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B 0199
Aooa Ire NTTO oB 1 LN INFORUATIC N WITHIN AFD LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATIONIPERMIT PLIrntBlNG-NIECHANICAL _MOP BUILDING PROJI:Cr LDNN 1171 AR'ION PERMIT NO. 0 2 HCl 199 H.DINGADDRESS: BUq SANITARY NO. T APPLICAION SUBMITTAL DAII GV"11—wo riS C/P'r�c/ti VL��r _ OWNNEER/'S�N/A�%BQ/�P��'�{�� 'M M1�TIs-11• �1 s" • 1 . - `I A'W COINTRACI'OR:S NAME: LIC NO: N/C ❑ O CDNI'RDI.« J ? 7 ARCHITECT/ENGI EEEEjRR�._l-y�' LIC NO: lWa ezrs e/01715,11 ADDR SS' mfr l CONTACT: I'M N: F_1c,"9t/=D�'U/J��r (M$1 944- 't�trNr�Tll�r-rtrr�crz El consultant Fees Paid by App lieant(Initial) BLJII,DING PFRMI'1' INFO _ BLDG FiEC III.UMB h1EC11 IL1—QI/ rlrLv/ LICENSED CONTRACTOR'S DECLARdnON 1 hereby am him, I am licensed cartel provisions of Chapter 9 (commencing with Section7000)uf Division Sofma Ba,ma,samd Pmfessioms Cedo,aed my license ix is full force and el)bm. QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑ KI' I'CHEN REMODEL PERMIT ISSUANCE APPLIANCES -RESIDF,N'I'IAL License Class Jr. It Date Cmntmatur ❑ADDITION ❑ PLUMBING RE-1IPH ❑MULTI -UNIT ❑S3'RUCTURAL MODIFICATION ❑INTERIOR ❑CHIMNEYREPAIR IMPROVEMENT E]SWIMMINGPOOIS ARCHITHC7`5 DECLARATIONPAN1iLS 1 undaroa^d ms sh ed as public records Y planall The us UPTO 20M AMPS 2-0 Licensed Professional 201-I'llIAMPS OWNER-BUILDF!R UECLARA'nON 1 hereby ifiloo that 1 nm exompl Eon, the Co^Iraclor's License Low or the t fNlowing,ease.. ISectio^ ]031.5, 0nsiness and Professions C.Je: Any city or county ❑ BATH REMODEIIREPAIR ❑UFMOLI'I'[ON ❑ OTHER DVERIIXIIAMFS SIGNS ELECTRICAL which requires a permit to concoct, alm, improve, demolish, or repair any structure SPHCIALCIRCUHUMISC. prior m its issuance, elver requires Neappliwm fur such Permit file a signed slacencm that he is licensed pursuant m the provisions of the Contester. License Law (ChaPle19 (ccnmemaningwiN Section 71X10)ofDvision 3oflhe Business and Professions Coa0ar that he is exempt therefrom and the basis for the alleged exemption Any viulmion of TEMP. METER OR VOLS INST. COMMERCIAL: ❑ NEW BLDG/AUDITION ❑ I3GMOhITION Section 7031.5by.nyapplicaut for it ptnnit subjects the applicant to a civil penalty u( noI mora than live hundred ; dollars ($500) y employees with Ars as Nei... le compensxlinn, Las ew... of the prope..rmie ❑ r will do the work, and the structure is not intended or offered for sale (Sm. ]0Bnsincs. i and Professions Code The Con emns's License Law does nal apply to an owner nl POWER DEVICES El TENANT ❑ FOOD SERVICE IMPROVEMENT El OTHER SWIMMING POOL ELECTRIC OITI'LETS-SWITCHF_S-1TXTUR property who builds or improves theater, and who does such work himself or through his own employees, provided that such improvements are not intended or offered far sale. If, however, the building or improvement is sold within one year ofcompletlon,the NEW RESIDENTIAL. ELECT R SQ 14. SQ. FT. IR.ODR AREA S/SQ. FT. owner -builder will have the harden elproving that he did not hard .r improve for per. - pom of sem). ❑ L as owner of the property, em exclusively comments with lice^sed commmon to construct the project (Sec. 90YI, Business and Professions Castle:) The Contractors Li- ds improves emt.and writer of property ni bolm thre cense law does out apply m an.wnco 'OIAI / 6 / QTY. PLUM13ING PERMIT FEE. who contracts for such projects with a compeer(:) licensed pursuant to the contractors License Law. El 1 am encnlPl under Sec. . N & P C for his rennan PERMIT ISSUANCE - �O Owner Data ALTER - DRAIN & VENT- WATER (EA) VALUATION ^ S 7 0 0 1 WORKER'S COMPENSATION DECLARATION 1 here miffirm under penalty of pammy one of the following declare ions: BACK PLOW PROTECT. DEVICE STORIF TYPE CONSTRUCTION El I have and will maintain a Certificate of Comeentto sclhinsure for Workers Camp.