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29367 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. /�9 (k•N^ /�J BUILDING DIVISION / A'P.KATION/PERMIT PLUMBING-MECHANICAL. -/ BUILDING PROJF.CI'IDENTIFICA'1']ON L 9 3 6! BUILDING ADDRESS: n� n V4� SANITARY NO. APPLICATION SUBMITTAL DATE/7 ATE e /„stir. er7`:no P�ran �/} . OWNER' NAME: (' PH NE: CONTRACTOR'S NAME: LIC NO' C 4 •O OIP"pi 7� O 040,7AR N/C CONTROL# ARCHITECT/ENGINEER: IC NO: ADDRESS: CONI'ACc PHONE: - BUILDING PERMIT INFO go �� �� 4�6 -606/ Consultant Fees Paid by Applicant(Inulol) RLLDO ELLEEC.T PLUMB MEEC�H Lek U 1� N LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC P17RMIT FEE 1 hereby affirm(hat 1 am licensed under re,itiam of Chapter 9(commencing JOB DESCRIPTION �nIZ with Section'1000)of Division3 ofthe Businessand Pmfessiane Cade,and int hoenmis V00 PERMIT ISSUANCE RESIDENTIAL ineClfull aamd effect ❑SFDWI. El KITCHEN REMODEL �U License Class Contractor onor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE �D a Dat[ Contmm L f. 27 ARCHITECTS DECLARATION ❑MULTI-UNIT ❑SODIFICTIO Z O`�,Tj my p PANELS 1 understand m plans he used as public records MODIFICATION OZ-M UPTO2011AMPS [I INTERIOR El CHIMNEY REPAIR 1:4LW Licensed Profeaaional 2014000AMPS IMPROVEMENT OWNER-BUILDER DECLARATION Com ION OVER 1000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION I hereby affirm ohm I am exempt from the Convmmr's License law for the O U following reason.(Section]031.5.Business and Pmfe.ssions Cale:Any city or county SIGNS ELECTRICAL. ❑OTHER which requires or permit to construct,alter,impmve,demolish,or repair any structure Y� prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL Cl RCUIT/M ISC. ythat he is licensed pursuant to Use Provisions of the Contractors License Law(Chapter 9 (commencing with Session 7")of Division 3 of the Business and Professions Code)or TEMP.METIER OR POLE INST. COMMERCIAL: L C oL that he is exempt therefrom and the basis lin the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION e 4• Seemed]03 LSby any applicant far, moiudlecl,Nnt m e applicaa civil penalty of POWER DEVICES rn ❑TENANT ❑FOOD SERVICE 11....yy not more thanfif the property. employees mpl 1,as walk.the ro n,nnn Tem)laves with wages cam tion SWIMMING POD(.ELF.CfRIC IMPROVEMENT CXCX FS Q ❑ p per r p r g cenva ill do the walk.and thestructureContra not intended offered Law sale(Sec.TB4a,Business OTHER 6'3$ and Professions Code The nses th Contractors License Law does not apply s if owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who Juts such work himself or through his own employees,provided nonsuch improvements me not intended m offered for NEW RESIDENTLAL ELECTR SQ Ff. sale.IL however.the building or improvement is sold within aneyecr ofcamplmion,the SQ.FT.FLOOR AREA So%FT. ",itif uile.) will have the bather of proving that he did not Wild or improve lm par- pas[of sow �7 ❑s1.un owner of me pmpmy,am exclusively connecting s with licensed contractors m TOTAL: d ave Lot the project(Sec.,,.. Business and rty who Wi GM.i Thc Contmcmr's- move p. nselawdmsn such with aof p ntru ty whosedfds mius to are thercanantl QT'Y. PLUMDINC PERMIT FEE OJ who contracts fm such Pmjats with a conmetorts)licensed famous to me Contrunars License Law. PERMIT ISSUANCE ❑ 1 run exemp under Sec. ,B&P C far this Taman Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION W �09 sO 7 WORKERS crju on DECLARATION BACK PLOW PROTF.Cf.DEVICE 1 hereby affirm under penalty of perjury