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29896 (2) APPLICANTTO'FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'C' [6 BUILDING-ELECTRICAL - PERMIT NO. (�(� O�[x-/ BUILDING DIVISION. APPLICATION/PERMIT. PLUMBING-MECHANICAL G J o v • 1. - WILDING PROJECT IDENTIFICATION BUILDIN ADDRESS - j - - - ATE + - - SANITARY NO ++ APPLICATION SUBMITTAL DATE OW .WSN ME: PHONE: CONTRA O 'SNAME: CONTROL M. ., iRCHITE T/ENGINEER LIC NO: sT i CONTACT: - '^ . PHONE: _ t BUILDING PERMIT INFO -' ,' ❑ Consultant Eces Paid by Applicant(Initial) D ELECT—.. PLUMB MUCH '. LICENSFDCONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE I hereby 0)of that 1 of BJ under provisions of Chapter 9(comm¢ I, JOB DESCRIPTION' xr with Section 7000)of Division3of the Bus Profession Cod dm licen is' �pyI00 n y PERMIT ISSUANCE � + RESIDENTIAL: ' F u� annuitant force an 0 .�'J -!Y + y". ❑SFDWL ITCHEN REMODEL p p License ? Li r ✓ - - - f 'Fa{p Date 'Can[ [r APPLIANCES-RESIDENTIAL �� ❑ADDITION + ❑Ph GING RE-PIPE ARCHITECTS DECLARATION PANELS ElMULTI-UNIT El STRUCTURAL . y O dens and my plans shall be us d as public retools MODIFICATION O,Z`- t UP TO 200 AMPS • a ❑INTERIOR' El CHIMNEY REPAIR gg� Licensed Professional - 201-1000AMPS a IMPROVEMENT ' OWNERBUILDERDECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION y I h by off m that I a exempt f lh C erruetm's License Law for the x 3 0.V folio g ,r n (Sedum 7031.5,Business and Profs s o Cade Any city or courtly SIGNS ELECTRICAL / ❑OTHER FM OEa which requires permit to construct,alter, p demadishr repair any saucmre m.] prim t t 1 qure rethe ppli if min such fileasigned statement. SPECIAL CIRCUIT/MISC Math Ic nedPursuant ttheprevisions ofthe Contractors L L (Chapter9 - ^2 00 (commencng with b 7") fD's slo 3 ftheB mess and Prof..i ns Code)or TEMP.METER OR POLE RST''- COMMERCIAL: [hal he pt therefrom and the basis for the alleged exempt on Any violation of NEW BLDG/ADDITION [_1 DEMOLITION '^Y• Seer 90315 by any appl t f pe t bj el Ne appl c [to a I penalty f POWER DEVICES ❑TENANT ❑FOOD SERVICE t thanf hundred d II yempl ,i SWIMMING POOL ELECTRIC' IMPROVEMENT G1 tthpr pettym y ply with eg.a their I mp nsef ❑ C will do the -k,andthe structure' t intended oroffiredf r sale(See 7044Bu nes ❑ ER and Priflicasnew Code.The Commences License Law does not apply to an'owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves[hemon and who does such work himself or through his own employees;provided that such improvements nre not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. ' sale.If,however.the building or improveibent' sld with.one year of completion,Nej SQ.FT.FLOORNAMA„� $/SQ.Ff. owner builder will me theburden of proving thin did not build tl ormprovc for Dur- Pose of sale) A - ❑ 1,as owner of the Property,am exclusively eiratrLi ng whO licensed ntracnm to - construct the project(See.7044 Business and Professions Cod )The C l ¢tar's Li- cause i -'•'A'� O �(� r cense Law dues not apply t an owner f properly h b 'Id 'mpro es thereon,end QTY. PLUMBING PERMIT FEE 9 who contracts for such pmjeet with atom togs)licensed pursuant to the Contractors I b ' License Law. - - - 'l�t E r �� L, ❑I am exempt under Sec - ,B&P C fnr th s reason PERMIT ISSUANCE IrPI,rFI(I RV ALTER'-DRAIN&VENT-WATER(EA) VALUATION Owner' Data WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE+-• _ ..,+ I �' 0 I hereby affirm under Penalty of perjury one of the following declarations: ❑Ihave and will maintain a Certificate of Consent to self-insure for Worker's CompenDRAINS-FLOOR,ROOF,AREA,GOND: STORIES TYPE CONSTRUCTION aetion,as provided for by Section 3]00 of the Labor Code,for the performance of the _ work for which this permit is issued. FIXTURES-PER TRAP •• , ❑ 1 have and will,maintain Workers Compensation Insurance,as required by Section - ,, 37004.f Ne Labor Coydaeq,f+�ngr the�perforemma�a.