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S 1881 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1,19Y OF CUPERTINO BUILDING.ELECTRICAL PEISITNO. p WELDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL 1881 ItN1A1N(:YROJEL9'IDENTIFICATION B INGADDRESS: ]N)C TARY NO. APPLICATION SUBMITTALDATE OWNER'S NAME PHO i' CONTRACTOR'S NAME: LIC NO: Z o �9D �� 7_0 _0 / CONTROLM CHITECT7 GINEER: I.IC NO: ADDRESS: CON'rACr: PHONE: BUILDING PERMIT'INFO •-r - ge •-rte Glick p42 _©$r ❑ Consultant Fees Paid by Applicant(Initial) Bl1DDG EL—ECT/ PLUMB MECH k/-�.J��/i/ ([� 1 ILd' LAX ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY1 ELECTRIC PERMIT FEE 1 hereby indoor that I am licensed Maker previsions of Chapter 9(commencing JOB DFSCRIPTION ad Z with Section .MaPERMIT ISSUANCE )OtlO of Division 3uf the Business and Pmfeusiuns Gdel my license is RESIDENTIAL ENTIAL[ W O FSB in full force and effect. ❑SFDWL ❑KITCHEN REMODEL U License Class Lic.p Q APPLIANCES-RESIDENTIAL. ❑ADDITION �PLMMBING RE-PIPE. F+Zu1 Dom Commcdu mDy ❑MUCO-UNI'T El STRUCTURAL F,D w ARCHI s&hallfT,use DECLARATION PANELS MODIFICATION Z p'�Z 1 understand my plans shall be used as public records pZ„y,O UP Tn 2na AMT'S El INTERIOR ❑CHIMNEY REPAIR 24FW Licensed Professional 201400LIAMPS IMPROVEMENT ❑SWIMMING POOLS �W f; OWNER-BUILDER DECLARATION OVER 10110 AMPS ❑BATH R O O TI K C Q, I hereby affirm that I am exempt from the Corporates License law for the KO L U following reason.(Section 703 L5.Business and Professions Calc:Any city or roomy SIGNS ELECTRICAL ❑OTHER F W LLO F- which requires a pennil to construct,alter,improve,demolish,ar repair any structure prior to its inummo,dlsorequires the upplicnat unseen Penuiuo file to,colsammert SPECIAL CIRCIIITIMISC. yy Wit— T , That he is licence]pucsuam mthe pmvisione of the Commcmr's License Law(Chapmr9 �.^�0 (commencing with Sectio 7000)of Dlvi.sion3nfthe Business and Professionscure)or TEMP.METER OR POLE INSR COMMERCIAL' C... G 6 C Nal he is exempt therefmnt and the basis for the alleged exemption.Any violstitn of ❑NEW BLDG/ADDITION ❑D12MOLITION X^m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE r more Than five hundred dollars($500). IMPROVEMENT SSD ❑1.as owner of the property,or my employees with wages as their sole somatnsarian, SWIMMING POOL ELECTRIC El OTHER p., will do the work,and the structure is not intended or offered for sale(Sec.7044.Business yaj3 mW Professions Code:The Contractor's Licmoe Law does ou apply est an owner of OUTLETS-SWITCHES-FIXTURES �' .. propeny who builds or improves thereon,and who docs such work himself or through his own en,,1cjoes,provided than such improvements are not intended or offered Int NEW RESIDENTIAL ELECTR SQ IR. sale.ILhowever,the building or imprwemcm is sold within ane year of rompledon,the SQ.FT.MOOR AREA $JSQ.FE weer-builder will have rhe baNen of proving that he did n I build or imprevc for pun Five,of sale.). O s ❑1,as owner of the property,am exclusively contracting with Isensed contractors to TA F commaL the LaoiW(Sec 7004,Badness and Profe.