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S0001 B 0161 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-MECHA ELECTRICAL ICA 1 PFIi'VII�O'yL'S 0 y ^ y BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MF.Cf1ANICAI. SOOOI jam(\ 11 L6 li BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: e SANITARY NO. AI CATION SUtlMITTAL DATh Ino.klrco✓/ a ST OWNER'SNAME: PHONE: COONNRR-A/C�f'R'S NAME: LIC NO'. L/ z IAIJCT 7'I7- 87,25- /JC{.. 8L1/LaEILS �O NIC CONTROI.p ARCHITEC AINGINFER: LIC NO: ADDRESS: ❑ Soo ©e'A-'Da S.��os� '4.9sia� CONTACT: PHONE: BUILDING PERMIT INFO N' 1A ` �s2��5 nC^�q�,� ❑ Consultant Fees Paid by Applicant(Initial) BDG ELECT PLUMB MECII 'a, ✓A OCUa U ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMVr FEE I herthy apron lust l.r.license,]under provisions of Chapter 9(commencing JOU DESCRIPTION WOO with Section 70110)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL' WOO p PERMIT ISSUANCE. O %luj in full force and eR ❑SFDWI. [I KITCHEN REMODEL. ie U License CI I Lic.p d 6 APPLIANCES-RESIDENT'IAL f_1 ADDITION El PLUMBING RE-PIPE F A. Date C`9 DECLARATION N S ARCIIITECI-S DECLARATIDN ❑MULTI-UNIT ❑MODIFI MODIFICATION Z 0074. I understand my plans shall W used as public records PANELS - MODIIlCAT10N OZ-O UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR 1-4FWLied Professional 201-100(IAMPS IMPROVEMENT 0SWIMMING POOLS �W censOWNER-BUILDER DECLARATION OVER I OX AMPS ❑BATH REMODEVREPAIR [IDEMOLITION I hereby affirm that I am exempt from the Connector's License Law for the i6ytOyV following reasoa(Section 70313,Business and Professions Cade:Any city or c,,my SIGNS ELECTRICAL []OTHERul a<L Hra� which requires o permit o construct,seller,improve,demolish,or repair any strneture prior to its issuance,also requires No file e applicant such Permit it) a signed statement SPECIAL CIRCUIT/MISC. ttQf R! 6� that he is licensed pursuant the provisions of the Commons License Law(Chapter9 COMMERCIAL E5 (commencing with Section 710X)of Division 3 of the Business and Professions GrCods)or 'FEM P.METER OR POLE I NST. - ty e y that he is exempt memfmm and Nm e basis for e.]]moth csemplion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION F. Y• Section 7031.5 by any applicant for a permit subjects the applies.,m a civil penalty of POWER DEVICES [I TENANT El FOODSERVICE Spnot more than five hundred dollure 1$5100. ❑I,as owner offs,peopeny.or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC ❑IMPROVEMENTHER will do the work,and the strocmre is nal imended or offered for sale(See 7(144,Business and Promotions Code:The Contractor's License Use does no,apply to an owner of OUTLETS-SWITCHES-FIXTURES 6 Z^ property who builds or improves Hereon,and who rtes .h work himself or though his own employees,provided tam such improvonems arc not intended in uttered for NEW RESIDENTIAL ELECIR SQ FT. sale.If.however,the building orimprovement is sold within ane ycurofalmpletinn,the SQ.FT FLOOR AREA $/SQ.FT. ler-builder will have the burden of proving that he did nm build or impmve for pur- poseur sale.). /'� ❑ h as owner of the prepeny,am exclusively contracting with licensed contractors to 7 DTA (J colonel the project(Sea 7044,Business and Professions Coda]The Camaro,.Li- seLow does not apply toanowner(if Property obviates or improvesdisinter,and QTY. PLUMBING PERMIT 10 FEE who contracts for such projects with a Ornamentals)licensed pursuant to the Contmcmr's License Low. PERMIT ISSUANCE ❑I um exempt under Sec. ,B&P C for this reason ALTER-DRAIN&VENT-WATER( F VALUATION Owner