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00010171 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY U O a I C CITY OF CCPERTINO _ BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMmnc-MF,CHANICAL BUILDING'PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICA')ON SUBMITTAL DATE -owl flV_ATAZk gwp: OWNER NAMZA L�PHON` CONTRACTOR'$NAME: LIC NO'. ` AN LL !W_LV, ^L✓Cr/� L NIC CONTROLp CHITECf/E.NCINFER: IJC NO: ADD�RRIoESS: v1 ,, - ❑ yl �� G T+ C • p i '(b �L.I�Z'lV Iw r ll CONTACT: ,/.� C. PHONE: Q z '! ' r' BUILDING PERMIT INFO MAxk Fd�/�T ,C��' �71� q\CJ G'a� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB' MECH LICENSED CONTRACTOR DECLARATION QTY ELECTRIC PER IT FEF I hereby affirm that I am licensed d p of Chapter 9(commencing r _ JOB DESCRIPTION 0W�'Z with Svcdon]0W)ofD m3ofneBas a and Professor,Crile and my license is - RESIDENTIAL: T W O PERMIT ISSUANCE F n full force and effe El and ElKI'TCHEN REMODEL Is Liceme Cl' LContunaor ica �� Y APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE a, Date F.7us, ARCHITECT'S DECLARATION PANELS ❑MULTFUNIT ❑ L. STRUCTURA Z Om'Z I understand my plans shall he used as public records _ MODIFICATION OCZ4O _ ' LJPT02m)AMPS El INTERIOR 11 CHIMNEY REPAIR 4t:W Licensed Professions] 201-IOOOAMPS IMPROVEMENT [JSWIMMING POOLS - OWNERBUILDERDECLARATION OVER]Bob AMPS El BATH RCMODEf1REPAIR (]DEMOLITION p�CCLL¢¢11 a I hereby nflirm that 1 am exempt from the Carl mnnrs License Lvw home X O c.O following reason.(Section 9(131.5.Business and Professions Cade:Any city or country SIGNS ELECTRICAL ❑OI'HP.R r C h whah4.qu ce,a permit to anntiu.6 aim,Improve,demolish,m repair any amerce prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. }� ,but he is licensed pawrme,the pmvisionsofthe C.mmator',License Law(Chapter 9 a d with ](xro of 3.fineBusNeas and professions,coil. COMMERCIAL: O (commencing wi ). )or TEMP.METER OR POLE INST. LL y o c that he is exempt therefrom and the basis far the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION tDCI 4y Section 70315 byany applicant for a permit whjecls the applicant to a civil penalty of POWER DEVICES Ix fTENANT ❑FOOD SERVICE not more than Eve hundred dollars($500). IMPROVEMENT d pr',as owner Of the property,or employees with wager as their sole compensation, SWIMMING POOL❑LEC'TR1C will do the work,and the somemre is not intended or offered far sale(Sec.90g4,Besines, OTHER and Professions Code:The Contractor,License Law does not apply to an.weer of OUT SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through SQ FT. 0 his own.empmyees,provided Nat such improvements are not intended or offered for NF.W RESIDENTIAL ELECTR sale,If,however,the hadddng or improvement is sold within one year of completion,the S T.FLOOR AREA S/SQ.Pf. mancebrilder will have the burden of proving that he did not build or improve for par - paxa dr,nir). E]1.as t m TOTAL:twiner of the property,aexclusively announcing with licensed contractors to - 3� construct the project(Sec.70H,Business and Professions Code:)The Conduct's Ll- - cense Lawdoesnapp]ytosn ownerofproperty who builds or improves thereon,and ,QTY, j PLUMBINGPERMTT ' r or .FEE who contracts for such projects with a contract.,(,)licensed paramour to the C.ntrackr'a License Law. PERMIT ISSUANCE. ❑I am exempt under Sm. ,B&P C for this noses Owns Dam ALTER—DRAIN&VENT—WATER(EA) �} VALUATION WORKER'S COMPENSATION DECLARIII ARON BACK FLOW PROTECT.DEVICE ' N Q -i affirmnO© 1 I hereby arm under penalty.f Perjury one of the following declarations: A T/V l ❑Those and will