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31171 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINOd I UILDING-ELECTRICAL .RMI'r No ,..BUILDING DIVISION ,.x$�470APPLICATION/PERMIT PLUMBING-MECHANICALz. 31171 BUILDING PROJECT IDENTIFICATION DDRESS 1 pp��L �� SANITARYO.NAPI LICATIDN SUBMITTAL.Lim OWNER'S NAME _ PHONE: ACI ORS NAME - LIC NO:'Movil - NIC CON'I'ROI.x CHf1'ECTIENGINEHR: LIC 'SS: � q ) t E SSmG � G O'I Z(o!v vrVV CONTACT:L( `•�I(TI P�SNtE: BUILDING PERMIT INFO J11� 113 Consultant Fees Paid by Applicant(Initial) ` B�jJ�[I I•N ELECT PLUMB MF:CH F) SSq- 2n Z2 / ` LICENSED CONTRACTORS DECLARATIONQTY ELECTRIC PERMIT FEE x 41I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION "Z with Sectinn]IXNp of Divisinnlnfthe Business and Pr.fesxinns Cade,and my)teen>e is OO in full buce and effect. PERMIT ISSUANCE, IDENTIAL GF U U License ChowsLic.p WL C1 KITCHEN REMODEL NzW Dae Cameron APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE A RCH i'I I?CI'S DECLA RATION ❑MULT-UNIT ❑SI'RUCfURAL z0a,z Iunderstand my phim,hall be used as Public immol PANELS MODIFICATION OZ—O UPTO200AMIS ❑INTERIOR ❑CHIMN17Y REPAIR F.E'W Licensed Professional 2111-I(NNIAMI'S IMPROVEMENT aa'CC� OWNER-BUILDER DECLARATION OVER IIXpAMPS CI BATH REMODEUREPAIR FI DEMOLITION yy �Q 1 hereby affirm that 1 am exempt form the Common"'License Law for the pe 3 d F 11,11—in,reason.(Section 7031.5.Business and Professions Code Any city or....mySIGNS BLBCIRICAI, C1 OTHER YY11 u.y which requires o permit to emi,ma al¢r,improve,demolish.or repair any swctum a ,F[,4to prior in its issuance.also requires the applicant for such permiuo file a signed Sentiment SPECIAL CIRCUIT/M ISC. sssss �.� to.'heisliceaalporan,1.ehepnrvmmnudeh.Cnntracmr'sLienselaw(Chnprsr9 REP 0 6 2( 01 S/-OWL CC OO fcommencin6 with S«'ion l0olq of Division3ofine Business and Prnlbssi...Code)no TEMP.METER OR PULE INST, COMMERCIAL 1qx c C 'hal he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Way Section703 L5 by any applicanl tin.perunt suhiecte the applicantto a.ivilpmwlry of POWER DEVICES R1 III I ENANT ❑FOOD SERVICE 'more than five hanJ¢d dollars($50(). ~ C ❑I,as owner of the pmpcny.or my cmpinyeeswithwages¢s theirsole compensation. SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the smamm is not intended or offered for sale(Sce 7044,tlusiness ❑OTHER W and Probes....Ede:The Contractors License law does nm apply m an owner of OU'rLEI'S-SWITCHES-PINT'GRES 6 3^ properly who builds or improves thereon,and who docs.such work himself or through his awn employees,provided that such Improvcmcros am not intended or offered for NEW RESIDENTIAL ELECTR SQEf sale.If,however.me building or improvement is sold within one yew of completion.the SQ.FT FLOOR AREA $/SQ,FII owner-builder will have the burden of proving that he did not build or improve for par- •�y �T cofsaleJ. _ I 1 •1 �/ 5 19 �J•� I,its owner of the pmpehy,am exclusively mwrnw noong with licensed ncom,u' �II441 W� o.memn the project(Seo.7044.Raine.,and Prnresxi...Coal The Camrvcmr',Li- Z Cif Q 2 ".