- xmio., as provided for by Section 301X1 of the Labor Code, ton the performance of the work for which this permit is issued. DRAINS- FLOOR. ROOF AREA. COND. FIXTURES - PER TRAP 0 I have and will moi^min Worker's Compensation Inmmacc, us required by Sermon 3900 ofthe labra Codc, tonhe performanccofdm work forwhich this partial is iavned GAS - EA. SYSTEM -I INC.4 OUTLETS G 9.1 APN My Workers Compensation In,.... comer and Policy nnt^hcr arc: Caries Policy No.: OAS -IIA. SYSTEM -OVER 4 (EA) GREASUINUUSTRI. WASTE INTERCEPTORCOMP17NSAI CERTIFICATE OF EXEMPTION FROM WORKERS' ION INSURANCE BUILDING DIVISION FREES (Thissection need not he completed i f the permit is intent, hundred dollars IS 100) or le".)P GRHASFTRAP NCHRCK PI?II QI r $O SEW I!R- SAN I'TpRY-STG1tM EA. 2q1 PI'. Ii !RGY FR' Ireal fy that in the perfernnunanfthework for whid, flus, purmins issucd,Ishnll t em y any pi t any ten neo sn uv In become schjecno The Workers' Camper- i saY cos f uAfo .Dote WATER IIIiATER W/VEN'1'1131.ECTR App nT ' GR DIN. N C TO APPLICANTif, after making this Certi cam of Exemption. you should become subject m the Workers Comps Prost sof The Labor Calc, you must WATER SYSTEM/TREA""PING SOIL WATER SERVICE forthwith comply with such provisim or ns hall hcdecmedrevoked. CONSTRUCT ION LENDING AGENCY jIhamby.fllrnthanherc isaconswclin^ lendirgageoey fonheperformanceof VAIU„ Dae Re¢ipt« NEW RESIDENTIAL. PLMII. SQ. FIL Z 2 LAI" O 1 the work for which this permit is issued (See. 3099, Civ. C.) Landers Name st 1 Lenders Address is RU DING FE i -r� D 1 certify that 1 have read this application and stole that the above infomlatien 1 coram. I agerem comply with all cayman county nnlin:mens and smte laws relining m building consuuctimt,and hereby uathorieo representatives of This city to enter apon the QTY. MECHANICAL PERMIT FEE S J ISMIC FFE FERMI'I' ISSUANCE I! iCl'RIC FEL! above-mentioned propeny for inspection purposes. (We) same m save, indemnify and keep harmless the City of Cupertino ngainst ssttsaid City Iiabilitiesjudgmems, costs and expenses which may in any way acme agai^n in coslsequence of the granting of This permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL�ON-POINT SOURCE REGULATIONS. ALTER OR ADD TO MECIL eo FE-H.i PLU ING l 3 �O MECHANICAL FEE AIR ANDLING UNIT (101 Told CFM) H � © HANDING ON I'I'(OVIIR I(),"CFM) CONSTRUCUON'IAX Sigmatireof Appliausicintmnm Dale HAZARDOUS MST TRIALS DISCLOSURE E(HAUS"THOOD(W/DUCT') HOUSING Nil] ICA] FEE HEATING UNIT (TO 1 0i BTU) Will the.,disman, furore building eacupantscore or handle havaJous matnal as defined by the Cupertino Municipal Gds, Chapter 9.12, and the Health and Safety Code, Sermon 25532(.)7 .,/�' I Yes gUvn HEATING UNIT (OVER I00j)(l BTU) PAID Dater VEN'I'I LATION FA R(SI NO UP RESID) �tr Will the applicant m futum building occupant use equipment or devices which emit bund... air amtamma^ts us defined by the Bay Area Air Quality Management BOILER- COMP(3HP Oil 1(X1,000 BTU) dl TO BOILER -COMP (OVER I0103000 RTU) District? ❑Yes ')�Nn AIR CONDITIONER dt the Calie 1 have mod the hamNum maturiah requirements tmdcr Chapter understandthat iI'thc fomir Health came Code, Sections,thati 25533and 25534,I 1.any the the^gdmxners,shichan,11hantmt,Nmitismy revpntsvihllitymnotify Ne:ucupont ISSUANCE DATE NEW RESIDENTIAL.MliCfl. SQ. PR of Ne requirement. which must be mm prior m issuance of n Ctnilicate of Ocmp:mcy. cr 'UEDBY: T p : Ow.mmiuNorieedagcm Data OFFICE