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S 2869 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, t . • BUILDING PROJECT,IDENTIFICATION •' RDILDI G"ADDHh:55' SANITARY NO. APPLICATION SUBMITTAL DATE O o - . f},v Z f! 8t.vc0 • �r��ERT/n/D • �'f} �!- 9. W E `;, ��� _P�ONF:1 CONI'RAC'fOR'SNAMG: LIC NO: Cir 3 �{/7_ N/C . CON RUL# CHITECT/EN13R: 0 (467 ADDRESS'. - El / CONTACT �/ •N PHONE: -/ BUILDING PERMIT INFO AMES l S�8` 5 / ❑ Conenitaut Fees Paid by Applicant(Initial) BLD ' BLe©I_ PLUMB MECH LICENSED CON DRAG I ORS DECLARATION QTY. Y` ELECTRIC PERMITI FEE I hnmby arcrnthat I l d d p or LICENSED (e,nl rte Ins. I JOB DESCRIPTION Fma'z with Scoon JOW)ofDvi a3oftheBus' ss and Pn fd." n.Cnrld,mi yl'ee 'r PERMI'D ISSUANCE RESIDENTIAL: force OO in full and effect W-t- ❑SFUWL [I KITCHEN REMODEL GUO Llnunec Gloss Ln, APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE N 7j W Dom Contrnamr F ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL. zOmz I undefsmnd my pInns shut l he used as public records PANELS MODIFICATION ' Ozr4- UPTO2WAMPS ❑INTERIOR El CHIMNEY REPAIR (".E=�W L'mensedF reniowl - 201-In00AMPS IMPROVEMENT I]SWIMMING POOLS �I��� OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION W='d I hereby ofrirn that 1 ore exempt Doom the Compactors License Law rat he 01 O E V following rens....(Section 9031.5,Business mW Professions Gxle Any city oreumulYSIGNS ELECTRICAL ❑OTHER W 3 W i which carriers a,unit to construct.old,,improve,demolish,or ir a repany swclure Jl {0st prior m Jsu s isonce,also requires the iTherat for such Permit rile o signed statement SPECIAL CI RCU ITIM ISC to ' �. to that he is licensed pathe uuancen ...visinave theCoub ctnra License Law(Chapter 9 (commencing with Sione.700nofDiesdain3o1the Business andPmfesnioroGde)or TEM RMEI ERORPOLE BEST COMMERCIAL d pl o a that he is exempt therefrom and the basis for the alleged exemption.Any violation orn �9QLW B AXEADDH'ION El DEMOLITION W N Section 7131.5 by any applicant for a Permit the applicant to a eivil pcmdty of POWER DEVICES THN FOOD SERVICE. F>y not more than five hundred dollars($500) Q . VEMENT [IqQ I,as owner nl'the propuny,onny employees with wagesmlheir sole am�Punsation, SWIMMING POOL ELECTRIC ' FO will Ao the w.rk,..d thearnmed is not intended ornffymd for sule(Sec"9044,Business ❑0TH — W end Professions Code The Comments License I..dnee oat apply to an nwnda of OUTLETS-SWITCHES-FIXTURES 6t Properly who builds or Improves thereon,and who does such work himself or through his own employees,provided that such impnvamrets ore not intended or offered for NEW RESIDENTIAL HLECTR SQ C, sale.IL however,the building of improvement is sold within onoyearofcompletion.the SQ.PT.FLOOR AREA KXQ.FT. Pov°al°e%I��,r(b,u,,rild�er will have the buMan of proving that he did nm hander improve far pur- all' "`"e' TOTAL: lllbbenon's' r otect property,am exclusively contracting with Ileeno Contractors i- I 0 Vr ' construct the projmt(Sec.7844,Business and Professions CndeQ The Convacmds Li- � � , cense Law does not apply to an owner of property who builds or improves thnrcrn,end QTY, PLL INGPER ' FEE who contracts for such projects with a contmcmKa)licenced parsuanlla the Contractors CD �'Q - "License Law. PERMIT ISSUANCE V A ❑ Ia.vomTtanderSec B&PCrerthis seen �_Ce Q IIIR Owner Dam AIAHE-DRAINanVFNT-WA ) p�4ALUAI'ION �,JS OR KERS COMP ONDECLARATION BACK FLOW PRO 'CL OF G O J9 Ihenby affirm radar penal alp rjuryone ofthe following declarations. ZO I have lord will an in laina Ger mere 'Gonsenua self-insure for Wnrknra Compar- DRAINS-FLOOR,ROOF,AREA,COND. �STORIES TYPE CONSTRUCTION satin 1,as provided for by Semi 39 of the Lobar Code,for the purfoomenee of the work for which this permit is is: ed. FIXTURES-PER TRAP 1 hove and will mainmin Wt k :Compensation Insurance,as required by Section IV/V 3'100of the labor Coda forthe .