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99120084 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 110 CITY OF CUPF.RTINO BUILDING-ELECTRICAL. P 1Rb11T NO, ItU11,nING DIVISION APPLICATIONIPERMIT PLumnmc.mF:cunNlcnl. BUILDING PROJFILT IDEN'1'IF'IOATION BUILDING ADDRESS: SRNIIARY NO. APPLICATION SUBMITTAL DATE T OW>WS NAME,: �� PHONE, CONI' CTORS M LIC NO. /Add � —CO L'.0 3 Z Lam/ .P "�/ C3 2 N/c7 co TRGI.a GHITIiGT/ENGINEER: � C LIC NO: ADDRESS: ❑ CONTACT. PHONE: BUILDING PERMIT INFO 3 ) / Y ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLUMB MECH (a ❑ ❑ B? ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby afrom Nat 1 am liceosul under Provisions of Chapter 9(commencing JOB DESCRIPTION °oO with Sectimio)(ilofnivisiat 3ofthe Enuncsxand I'yficurba Code.and my'cense is fir ISSUANCE RESIDENTIAL Fad_ m full finite atldeBCrs'. S(I/ 0%GJ �S/'/ ❑SFOWL ❑KITCHEN REMODEL �UW) License Close LIC.M APPLIANCES-RESIDENTIAL. []ADDITION [SL�BING RE-PIPE ao<y Date— Conlrvdor ARCHITECTS DECLARATION O MIJLThUNI'f O STRUCTMODIFI RAI ATI6 T.❑m PANELS MODIFICATION 5w-Z IunderemnJ my plans shall be used as public records up TO 2(M AMPS pAIR �FO C1INTERIOROCHIMMINGP OL F.. l�c hittnxJ l'nJ'evional 201-1(X10AMPS RAI II REMEN'f CSWIMMINGPOOLS yydd OWNER-BUILDER exempt lion CLARAfION OVER 100b AMPS O HA'1'I I NIiMOUE1JRE1'AIR O DEMQLH'lQN O I hereby alum o That I am exempt firm rho Contnlemr's License city for the ❑CTHIB LL which reason.(Section]construct.1.0.Baxiner.imd ve,d moll Cnde:Any city cur county SIGNS 131.ECTRICAI. O which reyuiree n permit to nonthepiper,improve,demolish,Or repair any souclum statement That heslcensece,alsant to he the for f the Compach ctor'micfile se Lawdsmtctnol SPECIAL CIRCUIT/MISC. y thmmormcgwith Srsuamtmh)of Division ivions3nfthe Contractor's license Law(Chapter to 0 fm,he is iihourfa areioo]l..it of Divisi for of theeged essandmn.AyviolaMe7 or TEMP.METER ORPOLE INST. COMMERCIAL: 6 a p tL See he is exempt therefrom and N<basis for the alleged.,patent 9.Any violation of OTEN IILDG/ADDITION O DEMOLITION to Section 7031.5 by any nd"dianess($5n.it subjects the ppplicam macivil penalty of POWER DEVICES OIMPROV OFOOD SERVICE I mare than five bond"dollars my employees IMPROVEMENT ��O CLo Owner propcny,or is no[ moyceswithwagnasta,(Set. (M,L sale Busineson,s SWIMMING POOL ELECTRIC will dathework,cudthe so Ccreistm.nLicenscurmleredawdo(ansate(Sec.to an owner ❑OTHIiR and Professions Cede:The Comrannr's License Law Jces not apply m an owner n( OOfLEI'S-SWITCHES-FIXTURE' property who builds or improves Inc.,.,and who don such work himself or through his own employees,provided that such imprnvoinenta arcnot inrendeJ or nfercJ for NEW RESIDENTIAL ELEC'I'R SQ sale.ll:however,the building or improvement is stilt)within nncy or', cnmplUion,the SQ.17.FLOOR AREA S/SQ.IrI'. ner-buiHer will have the burden of proving that he did not build or improve IOr par Ms'of sale.). C I,as owner of the property,am exclusively contracting with licensed cnnlranors(11I OI L' coromet the project(Sec.]1144,Business and Professions Code:)Tho Contractor's LL ocnsc Law does not apply to he owner of property who builds or improves Theriot, it QTY. PLUMBING PERMIT FEE who commix for such projects with a co tramagM licensed pudunnuo the ContmnOYs License Law. I'1?BMD'ISSUANCE. 