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S 1322 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PEtIT NO. 1322 BUILDING DIVISION APPLICATION/PERNUT PLUMBING.-MECHANICAL `V BUILDING PROJECT inrNTIF'ICATION ILOING ADDRES - s SANITARY NO. APPLICATIGNSUBMTITALTATE /D) SI rrad-o VIs?`4 [7r Cv r-tiND SIX'S NAME: ^ PHONE: CONTRACTOR'S NAME: LIC NO: Joel `'ei�� -• nNIC CONTROLM wlocl1TDIzlCF.R:(• " LIC NO: ADDRIitiS:� ❑ L Va Jars 2SS a /`larke 275 S se CON'TAC F. rxOrvE: BUILDING PERMIT INFO S}µNe a.r ©I, tot y°B 2K7 Iiik6 tft) ❑ Consultant Fees Paid by Applicant(Initial) BLDG BT-r T PLUM MECH M738 22MAS?20zris LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT' FEE I harehy affirm and I am licensed under prnvi.ianc of Chapter 9(commencing JOB DESCRIPTION "Z with Section70Whof Division 3o0he Plainest,and Professions Code,mdmy irenseis RESIDENTIAL Ia)0 0 PERMIT ISSUANCE Cw=F. in full force and effect. ❑SFDWL UKITCHE?N REMODEL U I,icem,Class Lib.0 FZU Date-Comou'ur APPLIANCES-RESIDENTIAL )UUION ❑PLUMBING RE=PIPE rnQa MULTI-UNIT ❑S'I'RUCFURAL ARCHITECT'S DECLARATION F.p w PANFIS MOUII§CATION Z O rn T� I understand my plans shall M aseA as Public records OZ�O UP1'02W AMPS fliklOR ❑CHIMNEY REPAIR Licensed Professional ]01-1000AMP$ IMPkOVCMIiNT SWIMMING POOLS OWNER-BUILDER DICLARAIION OVER IIXNIAMPS ❑BATH REM1IODEUREPAIR El DEMOLITION y I lability affirm that I um exenpt 1'rntn the C011lmelara License Law Ibr Inc xOyU following re...m.(Seetian 7031.5,Bminexsand Professions Cale:Any ciDor county SIGNS ELECTRICAL ❑f�llEk tY 3 en H which remote,a Permit to construct,cher,improve,den nlM,or repair any a onam [+'�10a prior to its issuance,also requlms the applicant for such proud It)File o signed sentiment SPECIALCIR TISIV �} then he is licensed pursuenuothe provisions ol'the Conwctnrs License lbw[Chaper9 Ix (commencing with Section 7000)of Division Sof the Business and Professions Code) TEMP.METER OR (NST. COMMERCIAL: e c.o that he is exempt therefrom and the basis fnr the dlened exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION ^, Section703l5hyanyapPlicamfora pemtit.subjecis the applicant to a civil pemaltyuf MOWER DEVICV [I TENANT p�pJ�•npopD 9400 pa�F`NtY`JCE not entire than five hundred dollars(SSW). IMPROVEMEN BAR V AIFV Y ❑ I,as owner of the properly.or my employees with wages as their cele compensation, SWIMMING POOL ELECTRIC will dothcwurk,ammosaucture is not inendedoroffercd bacce(Sec.7M4,Business [I OTHER W m vad Professions Cade:The Contractors License law does not apply m im net of OUTLETS-SWITCHES-1RXTURLSCITYUf AA sr property who builds or improves thereon,and whit Aces such work himself or through hiv own entployce.s,provided that such improvements arc not mended or offered Ino NEW RESIDENTIAL ELECTR Sp L . sale If.howcvcq the bim uilding or pmvanent In sold within one yeorof competition,the Sp.PI'.I1.00R AREA $/SQ.Irl'. or-hoilder will have the burdmt of proving that he did not build or improve fnr par- pose of aIle.). ❑ L a,owner n(the propeny,am beela.ively eonameafing with licensed ccharacters tit nmtrah thePr)jet,(Svc.7f ,Bm3nurmd Profession,Code:)The Corona,nr'sIJ- closelawdoesnot apply toanowner(if property who builds or improves thereon.and QT'Y. PLUMBING PERMIT FEE who contract for such projects with a convacmrbl licenacd pursuanuo the Contractors (/V Liars law. PERMIT ISSUANCE 1 an a opt unit �- .B&P C far this mmon ALTER-DRAIN&VENT-WATER WA) VALUATION abor � D q WORT R'S COMPENSAI'(ON DECLARATION g BACK FLOW PROTECT.DEVICE ereby affirm under penalty of perjury one of the following declarations 61'�M I have and wdl human a Cannulae til Consent to self-insure for Workers Co.