(,ane,of flue work for which this pemtitfsissued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP My Workers Compensation Insurance carrier and Policy number are: - Cuvier Policy No: GAS-F.A.SYSTEMOVER4(EA) CERTIFICATE OF EXEMPT ION FROM WORKERS' ' COMPENSATION INSURANCE OREASEIINDUSTRL WASTE IN I a rBO101146 DIVISION EBESz (Th'.' bodaudd not bee mplemJ'fth 'tisforo h d 1iellars($100) 2 s "'-- `- — GREASETRAP Q- orle ) PLAN FEE leduffydromme,sersurnif lh kf which lM1 p I. sueJ,leholl SEWER-SANITARY-S'I'ORM EA.200 FT. not employ anyperson in an,manner soosm become subject o the Workers Compete BACK Y .H sa um laws of Coliforms.Date WATER HEATER WIVEILUELECTR z Q Applicant I NG FEE Uj NOTICE TO APPLICANT,IL alter making this Conifimin of Exemption,you should WATER SYSTEMITREATING become subject o the Worker's Compensation Envisions of he Labor Code,you most S LSFEE !� Par th comply with such provisions or this permit shall he deemed revoked. WADRR SERVICE W Q UO CONSTRUCTIONisocLFNDINOAGENCY NEW RBSIDBNTIALPLMN. SQ.IT, PAM (late Reecile# Ibot .whi,hmu Nanhereissed Sad.30lending agency forfhc per!nonce of W Uthe work rorwhich @Is permit is issued Sad.3097.Civ.C) Lender's Name U henerrs Address T L� a1 certify pan 1 have road this ppI f d state that the h informal....is - BUILDING FEE .. V) correct.I agree to cuinply with all city and county ordinances andamodlaws oplaningm ,QTY" MECHANICAL PERMIT PEE - build' g construction,ed hereby unthodu representatives ofthsoty Lever upon the SEISMIC FEE above untutored property for inspection purposes (We)agree to said,indibroy:md keep harmless rhe City of Guadiana against PERMIT ISSUANCE ELECTRIC PP.5 habilires,judgmerus,costs andexpenses which may in any way accrue agi ios4aid City ALTER OR ADD TO MHCU in constructed of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IOp00 CFM) SOURCERF tit.ATI ME NIC FEF. 'L f l/S /�� AIR HANDLING UNIT(OVER 10.000CFM) 11A 'TION TAXJq S 9ng�naammed ff`AAppplicobArnracmr Dote EXI IAUST HOOD(WIDUCT) GM A'1'ION FEE HAZARDOUS R LS DISCLOSURE Y� Willthcappleamuirfutu ..riding vpanlstnrenr handle[inaction,motorist HEATING UNIT(TO 100,000 BTU) w defined by the Cupertino M .pit Cod Chrpter 9.12,and the Health sad Safety Code,Section 25532pal A I IEATING UNIT(OVER 100,000 BTU) E]Yet No VEN'IT LATION I-AN(SINGLE RES I D) . Uafu ceiPl# Will the r"J...I on rum Ing owupam use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU) 7 ril ministers or ematonali dnant.s w,defined by rhe Bay Are.Air Quty Mmmm gucm District? BOILER-COME(OVER 100,000B .._ .. Dyes - ❑Na TU) 3 11 oyd the bb I d Ir requirements anderChaphar6,95 orthrGAIR CONDITIONERll- ISSUANCE DATE forma Health @ Safety Code Sf 2550525533 and25534.1 understandthtifthe NEW RESIDENTIAL MECH. SQ.fO'. � � _( 9� � building does I retlyh I t tt yvr,p '�Iryt tfy(h upant effbere r�t cymusl M1e arm ss era Certificate of Occupancy. Y "./m, 'A,again Dale ' TOTAL: ISSUEDBY L�"_2 b OFFICE