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30865 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-'USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. BUILDING DIVISION .,APPLICATIONIPERMIT a PLUMBING-MECHANICAL 0 o o e C BDILDING PROJECT IDENTIFICATION is J BUILDING ADDREBS� - SANITARY ANO. APPLICATION SUBMITTAL DATE jS 6 ' '3 9 T OWNERS NAME , k P ONE NT COTR' '��E: CNO: TCM/ .(^r� 3© .. NIC - CONTROL If HIT T/ENGI SER: 'tLIC NO C It v LI CONTACT; "pHorvE:'- - BUILDING PERMIT INFO YN`�' ®[,k - ❑ Consultant Fees Paid by Applicant(Initial) ,BLDG ELECT PLUMB . MECH LICENSED CONTRACTOR'S DECLARATION I V , 11;1/ EK EK 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing QTY - ELECTRIC PERMIT FEE �oz with section nwn)ufDivision iofthe Bgxiness and professions Code,amd my license is JOB DESCRIPTION . FUS in full)f Cls and effect. PERMIT ISSUANCE a SO RF" ID NTIA a Nu Dow Lrc.M - � ❑SFDWL •' ❑KITCHEN REMODEL Commcm a APPLIANCES-RESIDENTIAL l; Lice ❑ADDITION El PLUMBING RE-PIPE L.Dw ARCHITECT'S DECLARATION PANELS' ❑MULTI-UNIT [-]STRUCTURAL Oz- 1 understand my plans shall Fantasias public records (. MODIFICATION F UPT0200AMPS ♦ ❑INTERIOR :. ❑CHIMNEY REPAIR. ` � 7y'hLensed Prnfesstonal, PROVEMENT .d 201=IU010AMPS tea OWNER BUILDER DECLARATION j�.R.] 1 h by ffi m that lam exempt from the Contmcto peens Law for the OVER 10(1(1 AMPS BATH REMODEVREPAIR 0 DEMOLITION p�'�$O d V following—lot. 7031.5,Business s and Profe-mal Lor An i t a ant ER ,PP,.s g SIGNS ELECTRICAL _ E•'�"s'3� which requiresPermittotrot applicant improvedemolish rrepy ssumetmetatement ~ y prior[ t mss ale q free thesionsofor such Contractor's License flee signed statement; SPECIAL CIRCULUMISC. y $ that he is pursuant 70th)provisions 3 the Contractor a Lcenm,,rra,(Chapter in.,be is exempt Secfrour and he land. for of tee Business and on.Any vi lman of , G� G TEMP.METER OR POLE T COMM R IA W M C teat be is exempt therefrom and the basis fof the alleged exemption.Any lineation of ❑NEW BLDG/ADDITION ❑DEMOLITION IWC u^ Section than five any hundrelicvntfor a n,1$50 rmit subjects the applicvnnoacivil penalty of POWER DEVICES yyyy y t more than f ve hundred dol curs(empl... „ ❑TENANT ❑FOOD SERVICE OE]1,as owner of Ne property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the stmemra arm intended or offered far Bala(Seo.9044,Business ❑OTHER MW and Professions Code:The Contractors License Law deals not apply to an owner of OUTLETS-SWITCHES" RF - property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT R 3 SO mFf. sale.It.however,the building mimproveent is sold within one year ofc erfuniom the SQ.7..FLOOR AREA ' . $ISQ.ET. owner-builder will have the burden of purring that he did not build or improve for put-, pereofsale.). - ❑ 1,as owner of the property,am exclusively commniag with licensed amareou.to TO construct he project(Sec.9044,Business and Professions Cotle:)The Continuator's Li- cense Law does not apply to an owner of property who builds or improves Banner.and i censeLawdoesnotupplytoanownerofpropertywhobuildsorimprovesBanner,and QTY. PLUMBING PERMIT FEE who contracts for such pr0jemawith a contractors)licensed pursuan to no Containers License taw. PERMIT ISSUANCE y ❑ l am exempt under Sec. ,B&PC for this reason Owner - ALTER-DRAIN&VENT-WATER(EA),. VALUATION, Dam - _ .