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B 0499 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O � a/V BUILDING DIVISION APPLICATIONIPERMIT . PLUMBING-MECHANICAL S0001 .NUILIIING PNO.D!LT IDI:NTIFIC'ATION J NUILDINGADDRESS: SANITARY NO. APPLICATIOaNrSUBMITTAL DATI 3/ STC✓Lwr C. .'VQP �/.. ' t�J '� D N :S NAM@ 1'IIDNil: CONTRACTORS Nn7:F t0• LIC NO. b� NIC Cl1NTRfll.p ARCHITECT/ENGINEER: LIC NO: ADDRESS: 3 ❑ O t�-u✓ CONTACT. PHONE: �sy(zZ t . BUILDING PERMIT INFO ' ❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH 07 o ❑ C ❑ ❑ LICENSED CONTRACTORS DECLARATION 1 QTY I CLI,CTRICP 1. , FEE 1 nercny alum that 1'..licensed d n w .of Chapter 9(commending r JOB DESCRIPTION Qa'Z wile Sa. .. TW07,In elan 3nnhe Blx . .numfess' nx G+aa am nylev tons -. RESIDENTIAL: WOO PhltMII ISSUANCE rJ (J - F•�� infill tone and ellen�VoO' ❑SFUWI. ❑KITCIIIiN 12EMODh1. ,%U� LicenseClass _ Lic.p APPLIANCES-RESIF)FNTIAL ❑ADDITIGN ❑PLUMBING kILI'IPE hCa Dee Common 5w ARCHITECT'S DEC, aH0N PAN131.5 ❑MULT'1-UMr ❑STRUCTURAL F-Din l understand my plans shall be,used as public records qq MODII'ICATION pzn^o UPTO 200 AMPS C � ❑INTERIOR 1]CHIMNEY REPAIR FQNgFq Iy 1,icenscA l4nloesional 201-1000AMPS IMPROVEMENT SWIMMING POOLS CY2jOWNER-BUILDER DECLARATION OVRN I(KKIAMI'S [D13ATH R EMODEUREPAiR ❑DEM01.1'FIGN C W Q 1 hereby affirm that 1 am exempt from the Contractors License Law for the g O c.U following reason.(Section 7831.5,Business and Prnfeasions Code:Any city or county SIGNS ELEC`DUCAI. ❑OTHER ©31L F" which rego hn,.p.,air loco mel,ober,Improv.,dco mish,or raper any structure - O Prior to its issuance,also has,ircs the applicant for such neutral to file a signed statement SPECIALCIRCUDMISC. thatheislicensedpursuan0ntheprnvisionsofthe Commnor's Licensel.aw(Chup¢r9 W��O (commencing with Section 7kXPofD'oision 3 of the Business and Pmfexsions Code)or TEM]'.METER OR POLE INST. COMMERCIAL: dy c That be Is exempt therefrom and the b....far the alleged exnnpinn.Any vinlation al ❑NEW BLOLVADDI'1lON ❑DEMOLITION an Second 731.5 by any applicant for a permit subjects the applicant too civil Penalty of POWER DEVICES zm not more shim five hundred dollars($500). [I TENANT ❑FOOD SERVICE €'7y01]L.snwneroftbe property.or my employees w rh wages[is their sola compensation, SWIMMING THIOL ELECTRIC IMPROVEMENT 2 will do the work.and the structures is not intended or h iched for at, Sce.7044.Business ❑OTIIP.I2 W3 and Professions Codd:The Contractors License law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES 4i .. property who builds or improves Iheonn,and who does such work himself or through his own employee,prnvidnl That such for NIIW RESIDENTIAL ELECI'N SQ ET. - .]a.If,however the buildmmorimprovcnemis snlA within nneyeariefcompletion,the SQ.FT FLOOR AREA - S/SQ.I'I'. mer-builder will have the burden of Proving that he did not build or improve for put- p,xenfxalcJ. - - ❑1 f(h p pe ty exclusivelycontracting with licensed nt- t '1. (YI' - construct th poiccl(See.7W4,Business and Professions Cd )But ChztrL Li- ceL J t pplyt un fP pert h b IJ p th run and QTY• PLUAIBINGPERMIT. _ who Imansen,far h Plair,11with.u,l nall)firlired"Lalmoni alIlie Cou , License Law. PERMIT ISSUANCE fill ❑1 a exempt under Sec. B&I C for this meson ALT'IiR-DRAIN&VF.MI WA'I'IiN PA) VALUXI ION_ Owner Dae WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under Penalty of perjury one of the following Jeclamtions: ❑ Ihuvcnndwillnwimvinu Ccnlfi[ulm,f Comm�ra. Iff minor for Workers Cmnpam- DRAINS-FLOOR.ROOF,AREA,CORD. /�, S'T'ORIES TYPE CONS'THl1CT10N .ration,ac provided for by is issued. 