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S 1344 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPF.RTINO BUILDING-EL RUE RICA], PE IT NO BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 1344 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE WNER'SNPME: PHONE: CONTRA 'OR'S NAME: LIC NO: - N/C CON'East.X a C lU i ARCHG'ECI'/ENGINEER: LIC NO: ADDRESS: SY/0 h1 oi 64 CONTACT PHONEE BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT L MECH LICENSED CONTRACTOR'S DECLARATIONQTy ELECTRIC PERMIT FEE 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION WOO p WOO with Sectio,TlXgpd Division 3 oflhe Business anmmrs e.anPBHMI r ISSUANCE d PressiCuddery lieresols RF ID .NTIAL: NW invert f(,rlass e0ua. ❑SFDWL El KITCHEN REMODEL CUE License Class Lic.p If Q U API'LIANCIS-RIiSIDEN'TIAL [I ADDITION F_ a, PLUMBING PIPE H W Dale ❑MU:r-UNIT ❑STRUCTURA ARCHOECT"S DECLARATION F_p m PANELS MODIFICATION Z p 14 Z 1 undemmnd n,y Pl:ms shall be usuJ as public records OZ140 UP TO 200 AMPS El INTERIOR [I CHIMNEY REPAIR F�.F.W Licensed Professional 301-1000AMPS WPROVEMENT 0SWIMMING POOLS ak .4OWNIER-BUILDER DECLARATION OVIiR HIW AMPS ATH REMODEUREPAIR El DEMOLITION K Q I hereby if,.In.,I um exempt from the Connector,License law for the aqqa55 a.U following reason.(Section 9031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER t++'3i ti which requires a Permit to construct,alter,improve.demolish,or repair any stmm rre N E,01Q prinnniH issuunce,uhn reynireslbc upplicnm for such Aconin(,GleasigneJ smtement SPECIAL CIRCUIT/INISC. $iMy; That he i,licensed pursuant to the previsions of the Conlmcmrs License Law(Chapter 9 00 lcommencm,with Section 7000)nl Division 3 of the Business and Pmfessinns Ced0e, TEMP METER OR POLE INS, COMMERCIAL 1++ 11 y e C that he is exempt therefrom and the basis for she alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION Section 9031.5 by any applicant for a perronsubjens the applicant to a civil penalty of POWER DEVICES C1 TENANT ❑FOOD SERVICE xzOnot more than live hundred dollars(§SaB. IMPROVEMENT ❑l,as(,wooer ofthe pmpcny,or my employees with wagesu+Wcirsole compenmtion, SWIMMING POOL ELECTRIC g. will Jo the work,and the structure is not intended oroftared for sale(Sol.704,1.Business OTHER Y a. and Professions Code:The Conusctors License Law does not apply to an owner of ou rLIETs-SW i kilt:S-17IVrUR[z.S pospeuy wM10 builds or improves eluant,and who docs sorb or himself or through his own employees,provided that such improvements ate not fare.cd or enercd for NEW RESIDENTIAL ELI7CTR SQ FT. sale.If.however the building nrimpmvemem is sold within one year ofmmpleies'the SQ.FT.1100R AREA S/SQ.F1'. ur-builderwill have the burden of proving that he did not halt nor improve for par- !1 p W � D "tofxolef. 1� ❑Lax owner of the property,am exclusively con meting with licensed cmnracm0 m 44 TOTAL: amarum the rosiest(Sec.9044,Business and Professions CTed.;. 11.C(,nlmetoLIt- ��� se Law does nm n open apply,(,uwner of proy who builds or improves lherron,and QTY, PLUMBINrPE FEE O AS who contracts for such projects with a commands)licensed auauantto the Counselors / License law. PIiRMH ISSUANCEkr`'7e /RYA 1 (jr ❑ Ism exempt under Sec. ,R&1'C forthixreason ALTER-TRAIN&VENT'- :R ) VA, Owner Date (7� WORKERS COMPENSATION DECLARATION BACKFLOW PROTECT,DEVICE �'\1 �— Ihereby afG,m toiler penalty of perjury one of the tollowing decimations: d X • I have and will maintain a Certificate of Coi