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31274 (2) ,PPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 11TY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. 2 7 /I J�iBU1LDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL L� BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATk v S6 9 r rcs-- Ir Zq6 , OWNER'S AME: PHO. rr 4 CONTRAMOR'SNAME: G�S1h SSS 9 / Cr - G O� N/C CONTROLp ARCHITEC AINGINEER: LIC NO', q I RFSS: ��/(] �� ' ` ❑ IM1 Ffnme PHONE: y BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLU B MECH ❑ ❑ 11']1 - ❑ LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE affirm Thal 1 mn licensed under provisions of Chapter 9 mcomnsm ing JOB DESCRIPTION Qa'ZSection of Division 3 ofthe Braises,and Protession.s Cude,and 2n,license is �00 ) PERMIT ISSUANCE. RESIDENTIAL: ly d c nr I L� ❑SFDWL ❑KITCHEN REMODEL aUULic.p ❑ADDRION A,�LUMBING RE-PIPE rFir66 X� - Con F < <' APPLIANCES-RESIDENTIAL (yY ARCHITELT'S DECLARA ON ❑MULTIUNIT S RUCfURAL F N PANELS Z O h Z I understand my plans shall be used as public records MOOIFICNI'[ON r Zl- UP'1'O2W AMPS ❑INTERIOR El CHIMNEY REPAIR F-,'�..F.W Licensed Pmfesaional 201-I(Xp AMPS IMPROVEMENT S0.p(.E; OWNER-BUILDER DECLARATION C 1 hereby affirm that I am exempt from the Contractor's License Law for Nu OVER HNOAMYS ❑BATH REMODEI/RF,PAIR ❑DI!MOLITION Sdtx d 0U following reawm.(Section 703 L5.Rosiness toil Pmfcssm.,Code:Any ciryor countySIGNS ELECTRICAL ❑OTHER 1+131+.y which uqulres a permit to constrain,after.imprnve.demolish,or mpur any Noumure ^LLOa prior to its issuance.also requires the applicant fur.such Permit o rile a signed statement SPECIAL CIRCUIT/MISC. �;!1>.•..11 that he is licensed,.suenon the provisinmof the Cooloctor's License Law(Chapter 9 ad 2C (commencing with station 7000)of Division 3 ofthe Business and Professions Com)or TEMP.METER OR POLE INST COMMERCIAL: a a e a' that he is exempt merefmm and the basis far the ollcged e:emptinn.Any Nh m mo of ❑NEW BLDG/ADDITION ❑DEMOLITION LL Section]831.5 by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES �� nm inure man live hundred doll.($50d, ❑TENANT ❑FOODSERVICE IMPROV17MENT =Q Q ldo the work.and pmpeny,arm}cmptendedwithwagesarsed,(.mle compensation. SWIMMING P(I(IL ELGCI'RIC �L0 will dolhewons and Nemunurcisnot intended or of doesnotapply to an Business COLDER a3w mdse,whiob ilde:'1'he Contractor's Lndw Law n«snotapplyto an owner of OUTLETS-SWITCHES-FIXTURES pnhpcny who builds or i6id! h thereon,and who noes such work himself for through his own oweverece,building that such improvements thin not intended of uffcren for NEW BESIDES]JAL ELI?CI'k SQ IT. Nak.lL howevee the have the burden of fo men)is at h within one build ori prove for the Ff.FLOOR AREA $ISG FT. eowner-builder will have the buNen of proving that he did not build or improve for pur- e of sale). I,as owner of the property,am exclusively contracting with licensed m ominors w TOTAL: P A p� roslmcuhe Projar(See 7(..Business and Professions CmJI The Contractor's Li- �V if Isere.Law does not apply.an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE xho comrace for such projects with a comracwr(.