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99100087 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY • IT_ �Ioi I DOOR OFFICE CITY OF CUPERTINO BUILDING. -ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL. BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS - t cku SANITARY NO. APPLICATION SUBMITTAL DATE 6 y8_p OWNS q I ONE: . IRIr/\l/`'- ,;L� 59 CONTR DR'S AM�: LIC NO'. N/C ❑ CONTROL.M \RCHITECT/ENGINEER: LIC NO: ADDRESS: - - 1, 3 (� CONTACT: PHONE: BUILDING PERMIT INFO �' +1'� avf- �� ❑ Consultant Fees Paid by Applicant (Initial) HLDO ELECT PLUMB ME.CH ❑ q,-- � ❑ LICENSED CON'TRACTOR'S DECLARATION I hereby arum that 1 am licensed under provisions of chapter 9 (commencing with Sectim700m.fDivisi n 3ofthe Business vnd Pmfessint,Ccdeandmylicenaeia in full foreeand offer,. license Cl s Lic. p! Date Contractor Rhelt—SIMIA ARCHITECTS DECLARATION I understand my plans shot] be used as public records QTy. '' ELECTRIC PERMIT FEE , , 100 OO W^ luV '405 1Orn ,,az I Q W ,E +G U y C j1 "') JOB DESCRIPTION RESIDENTIAL: C -I SFDWL �fITCHP.N REMODEL. CADDITION El PLUMBING RE-PIPH Ll MULTI -UNIT ❑STRUCTURAL MODIFICATION ElINTERIOR [I CHIMNEY REPAIR IMPROVEMENT E] SWIMMING POOLS El BATH REMODEL/REPAIR [2 DEMOLITION ❑OTHER � PERMIT ISSUANCE gPPLIANCF:S-RESIDENTIAL' PANELS UP T02(IOAMPS Licensed Professional OWNERBUILDERDECLARATION I hereby affirm That I vm exempt from the Con¢acmr'e Llcansd Law for the following reason. fSection'JW L5. Nosiness and Nmfeasinnr Cnde: Any city or county which regnims a peril to moslmcl, eller, improve, demolish, or repmr any onnum friction,iswine,.ho,"mire;fic.pplicantfmaichperohn, file aslgoed doormen) lhathe is licensedpurwin t.lbe pro,kinnsofthe Chromium, License Law(Chapm,9 201-IOWAMPS OVER 1000 AMPS SIGNS ELECTRICAL OF SPPAIAL CIkCUI'I'/MISC. TEMP. METER OR POLE INST. CO MERCIAL: NEW BI.DG/ADDITION C DEMOLITION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT DOTTIER iC�Oa 7 cI V. V• ^y 1 d 3 j ' ^ (commencingwilh Serum 90tad)olDivision3hf dic Bminateand Profvsdlhm Cale)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of m Section by any applicant for a permit subjects the applicant a civil penalty of nl mom Than Five hundred dollam ($SW). dothe worMthe pm deny.nrmyemplended wlBtered for sale044,usiness will To marina, andthehe (mre is not intended Law Code The Comraereo License Law does sol apply d, via owner of no, apply to weer of and property and who docs such work property who builds or improves who Idea offered POWER DEVICES SWIMMING POOLELELTRIC OUTLETS-SWITCHES-PIXTURGS t such i, his owe or fo are not intended or offered for provided that such impros e SQ. PT. FLOOR AREA SISQ. FT ' however sale. If, howevu, the building or improvement is sold within one year of completion, ha sold w owner-builderwill have the burden of proving that he did not build or improve for pur-0) ILJ - pnvoutside.). ❑ I, os owner of the property, am exclusively contracting with licensed eommetors m ' onxmucl the project (Sec 9044, Business and Professions Cnde:) The Convacmrs G - se Law dons sat apply ro an art of property who builds or improves thereon, ons QT LU who contracts for such projects wish art mwmnga)Ilceosed pursoammthe Contrnemre with Lw. License Law. Ellam exempt under See. ,B&PCfhr this reason PERMIT ISSUANCE Ism[ r IN - ( Owner Date - VALUATION WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the folihwing declarations: LE W D DRAINS- FLOOR, ROCP, AREA, GOND. I hove and will moimninvCerifenmof Consent to self -Insure for Worker's Cmnpen- done, as provided for by Section 3700 of the Lab., Cade, for the perfo deduceof the ST S TYPE CONS'1'kUC9'ION work for which Nis permit is icsucd -FIXTURES-PER TRAP C I have and will maintain Workers Compensation Insurance, as required by Section erm�itiis issued. 