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31148 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL. 31148 BUILDING PROJECT IDENTIFICATION B ILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAD D D�w�dn ER's NA E:OIC PHON� RACfOft'S NAL. LIC NO: GZ NIC CONI'ROL /Zr • O-} J G ��3 O ❑ " ARCHRECUENGINEER: LIC NO: DDRESS: � .. Q �II E1'.f - T CONTACT. - PHONE: 9 S03 BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT. PI MECH ❑ ❑❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION I hereby affirm that I am licensed under provisions of Chapter 9 (cmnmencing Seation7o00)ofctDiviaion3ofthe Business ProfusionsCWc, �C�y05ae, with and anJ my licenseis PERMIT ISSUANCE RESIDENTIAL: f-�,- �U(F(] in full force and effe. License Class Lic.p . OSFDWL ❑KITCHEN REMODEL �ZZ0. DataContractor APPLIANCES - RESIDENTIAL ❑ADDMON UMBWG RE -PIPE ARCHITECTS DECLARATION PANELS py ❑MULTI -UNIT STRUCTURAL pv� IundemaW plans ahal used tic records MODIFICATION Z=f UP TO But AMPS ❑INTERIOR El CHIMNEY REPAIR Licensed Pmfesmirn 201-1030AMPS � tU IMPROVEMENT �a-j OWNER -BUDDER DECLARATION OVER IONIAMPS [I BATH REMODEURF.PAIR [3 DEMOLITION CY U I hereby affirm that 1 um evempl borrow hConvaemr's License Lew fur the I] OTHER following rcewn. (Section ]03 L5, Businns end Profusion CWe: Any city or county SIGNS ELECTRICAL W6 O ot which requires a permit to comm i alley, improve, demolish. or repair any structure prior to its lssuance,Wso regoirnme applicant fimsuch permit to fileasigned statement SPECIAL CiRCUTUMISC. !(�that he is licensed pursuant to the provisions of the Contractor's License law (Chapter 9 apo (commencing win Section 7000)of Division 3of the Busincssand Professions Code) TEMP. MITER OR POLE INST. COMMERCIAL: y M y that he is esempl therefrom and the basis far the alleged exemption. Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION ce t� �m Section 7031.5 byanyapplicanl for a pennitmIjects theepplicamma civil pcnaltyof POWER DEVICES - TENANT FOODSERVICE []TENANT Z y not more than five hundred dollms ($50). IMPROVEMENT 01,mownerof the ProPenY•or my employces win wage as their sole compensation. SWIMMINGPOOL ELECTRIC will do the work. and the structure is not intended or olTertd for sale (Sec. 7814, Business ❑ OTHER and Professions Code: The Contractor's License Law does not apply to an owner of OIITLEfS-SWITCHES-FIXTURES property who builds or improves thereon, and who does such work himself or through his own employeas, provided mat such improvements are nut intended or offered for NEW RESIDENTIAL ELEM SQ FT. S . FT. FL9DR gEJ s, Q SISQ. FT. L holder within one me g or improvement y p nt iHad owns will have the owner -builder will have the burden of proving Had he did not build or improve fur Aur - he build or improve W 9 D pose of sale.). / cos,as roj contesting TOTAL° Cid:ic"aConnuaoorsm construct me uct theproject Ism.dy,amesiness and not (Sec. ]Ian Business and Professions Code:) The Contemns Li- NAR 91 Oi(1 cense Law dcesnmapply loon ci who QTY, PLUMBING PERMIT F !I[{/ aofpmpeny with sedporimp toduCoeon,and whocs,Law. for such projcers wimacumracmr(s)lic<ned pursuant to the Comrvcmrs C'�'�Z' 1 License Law. PERMIT ISSUANCE vh �Vrt:H ONO ❑lam esemmon, d<r Sec. ,B&PCfor this reason Owner Doc ALTER - DRAIN & VENT - WATER (EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE I hereby affirm under penally of perjury one of the following declensions: ❑ Ihave antl will muimuin aCmificmc of Conenuo self -insure fur Wnrker'e Compen- DRAINS -FLOOR, ROOF AREA. COND. STORIES TYMCONSTRUcTON ,mien, as provided for by Section 37M aide Labor Cash, for me per cars a of the work for which this pernil is issued. FIXTURES - PER TRAP 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700 ofine Labor Code, for the perforrrouenneeeofine work for which ads eperm�it is issued. GAS -EA. SYSTEM -I WC. 4 OUTLETS OCC. GROUP APN m lar iat Put hi, CMynWorkersC Policy 0 GAS - EA. SYSTEM.OVER 4(E)1 EXEMPTIONFItOM KERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This section need not ocompleted lDhp perosis is for arm hundred dollars (11 0m GREASETRAP or less.) PLANCHF.CK FEE I certify that inure pefformenceoflhe work Ino which this permit is issued, I0a11 SEWER - SANITARY - STORM FA. 200 FT. not employ any person in any manner sr as to become subject m the Workers' Compen- sation laws of California. Date ENERGY FEE Z WATER HEATER WIVENT(ELEMR Applicant GRADING FEE Q NOTICE TO APPLICANT.If, after making this Cerifiaaleof Exemption. you should WATER SYSTEM?REATING a�become subject o the Worker's Compenation provisions of the labor CWe, you must SOILS FEE Aminsim comply with such provisions or this payroll shall be deemed revoked. WATER SERVICE L31 Q U' Z CONSTRUCTION LENDING AGENCY NEW RF.SIDENTIAI, PCMB. SQ. PALO L)QI herwhich rn hot issued construction lending agency fonhe performanceof pure ReceiptM Dnho 1-" me work for which this permit is issued (gee. 3f9]. Civ, CJ TOTAL: U Leaders Nome LendeYS Address TOTAL: t� y state that the ve inf srommum is I ready that I have read this application end mo BUILDING FEE �t to cu recd. I agree to comply with all city and county importunes and state laws relating to QTY. MECHANICAL PERMIT FEE V 4 building construction, and hereby authorize rcprcunutiva ofthie city to enter upon dte SEISMIC voce -mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgmenls, costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. -PLUMBING FEE in masequmue of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10,000 CFM) MECHANICALFEE SOUR REGU IONS -7-3/�y AIR HANDLING UNIT (OVER 10,001) CFM) •l ! CONSTRUCr10NTAX Signtme mApplesu omuecmr Date EXHAUST HOOD(W/DUCI) HOUSING MITIGATION FEE • HAZARDOUS MATERIALS DISCLOSURE Will the applicant orfutum building occupant store or handle hanummis material HEATING UNIT TO I00," BTU)' as defined by the Caption. Municipal Coale, Chapter 9.12, end the Health read Safety Code, Section 25532(a)7 HEATING UNIT (OVER 100.000 BTU) ❑Yea ONo VENTILATIONFAN(SINGLERESID) PAID Will the applicant or future building occupant use equipment which Data Receipt If TOTAL: lor ily Management BOILER -COMP (JHP OR IW,000 BTU) - us air contaminants as defined by me Bay Area Air Quality Menagcment ardtDist 11suldinfidosam District? District^ ❑Yes Otho BOILER - COST (OVER 100,00) 131 U) ' the hNmaterialsoun materials reyuiremmAIR CONDITIONER I have reel aza Chapter 6.95 of the Cali- ISSUANCEander ISSUANCE DA�TE}� forms Health & Safely Cade, Section 25505, 25533 and 2551.1 undmund that if me NEW RESIDENTIAL MECH. curnm mly huAeaglm, mel it ismyrespryvjfi(ytnnod them'cupmt \l ) OFFICE