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B 0139 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDINC-ELECTRICAL, PERMIT NO a� /� BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL ....gwo. b RO 34 BUILDING PRDJHCT IDENTIFICATION •�1 iJ i NJ BIALDINGAD RESS: _ ©� SANITARY NO. APPLICATION SUBMITTAL DATE o / 7 OWNER'S NAME: PHONE: CONTR NA LIC NO: - , 1 CONIRUI.p ANCIIITIiCI'/ENGIN.ER: LIC NO: AI ❑ CONTACT: 1 PHONE: BUILDING PERMIT INFO " 1 ) j_j ?4�PG � "2 ❑ Consultant Fetes Paid by Applicant(Initial) li l❑UC ELECT PLUMB A1ECII `✓) L�L�-IGLIC_ENSED IC(ONFRACOR:S D¢/CLARATION !V]!/ QTY. ELECTRIC PERMiT FEE I hereby affirm Nal I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION woo witb Scetian7nfN11 of DivisimnJofthe Business anA i`roPovirns Code.and mylicensc is RF_SIDENTIAh- WOO _ PERMIT ISSUANCE F-_k- in full force and eRe C$FDWI. El KITCHEN REMODEL QVV License Clyss_ Lir.. .7204 �� APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE. Z W Dae Cnmmctor �is6❑ RAL ❑MUI.TI-UNIT CMODIFI MODIFICATION R TILCF$DECIAN 1'10 h-5 m PANELS h10U1FICATION Z 0E2 a 1 unJemand my plans shall M used as public records CZ— UP T0200 AMPS [I INFERIOR CCHIMNfiY REPAIR l Licensed Professional 2I- XX)AMPS' IMPROV IWENT E]SWIMMING POOLS �? OWNER-BUILDER DFCLARA'I'IONOVER IINNIAMPS ❑BAI'II REMODEUREPAIR [I DEMOLITION a I herehy ailirm that 1 am vxempt float Ilse Coolrncmr's License Law for the ippi55,�O4 V following renvnn.(Section 901 L5,Bminew and 11mfrWims Cede:Any city or uantY SIGNS ELECTRICAL C OTHER which myunu pemit m connma,ulmq itnpmve,Aemnli.h,or repair any amvmrc grinmil,issuonce,also requires the applicant for such permit m file a signed statement SPECIALCIRCUIT/MISC. a "y that he is licensed pursuant the provisions of the Cnnwemr's License 1.av(Chap...9 4$ PraCode)., COMMERCIAL: h: q man he is exempt therefrom and the basis f rth alleghe ed Business xe andon.Any TEMP.METER OR POLE INST' a IS e LL man he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDGIADUITION ❑DEMOLITION ^m Section 7031.5 by onyapplicam fare permit adijmistheapplicant toe civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE F.Z nV1 IMPROVEMENT or mom than five hundred dollars What CC1,as owmr of the property,or my employees wish wagesm Neirsole compensation, SWIMMING POOL ELF7FIZ, ❑0 THER will da the work,and the stmcmre is nm intended proffered for sale(See 7014.Business 63 m and Professions Code:The Contractor's License Law dims not apply to an owner of OUTLETS-SWITCH FIXTUR' property who builds or improves thereon,and who does such work himself or through his own employees,provided Nm such improvements are not intended or offered for NEW RP.SIDENTIAL ELECT R saleJLhnwever,the building or improvement is sold within, year of completion,the SQ.FT.hLOOR AREA SISQ.FT. eobuilder will have the harden of proving that he did mol build or improve for aa. prose ol'sale.). ❑ I,its owner of Ne property,am exclusively contracting with licensed contractors to )IA comma the pmjen(Sec.704q Business and Professions Gdep The—onsc or's I. wme law does not apply ta as owner of property who builds or improves thereon.and QTY, PLUMBING PERM IT FEE ho contracts for such pumm.with a ormtmcnrUs)licensed pursuant m the Contmoo's License law. PERMIT ISSUANCE I amexempt under Sec. ,B&PCforthismwon ALTHR-DRAIN&VENT-WATER(Ei G VALUATION Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECC DEVICE. 