1 nm umai under Sec. .H&P C for this reason ALTER-DRAIN&VENT-WATER(RAI VALUATION Date WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penally of perjury one of the following declarations: 99001 — C l have and will maintain a Certificate ofCOnsem to self-insure for Workers Corruption- DRAINS-FLOOR,ROOF.AREA,CONE, STORIES TYPE CONS'I'RUCfION amino,as provided for by Section 37M of the Labor Code,for the perummnce of the work Air which this permit is issuedFIXTURES-PER TRAP 1 haute and will mormin Worker's Gmtticnsmion Insurance,es required by Seetion AL 3700nf the Lubar Co ,for performunu:�afd�tework for which this penneitho,1,1said, GAS-EA.SYSTEM-]INC.40UI'LITIS (CC GROUP �AI�O My War�au In �� hnlicy No 70 C1 GAS-E.A.SYSTEM-OVER 4 HAT 1p Cartier: CERTIFICATEOPE :MITIONIMOM WORKERS' GREASP/INDUSTRi.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES ('Thissatinn neW nor be compimed if the permit is(atone hundred dollmx(f 1(X11 GREASETRAP or less.) I'LANCHf:CK FEE I certify that in the performance ofthe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.210 FT. not employ any person in any manner to as Femme subject to the Workers'Counties- ENERGY FEE Oz amion Lanxt of Caffomia.Date WATER HEATER WNEWXLF.CfR GRADING ItiE z Applicant t.y t NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should Wq'IGR SYSTEM?RLA'1'ING SOILS Nifi h 5 become subject to the Workers Compensation provision of the Labor Cade,YOU mon WQ forthwith comply with such provisions Or this permitshall be,deemed revoked WATER SERVICE ^'--�•��,.,.,,,,,,,� CONSTRUCT ION LENDING AGENCY N17W RESIDENTIAL PI.MB. SQ.PP. PIT a z 1I to REcgip in 1 I hereby affirm that there is a conmmction lending agency funhe pertonnance d I the work for which this Permit is issued(Sm.30)].Civ.C.) L) Lcuder's Name TOT L } {)•l Lenders Address TOTAL: / I citify that 1 have read Ihw application and amm that the above information is BUILDING PE F It v0.: correct.I agree to comply withal)city and county ordinances and crate laws rolmingu, Q7y. MECHANICAL PERMIT FEE Ll VS Z building construction,and hereby authorize representatives of this city m enter upon the EISMIC FEF. ahm rve- urnioned pmpeny for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep ham less the City of Continua against h:F'L7AICI!P,P, liabilities,judgments,costs and penes which may in any way accrue against said City AL'IERORADDTOMECH PLUMBING FT;E in consequence of the grdnti (this permit APPLICANT UNDER NDS AND• ..COMPLY WITH ALL NON-POINT AIR HANDLING UNITOO 10,INNICFM) - MECHANICAL FEE SOURCE BEGUI. NS. ..c Lr AIR HANDLING UNIT(OVER 10,000 CFM) CONS'fRUC'HON'TAX Signature of Applicanl/Commctor Date / EXHAUS T HOOD OYMUCI') HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant Sunni or handle munitions material I]RATING UNIT(TO I00,(Nlfl BTU) art def rad by the Cupertino Municipal Gale.Chapter 9.12,and the Heahh and Safmy Code.Section 25532fa)^ I HEXPING UNIT(OVER 100,000 RTU) f� C Yes ON. VENTILATION FAN(SINGLE ftRSiD) PAID Dme Receiptp !7 a Wlithenppiicaamfoune building..ford use equipment ordeviCes whlCh. BOILER-COMP(JHPOR IW.INNI BTU)emmn it hrdnus air contaminants as def nod by the Buy Arca Air Quality Management 'TOTAL: District! C Yes No HOILF.R-COMP(OVER 100.000RfID I have mndlhe hurundoua matuiUEre maniacs under Chapter 6.95 Of the Cid AIR CONDITIONER ISSUANCE DATE BrnbtIdoes&r cLety Cade,Section25505,25539and255)4.I a.assay hIlvoifthe ry13W RES1138NTIAl.MLCII. SQ.IT. 12- Owner � J� C holdingaHccua ten emm Cudc e.Soefi nm,lhnl it 553 rtx 125:34.[[Understand thanrpanl of the requirements which must he and prior In issuance of Cenificate of Occupancy. Owner or amhorired agent Date TOTAL: ISSUED BY. OFFICE