$)Iicen od punoaol m rhe Contractors NDy 12 License Low. PERMIT ISSUANCE 1996 1 am exempt under Sec. .B&P C for this mason Owner Dote ALTER-DRAIN&VENT-WATER(EA) r L�lYL1111�Y$JN WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Lfll V 1 hereby amrm under penalty of lwrjary one of the following declarations: I have and will maintain eCertficate of Consenuo elf-insum for Workcrs Compere DRAINS-FLOOR.ROOFAREA.COND. STORIES TYPECONSTRULTION cation,as provided for by Scaion 3]00 of the WMr Code,far the perfomunce of Ne work fur which this vermit O issued. FIXTURES-PER TRAP ❑I have and will mainmin Worker's Compensation Imumnce,as required by Section 3700ofthe WhorCdq for the performance ofthe work forwhich Nis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN My Workers nyytitXpsnl u Ise carrier and Policy mm�lsn-nen^( Came, WG' Policy No.:— _, GAS-EA.SYSTEM-OVER 4(EA) CERTIPICATEO)HXI!MPTION FROM WOHKBRS' GRIiASE/INUUSTRL WASTE INI'IikCEPI'OR GDMPENSA'l'lGN INSURANCE BUILDING DIVISION MI S (This section men not b:completed ifthermil epis forone hundrtAdollars1S100) GREASETRAP nr less,) PIANCHECK FEE I remythat inme,ciformma'c ofthe work for which this permit is issued,l shall SEWER-SANITARY-S'TORM EA.21X1 IT. not employ any person in any intoner NO as m become subject to the Worker.,'Compere ENERGY FEE O z Nation Laws of Califomia.Date WATER HEATER WNENT/ELECFR GRADING FCai z O Applicant y NOTICE TO APPLICANT:IL mm,o aking this CmificmIs of Exemption.you.should WATER SYSTEMaREATING F-^ > Nome suhjml Q,the Worker's Cmnpcnstdion provisions of the Labor Code.you must SOILS FEE fonoviN comply with such previsions or this permitshall be deemed revoked. WATERSERVICE ILI Ou Q Qz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM B. SQ.FT. PAID Date ReceiplM V zIhereby affirm that is a constmction lending agency for Ne performance of the work for which this permit is issued(See 309],Civ.CJ C F' Lenders Name TOTAL: V Lender's Address TOTAL: LTJ i BUILDING PEE 1 certify that I have rend this applicationnnoand linin thatccs the above information is fa/) mildingagree.comply with all andcountyctatemwsremtngm QTY. MECHANICAL PERMIT FEE V z building conswaion,and hereby amhorire repreunmtives of this city to timer upon the SEISMIC FEE tbrve-finuioned property for inspection moi PERMIT ISSUANCE (Win)ngrce m save,Indemnify and keep huonless the City of Cupertino against ELECTRIC HE Iiabilitics.judgmems.costs and expenses which mayor any way acemcagainnsaid City ALTER OR ADDTO MECH. in consequence ofthe granting of this penrout. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFbf) MECHANICAL FEE SOURCE Rf?GULATION,9, AIR HANDLING UNIT(OVER Front)CPM) CONSTRUCTION TAX Signature of ApplicaMConvacmr Dara EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Willthemplicuntof future building occupant more or handle hazardous material HEATING UNIT(TO 100.100 RTU) defined by the inn Municip9l.G'odc.Chapter 9.12,and,he Health and Safety CdSection 23532132(aa)])? f'.{/ HEATING UNIT(OVER 100.000 BTU) ❑Yes VENTILATION FAN(SINGLE RESID)MT.TAI PAID Will the licam or Foram buikho n, rel use c I or devices which Dam Receipt p pp gbIs a Area n BOILER-COMP LEI?OR 100.(0X)BT emir hazardous air comaminanrs as defined by Ne Bay Arte Air Quality Managemem District? / TOTAL: E]Yes n<, BOILER-COMP(OVCR IIXI,OW IiTU L JNt AI R CONDI I'IONER Ilwve read the haraudous materials rryuiremems under Chapter 695 of Ne Cali- ISSUANCE DATE fomis HeaIN&Safny CdIs.Se lions 25505,25533 m 25534.1 undcrsmnd Nal if Nc NEW RESIDENTIAL MECH.huildingdovs caneoty . cok do responsibility to notiy the occupat IfJ, t �us'InI emel� eem.CDate ISSUED BY: OFFICE