<sions GaloO The Contin.,s Lt.. _mc Law does am apply n'an owner or property who hullds or improves thereof,and QTY. PLM M B ING PERM IT FEE who cataracts Torment projects with o tori amf(s)I erased pursuant to the Contractor's A Licence law. PERMIT ISSUANCE A 1 am exempt under Sec. .B&P C for this reason [! ALTER-DRAIN&VENT- IEA) ��4LUATION Owner Date ^/ ,( WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DF,V {a T- I herchy infirm under Peart,,of perjury one of the following declinations: '/ IM1ave anti will mainlainaCenifcntcof Conscntm self-insure lin Workers Cnmptn- DRAINS-14.00R,BOOR AREA,CU STO TYPIi CONS'TRUC'TION atitm,as provided for by Section 37(X1 of the labor Code,for the performance of the C/T work for which this peroft is issued FIXTURES-PE TRAY YIyV 1 have and will mainam Workers CsnnTamparion Insurance,as required by Section 370(of the Lathan-Code,for the performance ofthe work for which this permit is issue]. GAS-EA.SYSTENFI INC.40UTLE S OCC.GROUP APN My Worker's Compensation Insurance career and Policy number am: Cartier: Policy Net GAS-EA.SYSTEM-OVER 4(EA) CCH'I'IFICATF.OF I:XEMI'TION FROM WORKIiRS' GRF.ASPJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDINODIVISIONFEFS (T k,ceft meld not he evntptemd Oho permit is formes hundred dollars($100) GREASETRAI' nr less.] PLANCIIECK FEE Icenifyrhap in the performance of tbework forwhichchislcrmip isissued,l shall SEWER-SANITARY-STORM IA.2(p FT. not employ any pen in any manner m as ,,account, m the Workers'Comped- ENERGY FEE ca Z section laws T/ of California.Date WATER HEATER WNENELECTR Q GRADING FEE Applicant N(yfICE'f0 APPLICANT:If,after making this Cenificme tri Exemption,you should WATER SYSTFM/TREATING h SOILS PIPE a ? Forthwith the Workers Compensation this lmvit shelf of the Lubar Code•you mus � IbnhwiN cnntply with such provisions nr this permit shall M:Jcennl revoke]. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID VQ I herchyaRnn phut there iso construction lemdingagency far the performance of Dam Receipt If the work fur which this permit is issued(Sec.3097.Civ.C.) U. U Lenders Name TOTAL: W Lender's AMlrcsa TOTAL: -� AV 1 cenify that I have read this uppliution and state that the above information is BUILDING FEE ar correct.I agree to cranny with all city and county ordimmccn and sum laws relating m QTY MECHANICAL PERMIT FEE SEISMIC PEE U {Z, huild;ng constmgion,and hereby nmhoric rcLumiu tiflesofthlx say m contralto the above-mentioned Pm,ry for inspector Purposes. PERMIT ISS UANCE ELECTRIC FEE D (We)agree to save,indemnify and keep harmless the City of Caperton against liabilities,judgments,crisis arta expenses which may in any way acerae against said City ALTERORADDTOMECH. PLUMBING PEE in consequence of the granting i f this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 9010.000 CFM) MECHANICAL FEE SOURCE 0.EGU S. Zoo AIR HANDLING UNIT(OVER 10,000 CFM) CONS'1'RUCTION TAX Signature of ApllilanVCmoricl., xx Date EXHAUST HOOD(W7DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will rhcaPplicantor future bulldirgoccupam stow or handle Lomond.,maarial HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and rhe Healtn and Safcty Cale,Sernmer 25532(x)? HEATING UNIT(OVER IN,"BTU) ❑Yes 0N VENTILATION FAN(SINGLE RESID) PAID Dam Receipt p Will Ibe applicant or future building occupant use cqulpoonr or device,which BOILER-COMP(3HP OR 100,0(X)BTU) it hnO'Wous air contaminants as derided by the Bay Area Air Quality Management .T( A is^n? BOILER-COMP(OVER 100.0(111 BTU) ❑Y<s Fl No I have read he hazmdous materials rcquimments under Chapter 6.95 of the Cal,. AIR CONDITIONER ISSUANCE DATE Tome Health&Safety Code,Sections 25505,25533 and 25534.I undersand that if phc NEW RESIDENTIAL MECH. SQ.FT ^'') F i building Aces nm currently haveamnan6lhw it lsmy respsnsihility encmify the / ill of the requiremu then Lot...enis ounce ofd Ccnlicot dOcuncy. woe auk este]agent am 'TOTAL: ISSUED IIP: OFFICE