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29420 (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 BUILDING PROJECT IDENTIFICA'T'ION HUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 230 CP-z�Fv__ OWNER'S NAMB PHONE: OaC'I'OR'SNAME: hd LIC Nq(O I ``(( NIC CONI ROI. ARCHITECT/FNGINEER: LIC NO: ADDRESS: ❑ C VT CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG' ELECT PLUMB MECH ❑ f� ❑ ❑ LICENSED GaNn ed order provisions UIiCof haps QTY ELECTRIC PERMIT FEE C C Z 1 m.Th affirm Nal I a3 licensed under oof sCode. 9 @ommencinB ]OB DESCRIPTION with face]1d effect. Division]of the Business end ProfessionzCode,and my limn¢is �O PERMIT ISSUANCE RESIDENTIAL: full force and effect. �(- m � ❑SFDWL [I KITCHEN REMODELFU U License Class Lia# NGL Dam Contranor API'LIANCI'S-RPSIIJENTIAL ❑ADDITION ❑PLUMBING RF.-PIPE F,7srs ARCHITECTS DECLARA'I'[ON PANELS ❑MULTLNI UT ❑STRUCTURAL OO+-7J- _ ed es public metals MODIFICATION Z—O 1 understand my Plans shall he act- ' UP'I'0210 AMPS L 1 �/ ❑INTERIOR ❑CHIMNEY REPAIR F��{ Licensed Professional 20]-IWAMPS IMPROVEMENT ¢y� (OWNER-BUILDER DECLAMATION OVER IfifI(IAMPS -+ Q 1 hereby affirm that I am exempt from the Contractor's License Law for the El BATH REM IR El DEMOLITION xdx 06 V following reason.(Section 7031.5.Business and Professions Cole:Any city or county SIGNS ELECTRICAL [:]OTHER B131LF' which requires u permit m cnn.stmct,utter,improve,demolish,or repair any structure low 0 prior to its issuance.also requires the applicant for such pemtinn file a signed statement SPECIAL CIRCUITIMISC Qthat he is licensed pursuant o the provisions of the Contractors License law(Chapter 9 (commencing with Secrion2(00)of Uivisinn7nf the Business and Pmfexsions Gulc7or TEMP.METER OR POLE INST COMMERCIAL: 6 y o C That he is exempt Nemfrnm aroma hesis for the alleged exemption.Any vedminn of ❑NEW BLDG/ADDITION ❑DEMOLITION uXl 4• Smsion7031.5 by any applicant for a permit subjeonlneapplionns an a civil penalty of POWER DEVICES EITENANT ❑FOOD SERVICE Py' not mom than five hundred dollars IS50po F=Q I,as nwaecol'the roes,arta lams with woes as heir snle cam nation. SWIMMING POOL ELECTRIC IMPROVEMENT '- . O ❑ th P et YemP Y B Fe F- will da the work.and Ncswmttrc is not intended orolTereJ for sale(Sec.71414,Business ❑OTHER W and Pndessions Code:The Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who dons such work him.selI or through - his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ F. 1 sass.If.however,the building or improvement is sold within one yeaofcnmpietion,the SQ.VE FLOOR AREA E/SQ.FT. nwner-builder will have the burden m proving that he did not huild or improve far put- + poseofcale.). ❑1,as owner of the property,am exclusively cnntruning with44licensed contmotors,to L amsuuct the project(Sec.74,Business and Professions Cole:)T1w Cuntracmr's Li- NO 1996 come Law does not apply In an own,Uf Property who builds or intprovesthemnn,and Q'TY. PLUMBING PERMIT FEE, who contracts for such projects with a contractions)licensed pursuant to the Confiscates C"Y License law. PIiMMIT'ISSUANCC Ul- VVI-LTII JOV ❑lam exempt under Sec. ,B&P C for this mutat Owner Dae ALTER-DRAIN&VENT-WATER( VALUATION WORKERS COMPENSATION DI?CLARAI'ION - BACK FLOW PROI'ECK DEVICE I M1,eby affirm under peatilry of perjury one of Ne following dalarations: ❑Ihave andwill maintain oCenificam efConsem to