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S 0696 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BQuuruG.ELEcTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUNiR NC..MECHANICAL S 0 6 9 6 BUII.I)ING 1'ROJF. 1 IDBN'1'IFICATION SANIIAHY NO. AI'1'LICA1'ION SUPMI'1'TAL DAI BUILDINC ADDRESS: 76417 4P9�©� o- 3�4 OWNC ' NAME Pit NE::: CON RACTOR:S NAME: LIC NO: NIC CONTROL# AEES yis - a'�.HITPCT/F,NGINHER: LIC NO: QADDRESS: ❑ CONTACT: NONE: BUILDING PFRMPI'INTO ❑ Consultant Fees Paid by Applicant(Initial) HLIK EL PLUMB MECH LICENSED CONTRACTOR:S DECLARATION Q'Ty ELECTRICPERMI'F FEE JOB DESCRI7TION 1 hereby affirm that I am licensed under prvisinm of Chapter 9(commencing mce yo with Socuon 9gNB ofDivisiunlo116u lfusiness unJ ProlmsiunxCMe,nnJ myl'lense ix RESIDENTIAL: CSF n full fo..eandetfec, PI:HMI'I'ISSUANCB 115 h ❑KITCI{EY RIiMOUIiI. aUU License Class Lic.to APPLIANCES—RESIDENTIAL. ADDITION ❑PI,UMBINGRIi-)'IPE Hoa Dam Conoallol MUM 1-UNIT Cl Sl RUCfURAI. ARCHITECTS DECLARATION PANELS MODIFICATION z~O y Z 1 understand my plans shall h used as public records UP TO 2W AMPS O z-- ❑INTERIOR ❑SWCHIMNEY MING POOL F14L 1 Lice-'W professional 201-100OAMPS BATjIMPRjRPN OF SDH (RANO POOLS CY OWNER-BUILDER DECLARATION OV17R 1000AMPS ❑NATIi R EMODIi1JRL'PAIR ❑DIiM01,1'fION CCG 1 hereby aRrtm that 1 am exempt tram the Cmdracher's License Law for the (]OTNER �aU Indoving reason (Section 711115.Business and Professions Code:Any hiyor county SIGNS ELECTRICAL IA 3 a y which requires a permit at ensstrool,alter,improve.Jemnli.sh,or repair any aructum E-LLyO¢ prion.its lssuanca.alsach,tre.Oheapplicand for such Exempt to File a signed statement SPECIAL CIRCUIT/MLC. W> that he is licensed pursuant)the provisions of the Contractor's License Law(Chapter 9 'COMMERCIAL; a�� I emmencing with Section 9(kgb of Division Jnfthe Bulinus and Pmfcsslons Code)or TEMP.ME'1'ER OR POLE Lot M a e C that he is cxemp.thcmfcom and IM1e basis for the alleged nemption.Any violation of El NEW BhUNnDDI'f1pN ❑DIiMOhIT10N Xaa Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ❑TENANT El FOOD SERVICE —N Inlainivehundred dollars Costs)). IMPROVEMENT =6 L o nvoirrol the pmpeny.n,my employcevwith wog'esns thcinole eompenwOnn, SWIMMING POOL Iihli(,TRIC f 1-1., w 11 doth workand thcdmOlutc is cot imendednroBemd for al(Sec. Basile, ❑O1'l I1:R aim and Professions Crile:The Contramnr's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES property who builds or:nip-ves thcrum,and who does such work Dimwit m through his own employees,provided that such Improvements are not intended or nllered for NEW RF_SIUIiN'I'IAI.Ii1,ECTH SQ ET. she.if.however.the building or improvement is sold withinone yearnf completion.the nownIQ.PL IsLWRnItIiA SISQ.FI'. cr-builder will have the burden of proving that he did not build or improve for put- paw of mx al owns Y 1 Fl I, awner of the proMnR am exclusively connecting with licensed comncmrx to O msaum the projem(Sec.]MJ.Business and ns ProfessioC-O:)'ITe Com—no s Li- o seLaw docs11in apply set ne owner of progeny who builds or improves thereon.and QTY, PLUMBING PERMIT FEE cwon contracts for such projects with a am-umar(q licenced pursuant the Cmnmumre Licence Law. PERMIT ISSUANCE I an,exempt under Sec. .B&P C mr this mason ACII:R—GRAIN&VENT—WAfER(EA) VALUATION Q Owner �� p Date W WORKERS COMPENSATION DECLARATION BACK FLOW PROTIiCT.DEVICE "love and wilntrm-ads p<n:dty rte of Con ens Do nmawtng declarations:orkr ol and will maintain vCenifetmnlCnmmnno selFnsurc lar Wniker'x Contpem UHAINS—ILQOR.ROOF,ARI:A,CON0. S'I'ORB! [a 'ry1'S'YI'ECONS'IRUCI'If. cation,as provided for by Section 3700 of the Labor CMth e for e peth m ante of me - MAR '•`asD work Ictm ns which this Pil is issued. 