�nnrttc�ee of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UTLETS OCC.GROUP APN MyWaCartierr-,a=�/ /0-7-7 Policy Nor and r:number are:+ GAS-EA.SYSTEM-OVER4(EA)' p' CERTIFICATE OF EXEMPTION FROM WORKERS' - - - - " COMPENSATION INSURANCE t GREASE/INDUSTRL WASTE INTERCEPTOR - ,Cthis section need not bewmplerad ifthe Damm is for one hundred dollars($1(10) _ BUILDING DIVISION PEES or lase.) GREASETRAP r PLANCHF.CK FEE'/ I cenlfythat in the performanceof the work forwhich this Domain is Issued,Ishall SEWER='SANITARY-STORM EA.200 - molemploy any person y n mat h subject to the Workers'Compen- - .ENERGY FEE ' Z sation Caws of Cahfom Date n - O er s WATER HEATER WNENTMLECTR Applicant - - ,GRADINGFEE, i G y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING F become subject to the Workers Compenseak n provisions of the Labor Code you muss SOILS FEE m W forthwith comply with such previsions or this peul shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY '' i ]NEW RESIDENTIAL PLMB' " SQ.FT. PAI0Ihereby affirm th t there is a construction lending ager yf r Ne performaof aceip'N ,r the workfor whichhls peTilis ismad(See,309],Cis.C.)FLendersTOTAL:OLender s Address 1 certify that I have reed Nie application and stns that the above information is BUILDING FEE ' iw Val correct.I agree to comply with all city and county ordinances and elute lawn relating to QTY. MECHANICAL PERMIT FEE ' Ll z building conavuction,and hereby suthnnz,representatives ofthis city to enter upon the - SEISMIC FEE.' �. above-mentioned property for inspection purposes.. I ,-Cups (We)agree to save,indemnify and keep harmless the City of ertino against PERMIT ISSUANCE ELECTRIC FE �t habilities,judgments,coers and expenses which may in any way accrue against said City ALTER OR ADD TO SEEK, _ \� in consequence ofthe granting ofthis permit - PLUMBING E `r\ APP NIGER ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO M,"CFM)--• - SOUR( REO. 1 MECHANI AL FEEtA AJ jltl+oz�� AIR HANDLING UNIT(OVER 10,00(l CFM) CONSTR Si ire pppherrin Com acme Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE ,HAZAWOUS MA IALS DISCLOSURELt i Will the applicaatorfuture bui ng occupant smrebrhandle hazardous material" HEATING UNIT TO 100,000 BTU) as defined by,the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Code,Section 25532_(a)? -•- HEATING UNIT(OVER 100,000 BTU) ❑Yes 1, �Nni VENTILATION FAN(SINGLE RESID) - - PAID - Date t' ftxciPlM Will thedons.applicant nature building by the Ana i -ntor Marawhmh^ BOILER-COMPLIPOR Md"BTU) • - nit hazard us air contaminants as defined by the Bay Aren Air QunlityManngement ' TOTAL: "- niammp - '9 Dyes C-]No '• j $ _ BOILER-comp(OVER 100,000 BTU) + AIR CONDITIONER e . Ihave read Ne hazuNoos materials q itis under Chapme 6.95 of Ne Calm ISSUAN TE , fears Health&Safety Code Sections 25505 25533 and 25514 1 understand that if Be NEW RESIDENTIAL MECR, SQ.SFT. " building does not currently have a tenant,that it is my responsibility in notify the occupant' of the.,aim—ts which must he met prior to issuance of a Certificate of Occupancy. n OwnarorauthodzWagat Dale T AL: ISSUED BY: OFFICE , 1 ED r-L LO Qc VcrvLU �00 LO 2 O w n Oco a N 'V' ��\I W ¢ U U. q W OI -T w O Cfi co? U O � m NLO U. V 5 o U � N W Q)b ° c ° d S O bN. 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