3100of the LeborCodc. Intake performance ofthe work for twhihiclitthhisppe'Tim, W Is Cnl9pe I�µpce ams Pnf yNcsnT_;;ny ame, gee C CY 'GAS -EA. SYSTEM -1 INC. 4 OUTLETS OCC. CROUP ANN 'CAS-EA.SYSTEM-OVERITA) , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE, dead not be complemdiftlaeparrou isfor onehundreddo0ars(8100) or less) � O � GREASVINDUS'I'RL WASTE INTERCEPT N 'C 39 CREASE TRAP I certify that in theInTrouranceof the work for whichthis permit i, issued. l shall not employ any person in any manner so as m become subject m the Workers' Compete SEWCR-SANITgRY-S'TOkM EA.2W FT. ENERGY PEE Z 2 M cation Laws of California. Date Applicant I WATER HEATER W/VENT/ELECTR GR.{I�CNTT4 8 ju v V NOTICE TO APPLICANT. If, after making this Carnivore of Exemption, you should become eabje i m the Workers Compensation prov' sof the Labe, Codo, you rote, WATER SYSTEIATREATING SOILS FSB WATER SERVICE a DLender's w LU:I y y y V) Z forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that There is o construction lending agency for the perforance of the work liar which this permit is issued (Sec, 309], Civ. C) Name rPAID NEW RESIDENTIAL PLMB. SQ IT. B - 'TOTAL: - TOTAL : Lders Address en BUILDING FEE I army that 1 have read this application and state that the above Information is correct. ] agree in comply with all city and county ordinances and same laws relating is bung construction, vnd herehy aulhnrize repreeenletiva of this city In enter upon the - - - - ,QTS• MECHANICAL PERMIT 'FEE' SEISMIC FEE' idesomolimod property for inspection purposes. - (We) agtce m save, indemnify vnd keep hvrnlcas the Chy of Cupertino vgninat PERMIT ISSIIANCP. ELECTRIC FEE - lichilities,judgments, costs and expenses which may In any way acerae against said City m.,amencenf the gmntingof fid,,crmia. ALTERORADDTOMECH. PLUMBING FEE AIR HANDLING UNIT CTO 10.000 CPM) MECHANICALFEE APPLICANT UNDERSTANDS AND WILL COMPJB WITH ALL ON -POINT SOiRCE I� +yQULATION$t / /I/ I AIR HANDLING UNIT (OVER I(I,OW CFM) CONSTRUCTION TAX -����',(���J �A "I.� � ��[ Signvwre ofgppdivvnUChntmmnr D e HAZARDOUS MATERIALS DISCLOSUR CXHAUSTI IODD(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT (TO 100,000 BTI)) Will the applicant or future building occupant store or hen a huzaNnus material as defined by the Cupertino Municipal Choc, Chapter 9.12, and the Health and Safety Code Section 25532(x)7 HEATING UNI'C (OVER I W.OW IT ) - E]Yes ❑No PAIDTION Data.Receipt# VEN'T'ILAA CAN (SINGLE RBSID) Will the applicant or future building occupant use equipment or devices which mit hazardous air contaminants as defined by the Bay Area Air Quality Managemem BOILER -COMP (3HP OR 100,000 BTU)141. Banner?` ❑Yea, ❑No BOILER- COME (OVER 1001001 BTU) AIRCONDITIONER 1 have read the hohazardous material, requirements onde� Chhpmr fi.95 of Ne Call- famia Flealth & Safety Code Sections 25545, 25533 and 25534. I understand that if the building does not amend It alemtint that itis my responslbilityt nhit'y the ocapa I ISSUANCE DATE^, �5 � CrJ Y NEW RESIDENTIAL MECH. SQ. ET. of the it esu which mU eoLC•rll' Ieof0empancy. B , % ISSUED BY: '6C Ownerormannrieedigenl - Data TOTAL: OFFICE