19 X'TURES—PF.R'1'RAP 6 I not,and will ocomain WnrLo's Cotnpcnwnian 1-1-111110,m rcqulred by Section GAS—I.A.SYSTEM-I INCA QU'I'LF LS ]]plot the Lola-CMe,fnnhe performance of he work for which this wrionti,issued rts'CCGHDUP My Worker's Compensation Insurance tamSYSTEM-OVER carrier and Policy number am: ksIIY Vf' .1 11I"V AI's Carrier Policy No: CAS—EA. ^ ' CERTIFICA 117 OF HX IN PTION FROM WOR K171ZS OREASILINDUS'I RL WAS 117 INTERCEPTOR V COMPENSAHON INSURANCEL GDIVISION FEES Fpd,section need not ba completed ifdw permit is t chundreddollm01100 CREASE.TRAP PLANCI FEF Zp or le,,.) Iceni(y then in the performance nl the work for which this permit is issunl,I'bell SEWER—SANITARY—STORM EA.2001717. ENERC - I' employ any person In any manner m as to become'-nice.1. he Workers'Campen- O z suit.Laws nl Ca ifnmia.Oats WATER 1117ATER WDIENI'H:I.I:CTR GRADING .."E Z Applicant y NOTICE TO APPLICANT:If,after making thi%Ceni deme of Exemption,you should WAFER SYSTEMITRIiATING SOILS TH.m (-' Deos m comply m the Works/s Compensation provisions of the tabor Craft,you muse foMwith compp ly with such provisions or s permit shall he deemed revoked WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RP_SIDENTIAI,PLMB. SQ. PAID Ua¢ Reroip.x V z Ihereby affirm that is d coretmhtlID lending agency for the faahmounce of H.t F IM1e work for which this permit is issued(Sec.?09),Civ,C.) U Lender's Name O' IA Lender's Address BUILDING FEE I teddy that I have and this xpplicali--:tnd n:ne that Bo—hole information Is .. V] conch,l agree or comply with all city and county ordinances and.state laws relating l^ QTY. No IANICAL PERM IT PEE SEISMIC FEE -.-U z building construction,and hereby authorize representatives of city to enter upon the '—' lbovcnm-tinned ptnpeny for inspection purposes. PERMIT ISSUANCE ELECT'RIC F (We)agive to cove,indemnity and keep Frolics,One City of Cupeni110-gains Iiabilino.judgmel costs and expenses which may in any way accrue against said City ALTER OR ADD TO MSCIL PLUMUI F H in comeq-ence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NON.POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHA CAI.FE SOURCE REGULATIONS, I AIR HANDLING UNIT(OVER IQgXI CPM) CONSTRUCHON AS Signwurcnf A,dirmt,Cr lmcmr Dom EXHAUS'1'HUGE)(W/UUCP) IIOIISINGMI"NGATI ITE HAZARDOUS MATERIALS DISCLOSURE: Will the applicant or future M1-ilbro,crh-pant store or handle hazardous material HEATING UNIT LTO 100.010 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12 and the health and Safely IJ17ATING UNIT(OVER I0p00O BTU) Code,Section 255)20)? PAID ❑Yes ❑No VENTHADDN PAN(SINGLE BESIDE Doc RecciplM Will the applicant or l utum building-ecupem-lose equipment or devices which BOILER—C'OMPLUIPOR 1011,IHRl B'UI) Mous air ronmminanla as define)by the Bay Area Air Quality Management 'I OIAI, win? IIOIL17R—COMP(OVER HIDJIq)BTU) ❑Yes E]No AIR CONDITIONER I SUANNry�F I have sal da h oade,S s mat s 255 5,25533 an 2553Chapter understand of the Cali- forma gdoes&Safely CMe,Section25505,25511and255)11 undalI,+thatif the NEW RESIDENT IAL h1EC11. 5 a building Jars not currently lover Ien:nn,that It is no ce of D ability to n-tily(Occucupant — pancy. Owner _ of the rgeircmants which must le m0l priormi.ouatwc ofu Ccnifcmc of(kcupuncy. Owner nr outnrisW ngrnl Oats TOTAL: ISSUED BY: OFFICE