39 W of the lobar Code.ria the p:rfnrmance of the work for which This permit is issued, IIXTURCS-PER TRAP I have and will maintain Worker's Compensation Insurance,as required by Section 3900o1I he Labor Code,I the terminuncu of the work for which this permit is issued. GAS-P.A.SYSTEM-1 INC.4 OUT LETS OCC.GROUT' APN My Workers Comp[nulinn hvsumnce rennet moil Policy number am: Cams,: Policy No.: GAS-EA.SYSTEM OVER 4(EA) OrRIFICAI B OF EX EMPTION FROM WORKERS' GRIiAS[JINDIIS'I'NI.WASTE IN'I'ERCEP'I(Ik COMPENSATION INSURANCEBUILDING DIVISION PEES rnissectummardmlMcompined iflhcpetmitisf.ronehundmddollars(SI(pI GREASETRAP or less.) PLANCHECK PE I ccnl fythat inthe pedurmunceoUba work 1b,which this permit is issued,l shell SEWER-SANITARY-S'IGR M EA.200 P I'. not employ any person in any manner sn asJo , e nnthe Workeri Comic.- It it z sedan Laws of Lf 1) �L. h '�11• WATIiR HEATER W/V[:NTMLECTR O O Applicant w /�Y-v�- ^ cRAlnec p r: Z NOTICE TO APPLICANT.IL lief anner,this Cenifca¢of Exemption,you should WATIiR SYti'I'I7MRRL>A'1'ING F' N become subject to the Workers Compensation pmvisbns of the labor Code,you mon SOILS FE' WQ forthwith comply with such provisions or this Permit shall jr,deemed revoked. WATER SERVICE 4' CONST RUCTION LENDING AGENCY NEW RESIDHNTIA1,PLMB. SQ.PI'. PAID V,0 l hereby affirm that there is a conswcfion lending agency for the performance of )em Receiptp the work for which this parn+it is isdmxI(Six.3097,Co,C.) u" Lender's Name TOTAL, O LU Lender's Address - '1O1'AL 1 acuity that 1 have read this application and t to that the h inf.mei n is - - _ BUILD] ,1'IS �., h coram Samoans nnply with at]r...,I q d' d late .oltl gm QTY., ' •MECHANICAL'PERMIT+ + 1 .i PFF II. Vz bmild ng emn,ba,ion and bercby aahonz P t( cv of lhi' ilyt chair u, be 1 SEISMIC] ']. above mentioned property for inspection purples. PI7RMIT ISSUANCEELECTRIC b Q (WO)agree m save,indemnify and keep harmless the City of Cupertino against hid illdes,judgnnnl,. ...wnnd ex,ries which may in any way accrunageinst said City AMNO OR ADD'DO MITCH. - - in me,mance of the mmmirg of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING ONE NTO IDAX)CFM) MECHANICAL FEE SO REGUIATI 1 fYl AIIi HANDLING DNI'1'(OVEI11f1,1100 CPM1 CONS'1'RUC'1'ION'I'AX Sigumture of APPI candronctiefor Data EXHAUST GOOD(W/OUCO HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazadhoa material HEATING UNI'I'(TO IlI0,fN10 BTU) as defined by the Cupertino Mumaipd Code,Chapter 9.12,and the Health and Safety Code,Seaham 25532(.)^ �- ITEM I NO UNIT(OVER I MM)It I'U) Will the No V17NI'ILATION PAN SINGLE kHsUB ]AHI Dec Reniptp Wrdorsvpplicamorfuture building occupantuse yAea Air mute or Maraconces mh BOILER-COMPCHPOR 100.000BTU) Ateent Iezedoux air umloneuumx as dclincd by the Pay Arca Air Quality Munugcmem pTAI; DosvieT! ]]Yes BOILER-COMP(OVER I W OM)BTU) QNu I have heart the hazardous materials requirement under Chapin 6.95 at the Cali- AIR CONDI'I'IONER ISSUANCE DATE fomia Health&Safety Cole.Sections 25505,25533 and 25534.1 underttand that if the NEW RESIDENTIAL MHCH. SQ.EF buildingdoes nnlmmnydy have.emmr that it is my re,forimbilitymnotifythe rcsuper ofl��prire I wh'hrX. ptinrm to ra e of a Ccni��Orensrry, Owner"]inalmrzei ag,[I'•/ f - Dae,' TOTAL: ISSUED BY: -� - OFFICE