one of the following dedmatinns: ❑Ihavaandwill mainmina Cenifcme of Conservmself-insure for Workers Comp•n- DRAINS-FLOOR,ROOF,All G.COND. STORIES TYPECONSTRuEnois .air..,as provided for by Section 37M of the Labor Ctdfor he performance of the work far which this permit is issued. FI%TURES-PER TRAP - ❑1 have and will maintain Workers Compensation Insurance,m required by Section 3700 of the Lubar Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AIN My Wnrkc' dos ' I t jCr end Policy numbc�y: a 1 GAS-EA.SYSTEM-0VER4(EA) Gruner. '-f��[Policy No.:�4O O `/ CERTIFICATEOFEXE MONFROMWORKERS' COMPENSATION INSURANCEORPASFANDUSTRL WASTE.INTERCEPTOR (This seaai. nuee dnm becampld ifthepcmtit is fm...hundreddi larsHIM) BUILDING DIVISION FEE or less.) GREASETRAP PLANCHECK FEE comity that in the primounce at work for which this precut i,oissucd.'no;Wl SEWER-SANITARY-STORM EA.2W FT. not employ any person in any mann o m the Workers'Compen- ENERGY FEE �.z added Laws.f Cdi e.Date yerpnea/ ate WATER HEATER WN[IMLEM Applicata ( _ GRADING FEE �© y NOTICE TO APPLICANT.If,after me(-ng this erifcate of Exemption,you should WATER SYSTEM/TREATING ^ s abeema,subject m the Workers Compensation provisions of the labor Code,you must SOILS FEE forthwith comply with such rovisiorm ormis Permit shall badmoved revoked WATER SERVICEgg L. 7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIALPLMB. SQ.PE PAID ' U 0 I hereby affirm that them is a construction lending agency for the performance of Data Rec' 1 O t•+ me work far which this permit is issued(Son.30y7,Civ.C.) Q !. Lenders Name r Q(I-r AL: L7 Lender's Address TOTAL: aI certify that 1 have read this application and state Omr the shave information is BUILDING PER rp- a 7iK/ rA correct.Iagree to comply with all city and county oNinunces and some laws relating to QTY. MECHANICAL PERMIT FEE building construction,and hereby authorize representatives ofthis city to enter upon he SEISMIC FEE ahova-meml.n W property for inspection proposes' 11 p a (WO agree to save,indemnify and keep hard less the City of Cupertino agar PERMITISSUANCE. ELECTRIC FEE O a3 liabilioi[s,judgmenos,costs and expenses which may in any way accrue agaimt mid City Af-TERORADDTOMECIT in consequence ofthe grunting ofthis permit. PLUMBING FEE !!JJ V APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'O IOp00 CPM) MECHANICAL FEE SOURCE REGULATIONS. a3 AIR HANDLING UNIT(OVER I RON)CFM) CONSTRUCTION TAX 36 gad Signature of ApplicanVConeractor Done EXHAUST HOOD fWMUtnD HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building resolution store or handle humidor,emend HEATING UNIT(10 100.000 BTU) as ciefinM by the Cupertino Municipal Code,Chapter 9.12,and the Health dad Safety Code,Section 25532001 HEATING UNIT(OVER 10LO 0 BTU) ❑Yes 7 N VENTILATION FAN(SINGLE RMID) PAID Will thea licam m fuwm buildin t uu n ui r nr device which Date Receipt M pp dbytheTi I pmrn BOILER-COMP OR IOgIX10 BTU) .11 JS emit hazmdous air contaminants as defined by the Bay Arca Air Quality Mamtgement TO'1'A DixWn9 ❑Yea FIN. BOILER-COMP(OVER 100,000 BN) I have read the haraodous demands requiem.under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE fomes Health&Safety Code,Satiom 25505,25533 and 255U.I undmstatd that if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have a tenant,that it is my responsibility to notify the occupant of me mems what/h/yt�st ha met prior m issuance of a Curti upancy. , O*rrormforoml agent at ~_ Date GG TOTAL: ISSUED BY: OFFICE