Date WORKER'S COMPENSATION DECLARATION PACK FLUW PROTECT.UI:VIC 1 hereby affirm under penalty of perjury one of the following declaotions: 0 0 0 `❑I have and will notoriousa Certificate ofConaenuo mlf-insure for WMkers Crimpy- DRAINS-FLOOR,BOOR AREA,CO ND. STORIES 'TYPE CONSTRUCTION action,as provided for by Section 3700 of the labm Latour Coda,for the perfornner of the work for which this permit is issued. FIXTURES-PER TRAP ❑1 have and will maintain Workers Compensation Insurance,as tcquirtJ by Section 370(1 of the Labor Code.for the perfornnmce of the work for which this Permit is issued. GAS-P.A.SYSTEM-I INC.40UTLF.7'S OCC.GROUP APN My Workers Compensation Insurance carrier and Policy number are: Cartier. Policy No.: GAS-FA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' GRFASFIINDUSTRL WAS'TP.INI'ERCEFI'(]R COMPENSATION INSURANCE BUILDING DIVISION FEES (This section need no,becomdcarl ifNepermit isfor one hundrddollars($100) GREASETRAP or lean.) PIAN 'EE I vent that in the Performance of the work forwhich this permit is issued,Ishall SEWER-SANITARY-STORM EA,200 FT. ' not employ any person in any meaner so as to become h' to the Workers'Compel- R FCB z `Z onion Lawsof Culiforni m /���-(� c WATER HEATER W/VENT/ELFCI'R w APPlicunt I GRA 4INAfISI� r24 NOTICE TO APPLICANT.IL ma king this Certificate of Exemption,you should WATER SYSTEM/IREATING Gill Vt a7 become object 1e,the Worker's Compensation provisions of the I.mWr Calc,you mus, SOILS FEE {21forthwith comply with such provisions or this Penni,shall be deemed revoked. WATER SERVICE UQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID 0 1 hereby aR that there is a construction lending agency for the perfomnrice of U Receipt p H the work for which this lFc�it yjg uW(Sec.3097.Ci,C.) 0ULender's Narnc OIAI' Landers Address TOTAL: G tlU1LDING PEE 1 certify that 1 hove mail This city unit county ouend sine that the stove Laws fining iz fA cording construct comply herebylushori coumynrdinunces and nate entreladngm QTY. MECHANICAL PERMIT PEE L) z building conswction,and hereby authctrize represenlalivre of this city to corer upon the SEISMIC FEE uMne.mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree m save,indemnify and keep hastnlesx the City of Capacious,niftiest ELECTRIC PER Iiabilitics,judgmenu,minimal expenses which may irony way acencinains,said City ALTER OR ADD TO MECH, PLUMBINGFEE in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL PER SOURCE REGULATIONS . l s��Y/•A(�J h`�{hWW, Fyn- qgy AIR HANDLING UNIT(OVER I0,0X10 CFM) CONSTRUCTION TAX SigmaiucofA imIlUm rector Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will theapplicantorfuture building accapantnore orhmndle bumdous mMerial HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely Coxa Section 25532(e)7 HEATING UNIT(OVER 100,010 BTU) El yea ❑No VENTILATION FAN(SINGLE RESID) PAID - Date ReceiptN Will the applicant or future building occupant use equipment or devices which •emit hazardous an contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(311P OR 100,10)BTU) TO Dunnn7 ❑Yee ❑Hct BOILER-COMP(OVER 100,000 BTU) AIR CONDITIONER I Health Safer hazardous material 5,25533 an under .1 and rsta drbethat Cali- ISSUANCE DATE Wilding Health&Safety Cade,e a Sections t,that,25533 end 25534.1 understand the that If the NEW RESIDENTIAL.MECH. SQ.FT. asilding dlCsnM currently haVCaUrlarlt lhel it is rayfasponslhllllymnIXify lhC MCYPan1 (/ a of the rt rare ten hich vi nor to issuance of a Certificate_of Odcup - �� TOTAL: R A I G Ownermmium agent Date ISSUED BY: OFFICE