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31222 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY'aOF CUPERTINO - BUILDING-ELECTRICAL. PERMITNO. /�/�/N BUICDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL L L L BUILDING PRIpECT IDENTIFICATION BUIL DING ADDRESS: - SANITARY NU. APPLICATION SUBMITTAL DATE o OWN�R'NAME PHONE: V CONTRACTOR' NAME: �! N/C CONTROLN RCHITECT/ENGINEER: Z LIC NO: qUD S5: ❑ • D f� �uoLl CONTACT: PHONE:, BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT• PLUMB MECH ❑ ❑ P ❑ LICENSED CONnsedma make DECLARATION QTY ELGCI'RIC PERMIT FEE I hereby affirm that I..licensed under provisions of Code,r9(cam come ig JOB DESCRIPTION {QyaO wifullfinn ndeffec Division 3nl the Business nnJ Professia«s GJc.and my license is F�Oin full f,Class effect. PERMIT ISSUANCE R._ (DENTIA r �VUF Limns Class Lie If _ ❑SFDWL ❑KITCHEN REMODEL ,F U Date Counselor APPLIANCFS-RESIDENTIAL. []ADDITIONP_ LUMBING RE-PIPE N W p,PN ARCHITECTS DECLARATION O PANELS ('' - ❑MULTLUNIT ❑STRUCTURAL. Zprr�Z IundcrswnA my plane shall be used as public records MODIFICATION OZ—Q UP'1'02WAMPS ❑INTERIOR ❑CHIMNEY REPAIR F�F't�s Licensed Pofesninnal 201-100(IAMPS IMPROVEMENT OWNEIinc.,.,i'fmmiCe Contractor's ON OVER Hal�AMCS ❑BATH REMODEL/REPAIR ❑DEMOLI'HON 6 I nave affirm that 1 am exempt from the Cantos C's License Law for the 4 V following reason(Section lemm,Rosiness andProfessions ver de is demolish, Code: pai city at county SIGNS ELECTRICAL ❑OTHER which reyuircs a permit OF canswa.stmt improve,demolish,nr repair any swcmre - ^O prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. H;!�y than be is licensed parmad to the provisionsofthe Connector's Llcenx Laws(Chapmr9 0 (commencing with Section 9000)of Divisiom3af Ne Rosiness and Rafcssions Cash)or TP.MP.METER OR POLE INST COMMERCIAL_ d{y o y that he is exempt parefrnOF and the basis for the alleged exanptimi Any violation of El NEW BLDG/ADDITION ❑DEMOLITION ^w Stttinn 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE ZZ�, not morethan five hundred dollars 05IX0. IMPROVEMENT Q0,1,as awnerof Ne pmperty,army employees widr wages as lheirode smu'venvmioq SWI MMI NO POOL.ELECTS IC will do an,work.end Me smear,is ern W intended or offered for PC,Business ❑ ER M and Professions Code:The Contractors License Law Jens not apply to an Owner of OUTLET'S-SWITCHES-FIXTURES property who builds or improves thereon and win does such work himself or through his own employees,provided that such improvements are not intended an o0cred far NEW RESIDENTIAL ELECTS SQ FT. sale If,however the building or Improvement is sold within one year ofecandetion,the SQ.`716-oft 10 5/SQ.PT. owner-builder will have the burden of proving that he did not build or improve for pur- pose of xle.). p� ❑ 1,as owner of the property, lice am exclusively contracting with Retuned contractors to TOTAL: ax �� contract the project(Sec.9044,Business and Professions CNet)The Contractors M- MAY cense Lawdoes not apply to an ow merof property who builds Or i mpmon, ves thereand QTY, PLUMBING PERMIT PE gYl/'�t VY CITY ur who contracts for such projmtf with a contmclicettw tor(s)licensed pursuant the Concmr's CITY UUF't License law. PERMIT ISSUANCE V H I'N� ❑ Lem umnpt under Sec. ',B&P C for this mutant ALTER-DRAIN&VENT-WATER(EA)Owner Oute VALUATION A'H WORKER'S COMPIiNSON BE C1.ARAl'ION BACK FLOW PNOTEC'I'.DEVICE I booby affirm under penalty of perjuryane of the(allowing declarations: ❑ I have and will