[.- DRAINS-FLOOR,ROOF AREA,CONDSTORIES TYPE CONSTRUCTION sntian,as pmvldcd for by Section 3700 of the Labor Cale,fnr the Perfomenee of the work tar which this Permit"issued. FIXTURES-PBR'TRAP F1I have and will maintain Workers Cnntpensntinn Insnrnnm,as obtained by Section licit of the Lubar Code,for lhepudonnunce at the work larwhich this Permit is Issued. OAS-17A.SYSTEM-I INC.40U'II_VFS OCC GROUP MIN My Workers ComPtnemion Insurance currier and Policy number are: Carrier: Policy Noi: GAS-II.SYSTEM-OVER 4 HA) CERTIFICATE OF 17XEMVI]ON FROM WORKERS' GREASFANDUSTRL WASI'17 INIFERCEITOR COMPENSATION INSURANCE BUILD VIS NFT IS (Ibissambon need not be completed if the perosit is for one hundred dollars(S1W) GREASETRAP nr less) PLANCIfECK PEE I certify tom in the pertournmeeofibe work fnr which this permit isixsued.l shall SEWER-SANITARY-STORM C\.2W FT. not employ any Person in any manner so m m hecome subject mile Workers Compen- ENERGY FEE C) nation laws of California.Dam WATER HEATER W/VENT/ELECfR GRADINGFEE Applicant z NOTICE 10 APPLICANT:If,after making this Cenilicue of Exemption,you should WATER SYSTEMITREATING SOUS FII? F neat..W anhjem m the workerm :ComemmimI proonsvisirotmet e Lagar Code,r',a tifanhwilh cnnid,withsuch Provisinnx nr this pen in hall Im deemed revoked. WAIL?R SERVICE Q CONS'I'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FR PAID z I hmebynifrm that them is a clarlullm leulingageney for the perfoommum of )ate ReceiptN O O Ihe work for which this permit is ismed(Set.3097,Cin.C.) O U LTOTAL: cri Name Lender's Address y 1 certify then 1 have read his application lad Into that the above infome o n is BUILDING FEE (n toren.l egreemcomply withal)city and county ordinances and sum laws relating ro QTY. MECHANICAL PERMIT FEE Uz building construction.and hereby authorize representatives of this city to enter upon the SEISMIC FEE uMne-mentioned properly,for inspection purposes. PERMIT ISSUANCE (We)agree a save,indemnify and keep hemless the City of Cupertino against I[LIiCIRIC IIF. Iinbilities,judgmetns,cost and expenses which may in my way accoue against said City ALI'ERORADDTOMECII. PLUMBING PEE A amwquence Nthe granting S ANpermit. APP AN'T UNDER. ANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(I,INN)CPM) S( RC REGU ATI & MIiCHANICAhIIiE AIR IIANDLING ON]'I'(OVI?R IO,fNMI CFM) C(INS'IROCTIO real Appea Contractor ,all EXHAUST HOOD(W/DUCT) HOUSINGNIHIGATIONFEB HAZARDOUS MATERIALS DISCLOSURE Will theapplicant moment building occupamsere or handle hazaNous material HEATING UNIT(TO 1000y)BTU) as defnal by the Cupertino Municipal Cole.Chapter 9.12,vad the Health it Safety Code,Section 25532(x)? HEATING UNIT(OVER B)0ktXp IITU) ❑Y's Fl No VENTILATION FAN(SINGLE RP_SID) PAI) Dam Receipt N Will the applicant or future)wilding occupant use equipment or devices which emit hmardo.,air connotations as defined by the Bay Arca Air Quality Mumleardent BOILER-COMP(3HP OR 100,(0X)BTU) TOTAL: IL District? BOR -COMP(OVER 1X),00 IfITJI El Yet ❑No have rend the huwdnus materials rcyuirene...under Chapter 695 of the Cali- AIRCONDITIONER ISSUANCE DATE I'i in Ileulth&Safety Cade,Sections 25505,2,5533 and 2.5534.1 understand that If Ihe NBW RESIDEM'IAL MITCH. SQ.IT. building dory mm cercntly have a tectum,that it is by rosrymsilat..m notify the occalsoU of Ibe raryirentents which must he net prior no issuance of a Cenifcate of Occupancy. ;lt Owner nr authorized aBemDale L: ISSUED BY: / OFFICE