1 hereby am.,,under penalty of perjury one of the following declarations: IM1vve and will maintains Cemificum nfGmxmmselt-insure for Workers Cnmpem DRAINS-FLOOR,ROOP,AREA.CONE). STORIES TYPE CONSI RUCTION sution,u.provided for by Section 3700 of the LNm Code,for the performance of the work far which this permit is issued. FIXTURES-PER TRAP 1 have uad will tnainmin Worker's Compensation Insurance,as required by Section 3700of the labor Code,for the peffiamares.1 tire work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 Ol1'lT.lifS OCC.GROUP APN MyW.11,71NCompesoiiogJyxtl'mcg carrier and Policy number e: GAS-EA.SYSTEM-OVER 4IFA) Cartier. II Policy No.: ERTUTCATE OF EXfl policy IRU WORKERS' GNEASE/INDUSTRL WASTE INTIiRCfa'TOR 11 COMPENSATION INSURANCE BUILDING DIVISION FEES (This section need not be completed Ethic permit is furore hundred dollars(S100) GREASETRAP orlcssJ PLANCHIiCK FEE Loy any perm in he nce rin in work for which this Perthe Wokt is e"'', per-shall SEWER-SANITARY-STORM P.A.21X1 FT not employ any person in any manner ur es m become subject to the Worker%Compen- ENERGY FEE O Z it.,,Laws of California.Date WATER HEATER WNE a GRADING FEE Z Applicant tr VI NOTICE TO APPLICANT:If,after making this Ciminero,of Exempdoo,you should WATER SYSTEM REATING become subjem to the Worker's Compensation provisions of the Labor Crate,you most SOILS PER Laky forthwith comply with such p...mouser Ibis pr:nnir shall he deemed revoked, WATER SERVICE IIY VI' vvi Q � Z Catthe isacmmartNOINGngagenY NHWRESIDENTIAL PLMO. SQ 17r. IAIU to Receiptp V O kf..ayaffirti proritre iso issued leading agency forthe performance of f-' Newark for which this lermin is issued(Sea JIW7,Civ.CJ Lenders Name TOTAL: {UTa IenJefx Address TOTAL: y I cmify that I have read thio application and store Nat the above attenuation is BUILDING 1. . IA comem.l agrecm comply with all city and county nNinanees and nkat laws relating to QFy.. MECHANICAL PERMIT FEE V Z building comwaion,and hertby authomn mpresenatims.Ohiscity m<reropor the SEISMIC FEE above mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree m save,indemnify and keep harmless the City of Cupenino against a r4p ELECTRIC 1;17E Iiabilities,judgmems,costs and expenses which may in any way acme against said City ALTERORADDTOMECH. PLUMBING IRE in consequirom of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00007M) MECHANICAL FID 7. SOURCE RECUTATIONS. g AIR HANDLING ONI'T(OVER IO,IXq CPM) CONSTRUCION'TAX Signature of ApplicantlComrvcmr Date EXHAUST HOOD(W/DUCIT HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building uscupam store or handle hmaedum,material HEATING UNIT(TO 100.000 BT U) as defined by the Cupertino Municipal Cute,Chapter 9.12,and the Health and Safety Cale,Section 25532(.,)? HEATING UNIT(OVER 1011,"BTU) C]Yet, []NO VENTILATION FAN(SINGLE RB9ID) PAID Date Rmeilvx Will the applicant or future building mecupant use equipatenl Or dlisi Which main homardous air contaminants as defined by the Hay Area Air Quality Management BOILER-COMP(3HP OR I04(N)O BTU) TOT Distinct? BOILER-COMP(OVER IW,INNI it rut ❑Yes E]Na It I have read the hazardous materials rmwluirenmtnN under Chapter 6.95 of the Coli- AIR CONDITIONER ISSUANCE DATE �p fmniu I Iculih&sit lety Calc,Swtime 25505,25533and 25534,1 understand that if the NEW RESIDENTIAL MBCI I, SQ.Fm �� P r(J hnildir"Ito s not mlmany haven tenon,that it is my responsibility to ratify the oeatpwn ofthemenawhichmust tan or toisvnnc nfuCenifcate of Occu arc — n Owneror authnrizW agent Date ISSUED BY: OFFICE