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B 0118 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 7SANN,11 0118 BUILDING PROJECT II1EST IPICAT'ION NO. APPLICATION SURMI'17AL URE OWNS 'SNAME: HONK: CUNT' CTURSNA iCON'I'ROl.a�AR.I ITEClUENGIWER: 1 LIC©: AD RESS: Y C(1'I'ACT: 'I'U(�)rIN I!2: p� BUILDING PERMIT INFO�A .{/J(ViT7� ��� l'J'-O`er-- ❑ Consultant Fees Paid by Applicant(Initial) If1.DG it ECT PLUMB MECH CIY C� E11— P-' oLICENSED CONTRACTORS DECLARGI'ION QTY. ELECI'R IC PERMIT FEE J06 DESCRIPTION 1 hereby affirm that 1 am licensed under previsions 01'Chapter 91a+mnancing ,pZ with Section70(1 Division 3..f the Business and Profeasiam Cadomal my license is '1 RESIDENTIAL: PERMIT ISSUANCE .,J c in full firce and cRect. ❑SFDN'I. ❑KI'ICH6N RF.MODEI. aVZV License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPH IQW Dae Common, ❑MUI:I'1-UNIT ❑STRUM URAL A 911 TELT'$DE'.ARATION PANlilti zpm2 I 1 yPla sk a, Boli.records rI O MODIFICATION m— I UPT020OAMPS L-� ❑INTERIOR ❑CHIMNEY REPAIR OZ�Q IMPROVEMENT SWIMh11NG POOLS �,��Yl L' 201-1000AMPS ❑ Sy; OWNER-BUILDER DECLARATION OVliIt IIIINIAMPS El❑BAIItREMODPIIREPAIR ❑UEMOU PION t+-¢ l he a0trm Ihat I tun exempt from the Cortracna-,License I.aw for me X O a V following n.IS 7031.5•Bminecs and Prot inns Cock Any city or county SIGNS ELECTRICAL W 3<L N which re ire sa permit m e.mmla,alter.impmsc.demolish.or repair any swcwm F-�C¢ prior In its issuance,also requires the...heart lbrsurh permit to file usignedumemem SPECIAL CIRCLE VMIS mut he 1,licensed puramlmn 1111 prorninmonhe Contractor'I license L.,,Chapter COMMERCIAL ...GO (commencing with Section 91XX11 of Division 3111 the Business and Pilmsinns Cdgnr TEMP.MI!'fl!R OR MIX a a e C the he is exempt dwmfrom and the basis for the alleged exemption.Any vinlaion of ❑NGW'BLDG/AUDITION ❑DEMOLITION �m Section 903 1,5 by any applicant for a Permit subjects the applicant to a civil Penalty of PO ER !VICES ❑TE:NANT ❑FOOD SERVICE ZCnot on than five hundred dollars Sign, IMPROVEMI?NT LL� Q I,its owner Of(Ile on a property. nYemIII'w wages as their sole conmcmrdou. S MINGM)OLI!LT HUC 1-. willdnthewnrk,andthestree,umisunm ltendednroffemdl'nrsale(Sec.9W4.ILainess ❑UTHI?R i 3 m and E'rofessior,Code:The Commarm's License CO.docs not apply m on owner of Otll'L. - I'1'CHIS-PIXY RP / -- propeny who builds or improves thereon,and who does such work himself or through Mre s own employees,provided that such improvements onot intended or offered for NEW RI!tiI L EL[CTR SQ Ff. ,III,It.howe.cr.the buildingnt lnpnwcircnl is sold within one year of completion,the SQ.PT.I FLOOR AREA YSQ.FT. crbuilder will have the burden of proving that he did not h..dal or improve for pur- poseofule.Y T 'AI/: ❑1,as owner of the propeely,an,exclusively continuing with licensed contractor,to construct the project Sce,90W4.BUsinesa and Profession Cude:l The COnvaoto/s Li- on scLawdoes not opply'o un owner Of property who hold.or itnpravcahemon.and QTY. PLUMBING PERMITFEE who eounwis for such projects with u conuuchan)licensed puoram In the Contractor's License Law. PERMIT ISSUANCE ❑ I am exempt order see. .R&P C for mi.reas..n AL'I[R-DRAIN&VENN-WATI!R(EA) VACUA*[[ON Owner Due `n O WORKER'S COM PENSAI'I on DECLARATION BACK Iq.OW PROTECT.DEVICE (J/( Q o 1 hereby d%BE mai under penalty of pe jury one of the following doelWater', �Ihave and will nminlainaCcrtificmro(Cnnsem mself-insure for