maintain a Certificate of Cmacnno self-insure for Worker's Compete DRAINS-FLOOR,ROOF,AREA,CORD STORIES TYPE CONSTRUCTION cation,as provided for by Section 3]1X1 of the Lubar Code.for the Performance of the work for which this permit is issued. FIXTURES-PIRI TRAP ❑ 1 have and will ritual is Workers Camperou an Insurance,as required by Seel nn 37004the labor Coda for Ne crfnmunce ofb Eta which Nix permit isissues! GAS-EA.SYSTEM-]INC. OUTLETS OCC.GROUP ppN My Warks' ata matin acarie,and Por, Comer. ^ G Policy No� +Vl/�s�� GAS-EA,SYSTEM-OVER 4 WA) CE IFI ATE EXEMPTION FROM WORKERS' COMPENSM]ON INSURANCE GRF.ASFJINDUSTRL WASTE INTERCEPTOR or IeasJ (This section need nmm ot bepleted also permit is flavor hundmd dollars GREASE TRAP (SIOD BUILDING DIVISION FEtIS PLANCHECK FEE I rectify that in the aprif ny of the work far which this thepermitrkes'Coa hull SEWER-SANITARY-STORM EA.210 Pf1 not employ any person in any manner m as to breams subject m the Workers'Cnmpen- ENERGY HE Z mlitea Luwsof Culifomia.Umc' O Applicant WATER [EATERWNIiNT/ELECTN GRADING HE i NOTICE TO APPLICANT:IL after making this CeniOcme of Exemption.you should WATER SYSTEM TREATING a , become subject la the Worker's Compensation pmvkit n of the Labor Code,you must SOILS FEL? forthwith comply with such pmvidimsa,this permitshall be,deemed revoked. WATER SERVICE Q CONSTRUCTION Ltion lending agency NEW RCSIDLNTIAL PLMR. SQ.FT. PAID U l for by which thi End mercisaed(See construction agency(onhc Performance of Date IL. H the work for which this permit is issued(Sec.9(199,Clv,CJ 0U Lenders Name _ TTL: Lender's Address y1 certify that I have read this application it Mane[hut the above information is BUILDING FEE EA) correct.iagree to comply with all city and county ordinances and state lawn ming to Q'PY. MECHANICAL PERMIT FEE U building nnts0uctian,limit hereby authorize representatives of ihiscity memerupnnthe SEISMICM above-mentioned purposes.progeny far inspection purses. PERMIT ISSUANCE (We)agree to cove,indemnify unJ keep hamtless the City of Cupertino against F.hECfRLC FEE Nv lishilines,judgments,costs and expenses which may in any way sector,against said City ALTER OR ADD TO MECH. in nsrquence a(the timgaft ' ,mit. PLUMBINGFEE APPLICANT STAN , D W .L COMPLY WITH ALL NON-POINT AIR HANDLING LED(TO 0,000 CFM) OUR '. TIONS � 9MECHANICAL - Si � , AIR HANDLING UNIT(OVER 10,030 CFM) CONSTRUCTIONTAX amrefApplicanu tar Dam EXHAUST HOOD(W/DUCO HOUSING MI'fIGAT10N EF: HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building orcupanrstore or handle hazardous material BEATING UNIT(TO IMLOOD BTU) as defined by Ne Cupertino Municipal Code,Chapter 9.12;and rhe Health and Safety Code,Section 25532(a)t HEATING UNIT(OVER IMAX)BTU) [I yes ❑No VENTILATION FAN(SINGLE RMID) PAID Date Receipt# Will Ne applicant or future building by Btuse aquiil Quality Management BOILER-COMP3HP OR 100.000 BTU) emit hazardous air contaminants as defined by the Bey Area Air Quality Manugemem Dlsmic'1 TOTAL: ❑Yes (]No BOILER=COMP(OVER 100,000BTU) I have real Ne hazardous materials requirements under Chapter 695nf Ne Cull- AIR CONDITIONER ISSUANCE DATE famin Health&Safety CMB,Sections 25505,25533 and 25534.I males nd Nat Rion NEW RESIDENTIAL MECH, SQ.PT. bnildiug does not currently brvo a moot,that it is my mapmeibility to amity the occupmrt of Ne mqulrements which must is met poor to issuance of s Cenifivem of Occupancy. a Owner m auNorized agent Date TOTAL: ISSUED BY: OFFICE .