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29567 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITYOFCUPERTINO - .. BUILDING-F,LFi7FRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C 7 BUILDING PR(I 1CTUIRN'IT PICK]ION J r BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE l O/&O `'► 1� C/E�Lwr� 6 NERS NAME: PHONE: NTRACI'OR'S Mli: LIC NO. NIC C( 'I R(IL t ECI'IEN INFERNO. DURESS ❑ DeQ� <LN — „' ` � I'1 II1I BUILDING PIiR LU INFO CA Y_Ipk-\eY, k�q{p ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH 'Ankto 71 LICENSED CON'TRACTOR'S DECLARAT ION ' QTY ELIiCTRIC PkiRMIT FEE 1 hereby%flit.Nal 1 am licensed under Provisions of Chapter 9(commencing JOB DESCRIPTION O�Z with Section]000)of Dirisinn 3o(me Business end Profusions Code.and my license is WOO PERMIT ISSUANCE TIAL b-W� full home and effect. 'l. ❑KITCHEN REMODEL QUV Liccnsc Class Cumo APPLIANCES-RESIDIiNTIA. ADDITION ❑PLUMBING RE-PIPE F 7ja Date Comrnetor VI¢ ARCHIE PUT'SDECLARATION ❑MULTI-UNIT C1 STRUCTURAL, 2 O ria Z 1 understand my plans shall he used as public records PANELS MODIRCATION UP TO 200 AMPS OZ—G ❑INTERIOR El CHIMNEY REPAIR Licensed Professinnol 2111-I000AMPS IMPROVEMENT F Oar I on exempt fr IIIi he Contractors OV17R I WUAMPS ❑BATH REMODEIIRBPAIR El DEMOLITION I Hereby affirm that 1 1. exempt from the Eosins o License Law forme my �a OaU following reason(Section]O3L5,Business and ve.dentnx Code:Any city at county SIGNS ELECTRICAL ❑OTHER 613 LL h which requites n pcmtit to construct,alter,improve,demolish,m repair any swcwm totno prior to'its issuance,also requires the applicant for such perniuo file a signed statement SPECIAL CIRCUITIMISC. 999 y that hula licensed putnuam 1. he provision.of the Commnur's License Law(Chaptm9 ad epO (commencing with Section 7000)of Division J ofthe Business and Professions Code)or TEMP.METER OR POLE INST COMMERCIAL: E.d y that he is exempt therefrom and the Mvsix for the alleged exemption.Any violation of / ❑NEW BLDG/ADDITION ❑DEMOLITION X��6• Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES ( TENANT ❑FOOD SERVICE Z not more thud Eve hundred dollars(S500).} IMPROVEMENT ��6 � has owner ot,he prnpeny.onny nnPlnyeex w'itn wa8u as their sole cnmPensmion, SWIMMING POOL IA,IiCfRIC SFO willdothewonk,and lhesrrcmrc is not intended methanol form(Sec.7044.Business OTHER Icy—m and Professions Code:The Committers License law does not apply to on owner of OUTLETS-SWITCHES-FIXTURES 6'3 property who build%or improves thereon,and who does such work himself or through his own employees,provided that ameh improvements me not intended or offit fur NEW RESIDENTIAL.ELECPR SQ IT sale .ILhowever,""building or improvement is sold within one yearof annpinion.the nl SQ.ITT MOOR ARE $/SV.IeI'. owner-milder will have the burden of proving that he did not build or improve for put- poseofmie.), s Ta J ❑1,as owner of the properly,an exclusively contracting with licensed contractors to TOTAL:, e mstme,the porno(Sec.7H4,BuAre,,and Pod..i...s Coe,The Conlmctora LI- I cense law does not apply b,an owner of pospcny who builds or improves arcon,and QTY, PLUMBING PERMIT 17EE 2Z 'C m who comas for such projects with a Tourist licensed pursuant to the Committeese License Law. PERMIT ISSUANCE 1 am exempt under Sec .B&P C for this reason wn<r ALTER-DRAIN&VENT-WR'I'ER IEA) / �� I VALUATION n . ODateWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /I T hmereby affirruder Penalty of perjury one of the following declarations: 4 •0(have andwtll muimain a Certificate of Consent to self-in.um for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,GOND. STORIES TYPE;CONSTRUCTION Madero,its provided for by Section 37W of the Labor Code,far the performarim of the work lin which this Penni,it