self-insure for Workers Comped- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION sation,as provided for by Section 3700 of the Labor Code,nation hperfintnanco of the work far which this pemtf is issued. FIX'1'ORES-PERI RAP I have and will maintain Workers Compensation Insurance,as required by Section - 7700 of the labor Code,for the wrtormance ofthe work for which this permit is iexged, GAS-EA,SYSTEM-]INC.4 OITITIIS \ OCC.GROUP APN Myrier. ©Unlcnsvtl0uWauWn�eearzie Policy No,Y Maniac l7 LQ•Q.1gW GM)L�ig�3 GAS-EA.SYSTEM OVER 4(EA) CERTIFICATE OP EXEMPTION FROM WORKERS' OHIiASF%INDUSTRL WASTE INTERCEPTOR INSURANCE (This section need not becompletcl ifthepentat is fosse hundred dollars(SID(d) _ BUILDING DIVISION EEE$ I or Less.) GREASETRAP _ PLANCHECK FEE (certify thatinin performance my Nework linwhich this the W rkent'Compel- SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner sn as ns became subject m the Workers'Comped- ENERGY FEE Qz varied Lows of California,Dare WATER HEATER WNENTMLECTR z Q Applicant - GRADING FEE NOTICE TO APPLICANT:IL after making this Cenificate at lixemplinn,you should WATER SYSTEM?HEATING become subject to Ne Workers Compensation provisions of to labor Code,you must SOTS FEL? w+ forthwith comply with snch provisions or pnnnil sinal to deemed revoked. WATER SERVICE UJ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID U O l hereby affirm that hem is a conmrucdon lending agency for the performunceof Data Receipt# Fthe work for which this permit is issued(See.7197,Civ.C.) U Lenders Name- TO'LAU I[I Lenders Address TOTAL: y Nat 1 hove r d this applicminn and seam Not the abnrc info minion is BUILDING ME V) come,.l agree it)comply with all city and county ordinances and state laws relating m QTY MECHANICAL PERMIT FEE U 4 building constmction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE abro o-luentionul mpen,for inspection purposes. PERMIT ISSUANCE (We)agrte to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PL•E liabilities,judgments,onus and expenses which my in tiny way accme against said City ALTER OR ADD TO MECH. PLUMBING FEE inconsequence of the grunting of this permit. - APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB000 CIM) 50'lC GGLATIONS. MECHANICAL FEE �A .�9d NII IIANDLINO UNIT(OVI?R III,IXIII CPM) CONSTRUCTIONTAX Si real tumofApplica Cantnctor :'S—/bite EXHAUSTHOOD(WMULT) HOUSING MITIGATION FEF. ZARDOUS MATERIALS DISCLOSURE Will to applicant or future building occupantemre orhnndlebsouri us material HEATING UNIT iTO 100,000 BTU) as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety Cade,Section 25532(x)'! HEATING UNIT(OVER 100,000 BI LD ❑Yes 7 N VENTILATION FAN(SINGLE RESID) PAID Will the applicant or future building occupant use equipment or devices which Date Receipt# .club hmmdous it condominiumsasdefined by the Buy Arca Air Quails,Management BOILER-COMPQHPOR I00,000BIM) - District? TOTAL: ❑yes Fl No BOILER-COMP(OVER 100,000 BTU) lhaverxaxl ma nducifidlemphiremmuseader Cho plot 6.95 of Ne Cali. AIRCONDI'DONER ISSUANCE DATE fomia Health,&Safety Code.Sections 25505.25533 and 25534.1 understand Nat if the EJ NEW RESIDTIAL MECH SQ,14. building dsns nal cuaen0y have.amain,Nm It is my re,towihilhy Family Ne nompont of the requimm tubi which must be met prior m issuance ofit Cenificme of 0ccopare, Owner nr uuthnrimJ agent Data - TOTAL: JSSUEDB OFFICE