 1+ I.mw a rS ,B&P C fo,his reason ST n �� ALTER—DRAIN&VENT—WATER( ().to VALUATION 1{ WORKER'S COMP17NSATION DFCLARA'1'ION BACK FLOW PROTECT.DEV 2 © ^ V I hereby af(irrn under pe.toy of perjury one of the following declaa,ions: IJ lJ I have and will maintain a Certificate MConento self-insure for Worker's Coupon- DRAINS—FLOOR,ROO STORIES TYPE CONSTRUCTION xatim,as provided fur by Station 3700 of the Lnhnr Code,far the performance.f the work for which this Permit is issued. FIXTURES—PER TR ❑1 have and will maintain Workers Compensation Insurance,as required by Section 370d.fthe Labor C:We,for the Performance ofthe work for which this permit is issued. GAS—EA.SYSTT:M-I TNC.40 E OF OCC.GROUP APN My Worker's C.mPensmi.n Insurance cunicr and Polity number ore: �.. Carries Policy No.: GAS T,, CERTIFICATE 017 EXEMPTION FROM WORKERS' COMPENSATION INSURANCE, GREASE/INDUS1'RL WASTE INTERCEPTOR Inds section need not hecomplcted Pike permit is Room,hundred dollars(SIW) GRPETRAI s PAN; - 9 IIIEILIBNO DIVISIONtFEES or less.) ' 3 (0 ,:2(D 1 eerily that in the perfomtance ofthe work 4u which this permit is issued.)shall not anpiny any pecenn in an er sn as to b«onu ub'evunthe Wnrkcrs'C.nt SHWIiN-S ITARY—S'F9RM.P.A,2W fT� �, Z cation Laws of Callfnciou Date urn p.n- BNP EE O a z O Applicant WATER H WNE ELEC R so 1 Ji FEE NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSPhJ EATING F+ ; become object to the Worker's Compensation Provis ions of the Labor Cale,you most ^ q0Q d SO .S FEE forthwith comply with such provisions or this Permit shall be deemed revoked, WATER SER E Jnr L rI O CONSTRUCTION LENDING AGENCY NEW RESID 'IALPLMB. SQ.FF. PAID I hereby affirm that hem is a construction lending agency for the performance of Date Rose, It W. F the work for which this permit is issued(Sec.3097,Civ,C.) By-__ O U Lenders Name L: Lenders Address TOTAL: 6. 1 certify that 1 have read this appbcadon and state that the bo Momentum s ..1 - BUILDIN ITH O Z) correct I agree te comply with an city and county ordinances and statel minting no 'QTY' ' . MECHANICAL PERMIT 7— FEE 2 U building construction, ami hereby amrepresentatives oft) city to tb enter upmte - . I , SETS abate-mcmioned mnspeny fur inspection Purptsn. - (we)agree to save,indemnify and keep homeless the City of Cupertino again, PERMIT ISSUANCE EL ' 1 Flirt I iabilities j udgments.costs and expenses which may in any way nmme against said City ALTER OR ADD TO MECH. ^, in now,nonce of Om granting oft his pMnd P NO iFE `t APPLICANT U 1 ERSTAN99ff��-OND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) SOURCµtEG 1 •rMBC ANTCAL TIONT Xis \\\\\\ 1/ AIR HANDLING UNI'C(OVER IO,IN)(1 CFM) C STRUCTION TpX 1 ignamre of plicanthcotnrecmr Date EXHAUST FLOOD DVIDUCT) IN SING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the efficient.1 Lane,huilding.ecopvnlot bnr handle hnumdous material HEATING Call(TO 100daN)BTU) as defined by the Cupertino Municipal Coble,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? HEATING UNIT LOVER I00,140 BTU) ❑Yes ❑No VENTILATION IAN(SINGLE RESID) PAID — s ill the appnt Mlicafuture building«cupam use equipment ld devices which ])Jim Receipt N _11BOILER—COMP 1HP OR 100,000 B Mous air contaminants as defined by the Bay Area Air Quality Managemcm ( TU) Yolrlct? ❑Yes E]No BOILER—COST(OVER I00,M)BTU) I ve reaJ the hasardael materials requirements under Chapter 695 of the Cali- AIR CONDITIONER /} ISSUANCE DATE Latin H 51th $`Jct^CcxE,Sections 25505,255.13 and 25534.I understand that it the NEW RESIDENTIAL MECH. SQ.PIT building xs d bavea¢nam,that it is my resp.nsibility t.notify the«capon, / f the req ¢ Loc st at prior to issuance of a Certificate of Occupancy. (poster nr smoothed agent Dam TOTAL ''T ISSUED BY: OFFICE ,