• WORKER'S COMPENSATION DECLARATION n - Iherebyaffrmunderpenaltyofperjuryoneofthefollowingdeclarations— BACK FLOW PROTECT.DEVICE - O V O [:1 I have and will maintain a Certificam of Consent to self-insure for Worker's Compam, DRAINS-FLUOR,ROOF,AREA,COND. action,as provided for by Section 37M ofthe Labor Code,for the performance of the STO IES TYPE CONSTRUCTION work for which this permit is issued. PIXTURES-PER TRAP E]I have and will maintain Worker's Compensation Insurance,as required by Section 37W of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS - My Worker's Compensation Insumrice carrier and Policy number are: OCC.GROUP pPN Cartier: '' Policy No.: GAS-EA.SYSTEM-OVER 4(EA) - • ,CERTIRCATEOFEXEM"IONFROMWORKERS' ,; COMPENSATION INSURANCE GREASE/I_NDUSTRL WASTE INTERCEPTOR (This section need not Na completed if the permit is forone hundreddellars($100) - BUILDING DIVISION FEES or less.) ': GREASETRAP, PLANCHECK FEE I certify that in the performance of the work for which this permit is issued,I shall' S6WBR-SANITARY-STORM EA.200 FT. Zoat employ any person in any ou rater o as t9¢� rya subjla to he Worked Compete. ENERGY FEE cation Le4Pf�A to s.Dx.f'k, i' 1'N, d / _ 0 Z 0 xApplicant /L..i fsy,R /•.TI WATER HEATER WNENT/ELECTR r . r y NOTICE TO APPLICA If,after making this Certi GRADING FEE a of Exemption,you shdolit ,WATER SYSTEMTREATING _ a [^ ibecome,subject to the Workex'a Compensation provisions of the tabor Code,you must SOILS FEE c I " forthwith comply with such provisionsor,this permit shall be deemed revoked.{LIQ ed. WATER SERVICE _ �•' �X' COSTRUCfIONLENDINGAGENCY srZ NNEW RESIDENTIAL FUND. SQ,EL PAID .Ihereby affirm lhanBere isaconswcJnn lending for the perfomarom of Date 'Receipt M ' 0 -the work for which Nla permit is issued(Sec.3099,Civ.C.) - LludersName - W .. TOTAL: y aLenders Address .pp.gAL: I certify that I have read this application and state that the above information is BUILDING FEE ' ti N cancer.I agree to comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT PEE U building construction,and hereby authorize representatives of this city to enter upon the C� SEISMIC FEE -m alurveentioned property for inspection purposes. PERMIT ISSUANCE S�� t (We)agree to save,indemnify and keep harmless the City of Cupertino agaimr ELECTRIC FEE Iiabilities,judgments,costs and expenses which may in any way.exmeagainstmid City ALTER OR ADD TO MECH. ro in consequence hf the granting of this permit. - PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONIT(TO IO,WO CFM)' V SOURf,'E EGULATIONS. MECHANICALFEE^.. �t !. alk�1% //�� AIR HANDLING UNIT(OVER 10,000CFM) CONSTMICTIONTAX' Signatureo Apptcant/Comuctor Dete, EXHAUST HOOD(WIDUCU HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE Will theapplicant or name,building ncchpant since or handle havolme,material HEATING UNIT(TO IF(L"BTU)' as defined by the Cupertino Municipal Cods,Chapter 9.12:and the Health and Safety Code,Section 255321a)? HEATING UNIT(OVER 100.000 BTU) Y. r(]N. w VENTILATION FAN(SINGLE RESID) PAID Data Receiptil Will the applicant or fmure building awupam use equipment nr devices which nit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU), istrict? OTA ❑Yes _E]No � �' BOILER-COMP(OVBR 100,OW BTU7 I have tesdthe haallous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE - F forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,Pf. building does not currently have a tenant,that it is my respossibility to notify Ncup m e oc of the requlremen¢,whlch most be and prion0lssuvnea of a Certif am of Occupancy. ,. Owner or aumixedDate TOTAL: ISSUED BY: OFFICE rn • x. s 0 1° n 2 0 o mrr n ® O .:............ O A 0 ■ 0 N 197 000 0 N I Q 33 99T 33.447" 43 000" 17 000" CL o O O < g � Slip � I • � a O O xCD to N S 9 N J s ? �g' O x. O (D N S ti ■ CD J CO CD J N 3 Q fl 9 = W h (�Cb n S 1 O N,CD V CD S N X 7 O m a La J a SY a �p O V O 9 � S N 33 Cb CCD MD 0 R Sh.- CD o o' O S CN � I O 3 rn LC • s co �t � O o o o m 3 vz � 0 0 ® .......... sa � ;` ) 0 1 0 ■ 0 N 197 000 N CD CD • 33.553" 33447- 43 000" 17 n0o' OL • � N a o O O o < o tr � FTI x so M SON D O A � O (y S ? La rh «_ P 0 m mm H n ■ 9 _ Sn O a ce V Cb h -✓1 .t p S m O x m y. _ p m m p- N Lo 3 iL 3 3 S �I n 9 fl Cb 9' T a O p -G m m 9 CCD R � 5. n Q CD 7Q CD O Q T 4 o O O 3