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B 0112 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO I BUILDING-ELECTRICAL PER O BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. � '-0112 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: 7N,1,TARYHN0ICATION SUBMITTAL DATE i ©S Isc�s D r OWNF�i' NAME: PHONE: CONTRACTOR'S NAME: LIC NOON ROL# ARCHITBgVE) N ER: LIC NO: ADDRESS: 42, CONTACT: Q PHONE: BUILDING PERMIT INFO Ckris 23 _ pg7 ❑ Consultant FcesPaid byApplicant(Initial) BLDG ELECT PhUMB ccs LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT PEE ❑ ❑ ❑ I hereby affirm Nm 1 an,hcenred nude,,owismnn of chapter 9 mommenengJOB DESCRIPTION WOO whh section,Enol Of Division 3ofdo'c'nness and Prolesslann Grree,and my Inerse is FWO in full force and effect. IT ISSUANCE RESIDENTIAL �UV License Class Lie,a ❑SCOWL Cl KITCHEN REMODEL [F�4 Date Contractor. ANCES-RESIDENTIAL ❑ADDITION ❑PIAMBING RF.-PIPE p„7 y> ARCHITECT'S DECLARATION Z O y❑ I understand my plans shall be used as public record. S ❑MULTI-UNIT ❑STRUCTURAL. 024- 20 AMPS MODIFICATION rr+�I^W LlcenseA Rofesaranal ❑INTERIOR ❑CHIMNEY REPAIR OWNER-BUILDER DECLARATION IMPROVEMENT El SWIMMING W 6 I hereby affirm that I am exempt from Ne Contractors License Lane home S ❑BATH REMODEUREPAIR ❑DEMOLITIOry00L5 11 IAMO Ufollowing reason.(Section'1031.5,Business and Professions Cotle:Any city or county - ELECTRICAL ❑OTHER Men requires a pwmit to eonswn,inter.impmvq tlemolisM1,or recon,mYawewreAL CIRCUIT/MISC. / —L ¢,� that he is licensed pursuanttothe provisions of the Contractors License Law(Chapter9MC: (commencig with Section 9000)of Division3ophe Business and Professions Cotle)or METER OR POLE INST. COMMERCIAL: that he is exempt therefrom and the basis for the alleged exemption,Any viomtinn of ❑NEW BLDG/ADDITION ❑DEMOLITION MSection]0315 by any applicant for a permn subjects the applicant In a civil penally of R DEVICES Rvchundan($500). ❑TENANT ❑FOODSERVICE mperty,or my employees with wages as their sole compensation, ING POOLELECTRIC IMPROVEMENT CaFo i Jo�M1e work autl the atmcmro is notimended or ofiaind fur sale(Sca 9044,Business ❑OTHER nd Professios Code:The Cnntmems License Law does nor apply to an owner of TS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such impmvemena are no,intended or offered fur NEW RESsIDENTIAL ELECTR SQ FT, sale,If.however,the building or impmvemem is sold within one year of completion,the SQ.FT.FLOOR AREA S/SQ.EL cr-builder will have the burden of proving that he did not build or improve for pur- owner soofsme). ❑1,as owner of the property,am exclusively contracting with licensed eoension,to TOTAL: construct the project(Sec.](144,Business and Pmfessiom Cmm:)The Condition's Li- cense Law dues not apply to an owner-of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE Who contracts for such projects with.contmetof(s)licensed pursuant to the Corjbmvr r'x License Law. ❑].in e e. ,R P C fur this reason PERMIT ISSUANCE ALTER-DRAIN&VENT-WATER(EA) Date VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (hereby s0irm under penally of perjury one of the following dedaretions 3 O D O ❑I have and will maitnaiaa CerificmeofCousento self-insure fur Workers Compeer- DRAINS-FLOOR,ROOF,AREA,CONY ,alien,as provided for by Scotian 3900 of the Labor Code,for thema perfornce of the STORIES t'YPE CONSTRUCTION work for which this permit is issued. FIXTURES-PER TRAP ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 37Mof Me Labor Code,far the performancenf[he walk for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN My Worker's Compensation Insurance carrier and Policy number arc: Canner: Policy No.: GAS' EA,SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR (This evolum need rant he completed if thepermit Is forum hundred dollsa(41(x1) Bl1ILDING DIVISION FEES or Tess) GREASE TRAP PLANCI IECK FEE Loy any Person in the performance anymannero theas work for subjectch this o Perthe W rkera'cdrnown-I shot] SEWER-SANITARY-STORM EA.200 PF. not employ any Canon in any manner so as to become subject to the Wodere'Compen- ENERGY FEE O O sarc,InLaws of California.Date Acon WATER HEATER W/VENT/ELECTk GRADING FEE ti NOTICE TO APPLICANT:If,after making this Cisions fol Exemption,you shouts WATER SYSTEM/1'RF.AI'ING a > become subject 4t the Worker's Compensation provisions of the Lobar Cole,you muse SOILS FEE LkL forthwith comply with such provisions or this Permit shall he deemed revoked WATER SERVICE 0. Q U z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLATE. SQ.IT. PAID I hereby ten flint them issued(construction[ending agency for performance of Data keceiplM the weak for which this permit is issued(Sec.3(N9,Cl,CJ Q Lemdea'x Name V TO'T'AL:Lcndcr's AAdress TOTAL: 1 really that 1 have read this application and state that the above information is BUILDING FEE C) y comet.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL,PERMIT FEE U z abovengconsnedPurond hereby auttionp rposes. talives of ibis eitymemer upon the SEISMIC FP.B rs above-mentioned sort, for indmnify an keep to PERMIT ISSUANCE (W0.91.to save,Indemnify and keep harmless the City or Cupertino s against ELECTRIC PEE liebinecujudgme he costs and im'hinseernal. may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.1100 CFM) SOURCE REGULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX Signature of Applicant/Comfactor Date EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building ovcupatn store or handle hazardous material HEATING UNIT(TO 100.000 BTU) as def nod by the Cupertino Municipal Code,Chapter 9.12,and the fleallh and Safety Code,Section 25532(a)9 HEATING UNIT(OVER I00.1I0f)BTU) ❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID -- Will the applicant orfmrc nbuilding eccupoo[ Date Rceeds#use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)L_�Ihoriz� ihdous air contaminants as defined by the Bay Arco Air Quality Management IOTA es 0 N BOILER-COMP(OVERIW."B'fU) ve read the meallous-medals requirements under Chapter 6.95 Of CAA- AIR CONDITIONER ISSUANCE DATE h&Safety Code,eaScomou 25505,is my and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FT. / n n irroes omswhitly have Nonan[,that it is myce,of.i Omfitonotifylhe titia.pant /l7_ T rJN� mcnts which must M met prior m issuance of a Cenifiwte of Occupancy. honzc a ent - B Uma TOTAL: ISSUED BY: / OFFICE