N'rrkds COmpen- DRAINS-FLOOR.BOOK AREA.LONG, STORIES TYPE CONSTRUCT IC sntioa as provided fur by Seaian 37M of the Labor Code,lir the performance of the ark tit which Ibis permit is issued. iXTU N ES-PERI RAE' CV ❑1 I...c and will maintain Worker's Compensation Romance,as required by Section 1 INC.J OUTLISI:S 3700of the Libur Cale•fonhe Pcdmmormif the work for whmithisGAS-EiA.SYSTEM- pearch is issued. .GROUP ,/a-(,-sAPN /M My Workces Compensation Insurance carrier and Policy number am: GAS-EA.SYSTEM-OVER 4(EAI JJ ' aaU� Came,: policy No.: CERI'UgCATE Oil EXEMPT[ON FROM WORKERS' GREASEINDUSI RL WASTE IN'I'HIICEFOR - COMpENSATION INSURANCE BUILDING DIVISION FEES (This section need not M vocaletd if the Permit is future hundarldollam(SIM) GRFASETRAP N ' 'CK FM mlcss) Ia,anythalnlhn perlormanttol, ,,he work to, e,alWthis o the W,isismeounall SEWIiR-SANITARY-STORM EA.21N1 FT. Mol nnpinY any,,on in any:runner su ns m he'Umcsuhjeet m the Workers'Cntnpeo- 1Y FEL! QZ cation hxs of California.Dale W'AI'ER HEATER W/VENT/ELECTR ) AGING FEE Z O Applicant ' NOTICE!TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMMR17ATING SOILS FEE F +N" becona subject In the worker's Compensation precision ol'the Lahr Code,you must Ii:nloinda imply with such I...rion-ad ispennit shall he drenmdrevoked. WAT his SERVICE 0 a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB, SQ.IT. P U ,= Z Date Recciptp L) p Ifor whihthisthatemcm issued(Seeliminac.3097,ding agency lOnhe pertnrmancc of p � F the work for which this permit is issued(Sec.3092 Civ.C.) N T( qL OULender's Name �l Lender's Address BUILDING 1411! , d 1 certify that I have mad this application and state that the above Infortnmion 1s u +F. EA cmmiu.lag.rl comply with all city and county ordinances and sum laws relating to QTY MECHAIGLC/ArL PF;Rh11T � 91 FEE SEISMIC / g U z building communion,and hereby mnhorim onesurtativesof this city m enter upon the aMrvo-mcntioncd prnpcny Gr inxpcclion...Pose,. PPRMI'I ISSUANCE! E11C' Cilit2 (Wq ogrce m vve,inJemni(y keep harmless the Clty of Cupertino again... liohilitics.judgmems.costs and expenses which may in any way oceme agoinzt wid Ciry A I!R OR ADD'B,MECH. 'Lt R GFEB in corsquence of the gramingy s eas APPLICANT IINDE!RSTANUS ANI WILT,COMPLY WITH ALL.NON POINT AIR H DUNG UNIT(70 lfylag)CFM) N It CAI,FEE SOURCE E(' A'I'IONS. AIRUANDL G UNIT(OVER 1O.h)0CFM) C S'T CfIUN'I'AX Squaw f Ed C mu Dare E- I AUSTHOOD /DUCT) ;1'G MITIGATION FEE IIA ARE(GS MATERIALS DISCLOSURE E' appllcan Irl ilium huildin.......puntsmrcut handle brounlnus mmcdal HEATING UNIT TI()LIN, HI II'IVI as define y me Cupe"mr,Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER IM. I Cate,Section 25532fap ❑Ycs FI No VENTILATION PAN I SINGL 7 ESI PAIL Fac Receipt R«cipt a Will the upp1 coal or l inure bmkftacgucevpma use cgnipmenur devices which BOILER-COME(3111, fft,ow pre) t hasurdous air nmtaminems es defnW by the Bay Area Air Quality Managemcm U'AI-: Distria'2 BOILER-COM VER 100.!X10 BTU) ❑" ❑Nn AIR CON IONI!R ISSUANCE DATE ))lave rcuJ IM1c havrJnus n� •yuircmcnls under Chapter b95 nl the @li- E Email Health&Safety Cade.Suns 25515,SS.ii unJ 2553J.1 unredeemed tha if the NE ESIDENTIAL MECIL SQ,IT. I:uildingdoesimicamendyhamaerantt tit ix my respnnsihility ro notify the occupant nfinemqu' nen Ichmusthe t nnissuanee of a Certificate Of OccuWn<Y. `��(>� //.�1 Owner,, Mori J cot nmc '1'(YTALI ISSUED tlV✓�� ! ' OFFICE