or,self-imsum for Weekers Cooper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPIE CONS1'RUCTION smiun,as pmvicial for by See...391X)of the Labor Code,lar the pc,fonnonee of the work for which this permit is issued. FIXTURES-PER TRAP E]I have and will maintain Workers Comperandom Insurance,ua required by Section 370(1 of the Labor Cade,for the performance,of the work for which this permit is issued. GAS-EA.SYS FEM.I INC.4 OUT OCC.GROUP AIN My Workers Compensation Insurance Caner and Policy number art: Cartier. Policy No.: GAS-EA.SYSTEM OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL WASTEINTERCEPTORCOMPENSATION INSURANCE OR DIVISION LEES (This section need mol be cnmpldal ifthe peomit is for(,nc hundred Jr,llurs(§I(p) GREASE'I'RAP m it..) PLANCH[CK FEE I artily thus in the acrhmnance of the work for which this psoas is issued.I shall SEWER-SANITARY-STORM PA.200 FT. ' ' kENERGY tiF nn,emploanypersoninnymanneoy Isublect t the WoresCo.,.- z s WATER HEATER WNINTELECTva Applicant C�'1��ssyly� fiL !__II'� GRADING IrEli NOTICE TO APPLICANT':If,after baps rg Nis Certificate of Exemption,you should WATER SYSTIEM/TREATING - a ; become subject to the Worker's Compensation previsions of the Labor Code,you must SOILS PF:IE {A forthwith comply with such provisions or this pemrit shall he deemed revoked. WXI'ER SH RVICE CONSTRUCTION LENDING AGENCY NF.W RLSIDE N r1Al.PLMU. SQ.FT. PAID CU I hereby affirm that there is a construction lendingagency for the performance of Dam iptp the work for which Nis permit is issued(Sec.3099.Civ.C.) .TOTAL OLenders Name TOTAL: U Lenders Address Ly, 1 certify that 1 have real this application and sole that the abwc inferruf n is BUILDING FGF, correct.)ug. ,,comply withall city and cauntyardinance,and state laws ofding 'I Q'PY. MECHANICAL PERMIT FEF, V Z builling rourambron,and hereby indicates,streseninive,of Ibis city m th cuts,upon e SEISMIC PEE ahuve-mentioned propeny for impecti en puHrmes. PERMIT ISSUANCE (We)agree to save,indemnify and keep Tombless,the City of Cupertino against ELECTRIC Fl; Iiibilnies,judgni costs and expenses which may in any way same ugainvl said City ALTER OR ADD'[0 M I!CI I, PLUM RING FEE r,evarn coot he gruntingofthi,permit. APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO UT0O0CFM) MECEIANICA14F E SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 11,1100 CFM) CONSTRUCIDO �ian taXX �,(�Q/ 3l n g S,pmaw fAp canVConaachn f 11bou EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant nr(mere building nccupanl surrour handle haradous material I IEA'rING UNIT(TO 100,00()BTU) as defined by the Capsular,Municipal Cade.Chapter 9.12.and the health and Safety C(,da Sixion 25532(.)9 HEATING UNIT(OVER 100.0fMI BTU) ❑Yes [D No VENTILATION FAN(SINGLE RESIDE PAID Dam Rcccipt X Will the applicant or future building occupant use refrained,or devices which BOILER-COMP(3HP OR 100,(M1U BTU) emit Tormentors air contaminants as defined by the Bay Area Air Quality Maragemm�t TOTAL: Dishier? BOILER-COMP(OVER 100.100 BTU) ❑Yes ❑Nn I have mad the hazmdeas mu als,cquiremems under Chapter 6,95 of the Cali- AI R CONDITIONER ISSUANCE,DATE forms Health&Safety Code,Seamus 25505,25533 and 25534.1 underxmnd that if the NEW ii DENI'IAL PIECE I. SQ.FT. building does not currently have a moan,that it is my responsibility to notify the occupant of Ne,requirements which must bo met prior to issuance of a Certificate of Oecupmrry. Owner or nutharimd agent Dace TOTAL: ISSUED BY: OFFICE