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S 2196 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL - PESIT NO 2196 �1 9 6 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MecxANiCAI. J G • •^. BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS'. - SANITARY NO. APPLICA'T'ION SUBMITTA DATE OWNER'S NAME:. PHONE: CONTRACTOR'S NAME: LIC NO: Y � �� H/� g/��/, G�� M�.�y YN NIC CONTROLiI� ARCIIIT. TIENGINBER. /�— Vl LIC NO: ADDRESS: ❑ 8 G, (,/,(D /060 tv iv/LL CONTACT:- PHONE. �/�� /N✓� � BUILDING PERMIT INFO �y0'�� El Consultant ees Paid by Applicant(Initial) BLDG/ ELECT PLUMB MUCH / 1J ❑ El 1:1LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing _ - JOB DESCRIPTION QWa V]O p z with Section 90D0)of Divnn3oftha Business add Professi..ns PERMIT ISSUANCE. Code,had my license is RESIDENTIAL H4'W r, n full force and effect. � ElSFDWL [I KITCHEN REMODEL 6IJ,,_ U License ss Lie.N APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE F z W Dme Ti Contractor rn64 ❑MULTI-UNIT ❑STRUCTURAL ARCHITECTS DECLARATION zOmz l understand my plosshall Caused., mblwhomNs PANELS - MODIFICATION Oz4O - UP TO 200 AMPS El INTERIOR El CHIMNEY REPAIR F.�, .,W Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS OWNER-BUILDER DECLARATION OVER 100 AMPS [_1BATH REMODEUREPAIR L1DEMOLITION 4 d I hereby affirm that 1 am exempt from the Contractor's License Law Or the, 3F following reason.(Section 7031.5,Business and Profession,.Came:Any city or county SIGNS ELECTRICAL 1-14 ❑OTHER O which as mo a permit t.construct,tm tire,improve,demolish.m repair any structure ¢ yprior its issuance,also requires me applicant for such pennitto rile asi,mdata¢mem S PECIAL CIRCUITIM ISC. Ip+$ILVI/ `� that hm e is licensed pursuant the provisions on f the Contractor License Law(Chapter 9 IYidO (commencing with Section 9010 of Division 3 of Ne Business and Professions Coca)or ,TEMP M EFER OR POLE.INST. R 11' 4 q o C that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BIAC/ADDITION JOrJ,EMOLITION W m Section 7031.5 by anyapplicam for a parch Ejec.s the applicant m aoivii penalty of POWER DEVIC S ❑TP.NANT ❑P DSERVICE not more than five hundred dollars($5011). IMPROVEMENT F C ❑ 1,es ownca'of the properly,lir my wrployces with wages as their sola compensation, SWIMMING FXOI d_ RIC will do the work,and the structure is not intended or offered for side(See]044,Business ❑OTHER 3 EEI and Professions Code:The Contracmrs,Liceme Law does not apply to crusher of OUTLETS-S 1F.S 1 RES property who builds or improves thereon,and who does such work himself or through his own employee.,provided that such improvements an,not intended or offered for NEW RESIDENT EL, SQ fT. sale.If,however,the buildia,marpowemern is,md withirals.,aro.courpler i.tho SQ.FT.FLOOR AREA S/SQ.PT. mamerharlder will have the burden of Closing that he did not build or improve for put- pose of sale.). - ❑I,as owner f the properly,am exclusively contracting with licensed contractors to TOTAL: construct the project(Sec,70C4,Business and Professions Cade:)The Commences Li- se Law does not apply to an owner of Croperty,who builds or improves therein,and QTY. PLUN PERMIT FEE who contracts for such project with a cora a dors)licensed pursuant m the Contractor's License Law. PERMIT ISSUANCE. , El I am exempt under Sec. ,B&P C for this reason - - Owner Dara ALTER-DRAIN&VENT-WATER(MV A VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE J �7 Ae EJI hereby affirm under penalty of perjury one of the following declamations. i nose and will maintains CeniOente of Consenlmsel[-Insure for Workers Cnmpen- DRAINS-FLOOR,ROOF AREA,COND. FCRIES TYPE.CONSTRUCTION sation,as provided for by Section 3700 of the Labor Coderma for the perfonceof the -work for which this permit is issued. FIXTURES-PER TRAP E]I have and will commain Workers ComInpoasatio. surance,as secured by Section 39WoftheLaborCode,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.40U'FLETS GROUP APN My Worker's Compensation Insurance carrier and Policy number am'. Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' CREASE/INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES (9'hissection need not be completed ifthe permit is formehundreddollars($103) E.TRAP - orless) CREASPLANCHECK ME lb 7 , I cenify that in theperfomtaneeoffie work fur whichor permit i.issued,Ishall SEWER-SANITARY-STORM EA.203 FT. not employ any person in any manner so as to become subject m the Workers'Codi ENERGY HE 3 8 z sation Laws(if Cal Prime.Dam WATER HEATER WIVENTIELECTR r O Q Applicant GRADING FEE Ilb..tt rjl NOTICE TO APPLICANT:If,after makingthis Cenificate of Exemption,you should P WATER SYSTEM/I'REATING SOILS FEE � Mepmo subject to the Wnrkeds Compensation provisions of the Labor Cade,you must WI�-t OBIwithcomply withsuch.......ions or this permit shall be deemed revoked. WAFER SERVICE Qas CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM'. FC Data ceiprN z Ihereby affirm that Is...is a construction lending agency for the performance of {U>s the work for as Turn this permit i.issued(Side,3(92 Civ,C.) V TA Lender's Name r. Lkl Lenders Address - TOTAL 4 1 certify that 1 have rend this application and state that the above information is G FEF, fin correct.I agree to comply with all city and county ordma.ces and state laws relating to QTY. MECHANICAL ITS FEE n .C.) . ❑ MTCFIT building construction,and hereby auNariu representatives(if this city to enter upon the above-memi,,ned properly formspection purposes. PERMIT ISSUANCE E ECTRIC FEE (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilidesjudgmen,,co.tsand expenses which may many wayaccme Islas'laid Ciry AITER OR ADD TO MECH. CAUSING FEE in asequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0m)CF M HANICAL FEE SOURCE REGULATIONS. .� �� 9 AIR HANDLING UNIT(OVER 111,1103 CFM) CONSTRUCTION TAX Signature oCAN lice../ coram ate - EXHAUST HOOD(WIDUM) HOUSING MITIGATION FEE _AR US MATERIAL ISCLOSIIRL Will the applie.nlor mbuildin o .msroreo,handlehavn ousmntenal HEATING UNIT(TO 10k000 B'IU) i s defined by the Cupertino Muntampt ode,Chapter 9.12,and the Health and Safety Code,Section 25532(a)1 HEATING UNIT(OVER 1000D BTU) ❑Yes No VENTILATION PAN(SINGLE RESIp)- PAID pate ReceiptK ,AMA Will the applicant,,,future building atrophic use equipment or devices which BOILER-COMP OFT OR 100,001 BTU) emit hernial air contaminants as defined by the Bay Area Air Quality Management TOTAL: Distort' BOILER-COME(OVER 101,00(J BTU) ❑Yes Ed No I have read the hazardous materials requirements under Chapter 6.95 of the Cali= AIR CONDITIONER /� ISSUANCE ATE fomia Health&Safety Code.Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,ET 9 yY �1 / buildingdoes notcuren0yhaventenant.thatit is myresponsihility couraifythcoccuprnt L �(C) of the requirements which must be met Oi.. I.issuanarchf a Cedifiwm ofOccupuncy. Owner lir aut varesd agent Date i TOTAL: ISSUED BY: OFFICE