� • ceou Low does not apply to an owner of property who builds or improves do,mo,and QTY. PLUMBING PERMIT FEE ismeomracest ch pmjecrs withuttsmramortsl licence)pursuantmme Conuacior'n ❑ Ire a in , crS ,B&P C for tbleresun PERMIT ISSUAN Dam ALTER-DRAIN -V"I'-WN ' (EA) VALUATION W RKER'S ( PE ION ECLARATION BACK FLOW PR TE ICE 1jelIhemny affirm under Panaltyo(Purjuryone the followingdeclaceeion \O O Ox O l have and will mountain aCenifica,ofCamsenttowlbinmm for WorkersCompcn DRAINS-FLOOR.R AN STORIES TYPE CONSTRUCTION saran,as provided for by Section 3700 of the labor Cade,for the performance or the work for which'his permit is issued FIXTURES-Plitt TRAP 1 have and will maintain Workers Compensation Insurance,a required by Section 37W orthe Latin Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.40UTL I I txy�C.GROUP APN My Workers Conspenrnnm sa'ion lmacarrier end Policy needier are: rt(.- I 1 Cartier: Policy No.: GAS-G.SYSTEM-OVER 4(EA), I1I(n�'' ?0—/O— CERTIIICATEOFEXEMPTION FROM WORKERS' II V� COMPHNSAI'ION INSURANCE GREASIYINDUSTRL WASTE INTERCEPT ('Ibis section need not be completed ifthe permit is for one hundred dollars 1$100 ) UI V ISIfIN PI9iS or less.) GREASE TRAP ),I71j.ON CK � certify thm in the perfnnnance of the work for which Chic pcnuil is:seal,l shall -anot employ any perm.in any hemmer so as m section,subject mine Worker Compen- SEWER-SANITARY-STORM P,A.201 FEZ Seton lawsofCaliferaw.Date WATER HEATER W/VENT/ELECIR'��-- Z O Applic.mIN FEE NOTICE TO APPLICANT.If.after making this Certificate of Exemption,you should WATER SYSTEM?RWING become subjectto the Workers Compensation provisions of the labor Code,you mus' FEE Iirlovahemnplywith,nch,ro,i i.,u,dr,Permh doill be dimmed rxvcdcd. WXIFk SERVICE a � CONSTRUCTION LF.NDINGAGENCY NEW RESIDENIAL PLMB. SQ,FC PACO U O Inm.ny ammh the,retire ixawnwae.n lmmhng ag.mmy for the perrtinnnmme ar otic Nemdpta D. '•' the work far which ark permit is i...ed(Sec.3091.Civ.C.) O L) Lenders Name TOTAL: W Isndmr'a AJdrexs T I f.:' CL 1 cenify that I have read this app)icaeion and state that the above information is BUILDING FEEAFE correct)agree to comply withal)city and county ondinanca and state laws relating to QTY. MECHANICAL PERMIT FEE buildingeonstruction,and hereby aahorim repmsenwtives ofthis city m enter nPw the SEISMIC FEF,above-mentionedpropertyfminspectionpurposes. PERMIT'ISSUANCE(W'e)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE Iifbilon.,.judgmenO.coaswd cxlwnsere which may many way.c,r.e againn.mid City ALTER OR ADD TO MECH.in consequence of the gmntng of this Perrin. PLUMBING I>EE APPLICA UNDERSTANDS AND ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,000 CFM) MC:CHANICAL FEI3R: AIR HANDLING UNIT(OVER 10AX)CPM) CONS'rRUCr10N TAXSi w er p ommcmr Ila. EXHAUST HOLD(W/DUCIIf10USING MITIGATIONHAZARDOUS MAI'IiRI .S UISCLOSURF, Sol Will theapplicznlorfuture building emulator sm¢ur handle haaNtia.material HEATING UNIT(TO 100.00p BTU) as ddincd by the Cupenino Municipal Gale,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? HEATING UNIT(OVER I(X),11IX1 BTU) ❑Yes Fl No s/��,...y�LLc� VENTILATION PAN(S INGLE NESID) PAID Will thea heart or future bulldm 'use. a fA14T1¢x which Dole Receipt x emit Rwandans a�anmitments as defined by the Ama Air n BOILER-COMPOHP OR IW,000 BTU) e Diwric'l Y Y Mir Quality Management TOTAL: [DYet F-1 No � BOILER-COMP(OVER I Oblast BTU) r, q AIR CONDITIONER I have read the hwaNnus materials requiremcntx under Chapter 6.95 oft' ISSUANCE DATE .in][ It &Safety Chile,Secti15505,25533 and 25534.1malerstandmmt elm NEWRESIDENTIALMECH. SQ.IT.ter 'F nmcmremny have a' era it is my re.pon.mifity to notify me recupant rteinrmissmncc afaCenificutc of Occupancy. ,.,.at wou gem Date 1-. till I ISSUED BY: OFFICE