mainmina Certifcme.f C.nsentm,elf-insurefnr Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. - STORIES TYPE CONSTRUCTION station,as provided for by Section 3900 of the Lobar Cade,for the performation of the work for which this permit is issued. FIXTURES—PER TRAP k1 have and will maintain Worker's Compensation Insurance,as required by Section ] .1 he LaborC.de,for the perffofr_ome,c of the work for which((this permit is issued. GAS-EA.SYSTEM-I INC.40 TTS OCC.GROUP (/^AP MyWorker'simp tt AnINTJf1ANl1�RJyPN..Y1'I 4 2y1 A GAS-EA.SYSTEM-OVER4 .A) w � CERTIFICATE Oit EXEMPT"ION{FROM WORKERS' COMPENSATION INSURANCE GRFASFIINDUSTRLW E]NITRCEI'TOR s ° v5I116DINO Di VISION=PEES (Thissectionneed not be completedifthe permit 1,feronahundred call.rs($100) s '- --" — or less) CREASE TRAP PLANCIIECK FEE Ioyancertify perac the perfourrear of hisrental isi,wed.lshall SEWER-SANT RV-STORM FA.2001,1'. nal employ any person in any manner C3, o hien m Ne W.rkere'Compen- ENERGY FEF ,Z sation Laws o lIn I Do WATER H ER WNENTIELECTR 70 Applicam /MI nGIQ�� l�f l —npc— GRADING FBF, q Y NOTICE TO APPLICANT:IL after making this CertlBnam of Exemption,you should WATE .YSTEMOBEATING H > became,object to the Wmkel,Conmeaverloe provisions file Labor Code,you must SOILS FEE - forthwith comply with such provisions or this permit shall be deemed revoked. W ER SERVICE - CONSem is acON LENDINGAGENCY agency F.W RESIDENTIAL PLMB. SQ.pp. PAID U 0 Date Receipt# I hereby is hthi that mere is s wn(Sec.30]ending agency for NcPerformance.f LIs tti the work for which this perch is issued(Stu.309'1,Civ.C) _ Q H Lender's Name - - _ 'TOTAL: Lender'sAdd TOTAL: I comfy the 1 have read this application and ,are that rhe been fieforrarramin I, BUILDING LEE II/j correct.1 agree to comply with all city and county eminences and state laws relating it, QTY. MECHANICAL PERMIT FEE V 2 building construction and hereby authorizerepresentativesofthls city to enter upon he SEISMIC FEE above-mentioned property for inspection purposes. 1 PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT PEE ]iabilines,judgnents,costs and expenses which may in any way secure against said City ALIERORADDTOMECH. to asequence of the g.he,of this pound. ' PLUMBING HE APPLICA T UNDERSTAN S AND WILL C PLY WITH ALL NON-POINT ' AIR HANDLING UNIT(TO IOd"CFM) MECHANICAL PEE • SOUR'G EGULA'i'IONS. r( j e ham\ f�'[Ci� 1I�r( oO AIR HANDLING UNIT(OVER 10,(100 CFM) CONSTRUCTION'TAX ignm red'Appl�/TNmma.r 1 f(!., 1. P(L.11 Ca '�I✓I DDD/ EXHAUST HOOD(W/DUCT) HOUSING MI UGAT10N FEE HAZARDOUS MATERIALS DISCLOSURE Willtheappheant or future hnifindgacramem,koin handle hazardous material HEATING UNIT(TO 100,000 B'TU) os dented by the Cupertino Municipal Gude,Chapter 9.12,and the Health and Safety - Code,Section 25532(x)9 HEATING UNIT(OVER 100,000 BTU) El Yes _ No PAID VENTILATION FAN(SINGLE RBSID) Date Reengs# Will the aircontaminacant or ts a building bc.uptmtuse Area Air Qualitineri or y Managices ement BOILER-COMP(3HP OR 100,000 BTI]) emit hazardous air contaminants as defined by the Buy Aren Air Quality Mnnngement TOTAL 8 2> Uistricrl E]Yes BOILER-COMP(OVER 100,000 BTU) /!!!ll������ o 1 have renhamd.ns d the rmaterials requirements tinder Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE �••'/f '/v. \f1 fomia HwIN&Safety Cada,Sections 25505.25533 and 25534.1 understand that if the NEW RBSIDENTIAI.SUCH. $Q.FT. boill d stice,,,:mly catenate,that itismy responsibilirymnotify eoe open[ - she, - ment,A Hien v hmetpri.r c.faCc lcam.f cdntp�eyi A J O vV weer or authorized agent Date TOTAL: ISSUED BY: OFFICE