issued. FIXTU RIES-PER TRAP 1 have and will maintain Workd%Compensation h ateance,as required by Section L rJ 3700of the labor Code.for the performance ofthe work for which Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUAPN My Worker's Compensation brommce carrier and Policy miniver sm, W Carrier:_Policy Nu.: GAS-EA.SYSTEM"OVER 41EA) CERTIFICATE OP EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASF/INDUSI'RL WASTE IM'ERCEPNR '/ s BUI 1 G DIVISION PSIS (Thissec,iun beednothecomple,Nif,hcpcnnitis forone hundred dollars(SIM) GREASI7TRAPAA or Less.) I'IANCFIF,(,,K h E V• Loy mylperson is inmymeberol as lin subject perthe it Waken'Cripv�l- SEWER-SANITARY-STORM EA.200 IT. '•// not employ any person in any mannan so as m become subjcn m the Weaken'Crimper- IiNP.RGY 11E //Y/1 Z m,ionlawsuf Califromm Da, WATER HEATER WNENT/ELECTR Z(2 APplieant GRADING FEE s-s N NOTICE TO APPLICANT:If,after making this Certificate of Exerroinn,you should WATER SYSTEM/TREATING 1 f-' ; become subject to the Workers Contpo cnman ptstr nwns of the I.atntr Code.You mus( SOILS PEE forthwith comply with.such Provisions or this Permit shall fie deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID L) 0 Iherehy affirm that there ixucontraction lending agency Lathe perlimnance of Uma Receipt the work for which this penW al is i.a. (Sec.3097,Civ.CJ TOTAL. O v Le dens Name : Lenders Addm,,, TOTAL: 432,41 ('1� k}. G I cony that I have read this application and state that the above information is BUILDING R71:i • pQQ F+ to Corecl l agree m enntply wim;dl city and county ordinances xnJ stem I.ws reining m QTY MECHANICAL PERMIT FEE epF1 U z building conshoschon.and hereby uulnomte Mpresentatives ofthis city treater upon the SEISMIC ITEtA Dv ad,ve-mentioned property for inspemion par na,. PERMIT ISSUANCE (We)agree,o save,indemnify and keep harmless the City of Cupertino against ELECTRIC H17 Iianilitux.judgmenks ttrs1,and expenses whichmay in any way accme against said City ALT ER OR ADD TO MECH. PLUMBING FEE 4 ane tnc9aence of ma granting of this permit. bAl APPLICANT UNDERSTANDS AND WILL COMPLY W TH AL NON-POINT AIR HANDLING UNIT(TO I0.00d CFM) MECHANICAL FEE SOU EGUTATIONS. ///111AIR % AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRUCTION TAX Signa reef APPlicmr/C/Cnnucrn e /l:ac EXHAUS'THOODfW/DUCI) HOUSINGMI"1'IGATIONFHH HA RDOUS MATERIALS DISCLOSURE' Will the applicant or future building occupant store or handle haunters material HEATING UNIT(10 L 00,0(10 HIM) as def ned by N<Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code.S tyoaa 25532(al'I HEATING UNIT(OVER 100.000 BTU) ❑Ye ❑Nn VENTILATION FACE(SINGLE BESIDE PAID Date ReceiptM Will me applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR IW,WID BTU) sun hsaardom air contaminants ns defined by the Bay Arc.Air Quality M....cmem TOTAL: DometY BOILER-COMP(OVER IM,00I BTU) ❑Yes (]No ' I have mad the havNous materials Chapter 6.95 of the Cali- AIR CONDITIONER ISSUA .ED requircmen¢anter h,mia Health&Safdy CWc.Sections 25505,M533 ad 2553J.I undersand that if the NEW HESIDENTIAI.MECH. sQ.FT. nuilding dtea not cnrently nave a tcrmm,ma,'r in my reap,meilidin u,notify me rcerPant of the requirements which most he mea moor imuunee of a Cent Bane of Onvpaney. Owner or autnoved agent Date TOTAL ISSUED BY: OFFICE j �_ \ ( czkz G) Z - \ m ):2 & : ® } \ � / � ` k \ 2 \ ) ` ° ( ` � ` m ( =}m § � -nf � | | § | ` � n ° § ! \ � ox k k ` k ƒ ; ° � - _ - � m \ \ { , n ( ( § § \\\ > Cl) : Q ' © \ . - - | o - 0 Q § � ft( \ S \\} 0 f ; ; ; ; _ \ rr " 0 ( M [ | | 2 ; ©_ \ , \%\ _�pyy y / 0 2 ; m ; ; , ; , \ ■ G:, a _ ; a ! $ ; `\: ■— _ , /_/ - . ` " ` ` 3 ] @ § >: § 2 f|2 & " . . e k / " k/{ W, 0) e L , | e , ; 6 ` "§ / ° . jm � q / ' � i i I | $ ® `� .