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S 0170 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 CITY OF CUPERTINO RUILDINO-PlURc rRICAL PISAIT ND. 0170 I7 O BUILDING DIVISION APPLICATION/PF.RMIT PLUMB Nr;-MECHANICAL J BUILDING PROJECT IDENI'IFICAI'[ON BUILDING AUDRISS: SANII'ARYNO. APPLICATIONSUBMI]"IALDATI! 110 27qN , WoL e-84 � tip/nr ' W 'D -ti dI I),6d - ,elRu, G IQ q7 IOWNF:R'S NpM["yx , o} r:r'S f Y 711 CD' ACfDR' LICC�(� -VYCIPJ� SI T o l NIC CONI'ROI,p �ARCHITIiLT(IiNGINflliR: _ 1 I.IC NO: ADHD{ 1 {) /�( ❑ 61 \HWXi� ll V- 7� 'IVNt /�I� CON'TAC'T: PHONE: BUILDING PERMIT INFO wo`�//t 96 W © (7 ❑ Consultant Fees Paid by Applicant(Initial) LDC ELECT PLUMB MI LH LICENSED CONTRACTORS DECLARATION QTY. Ej,ECfR[C PERMIT FEE JOB DESCRIPTION I herehy m1irn,that 1 ant licensed under provisions l]1Chapter 9(conunencing OW"Z UfaOCnrcc anXX))ol)ivisionJofthc Busincssand PrIcssinre Crm and illy It curve is r PERMIT ISSUANCE? RESIDENTIAL: = with Secdnnndct ill =U~ Lice lass Lic.N ❑sl'UW'1. ❑KITCHIiN RIiM(llliil. Q U APPLIANCES-R1S[DIiN'1'1Ah ❑ADIII'1'ION ❑PLUMBING RR=VIPE: me Comrednr .<Q C]MULTI-UNIT ❑STRUCTURAL. A CHITECPS DECLARAT N PANEIS F y Z I understand my plans sM1a11 be used as public rccnN.. qqQQ nn MODIFICATION OZ— UP T02(X)AMPS P❑INTE�IR ❑CHIMNEY REPAIR F,vl f-yl Licensed prodemi...1 1201-IBOBAh1PS IMPROVEMENT ❑SWIMMING POOLS �•L�J OWNER-BUILDER DECLARATION OYER IUIa AMPS q�W.W7[OE,UREPAIR ❑DEMOLI'TION IY Q I herehy offrm that 1 am exempt from the Contactors Licensc Law for the •" O6 U following reason.(Section 0031.5.Business and Professions Code:Any city or county SIGNS[LELTHI L LL13 LL t- whim requires a permit m construct,ober,impnrvc.demolish.or repair any structure �405 prior do its issuance,also requires the applicant for such fermi,to lite a signed statement SPECIAL CIRC 1 $ riNn �,}-1 that he is licensed pursuant the provisions of the C.nractors License Law(Chapter9 COMMERCIAL; �f�p0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR JIM INS d{y M c that he is exempt therefrom and the basis fnr the alleged exemption,Any violin of ❑ BLUO/AIlDIT10N DEMOLITION Sect n 703 1 5 by any applicant for a permit subjecv,the applicant to o civil penalty of POWER II WICES ""' N'f ❑FOOD SCRVICF qnot more then live hundred call...($500) IMPR(JVEMEN'I' 2 � ❑ I.mowocrol he property,or employees will,wages (he rsole cam - 2 ycmp y gesso perounne. SWIMMING MIME.IiLEC'I RIC ❑OfllliR will Jo(lie work,and the vtmcmre is not intended ter offered lir sole(Svc.70,14,Business lay's and pmfcs (or,Code TTe Contmam's License Law does not apply in an owner of OUTLETS-SWITCIIIiS-14X'I URES property who builds or improves thereon,and who does such work himself onhrowgM1 his own employees,provided that such impmvemenu me n),intended or offered for NEW RESIDENTIAL ELECTS SQ FT. We,If.however,the building or improvement is sold within one year ofcompletion.the SQ.FL FLOOR AREA SISQ.IrIl o builder will have the burden of proving that he did not build or improve for pur- 1-1seeof sale.). 3(a I]I, f smiler n(the property.am exdY cnmracding with Iium nuJ c. ranors in L' J "11 construct the project(Sec.1014,Nosiness and professions Codcq The fontanel's Liat- m Law Jrrs not apply m an owner of propcny who builds.r impn,vvs thereon,and QTY, s PER IIT FEE aw who contracts for such Composts with a commctm(s)licensed forward to the Contractor's License law. IPERMITI5 17-!, NCO 1 um exempt under Sec. .B&P C fnr this reasonD IIIIA VALUATION Owner Dam WORKER SCOMPENSATION DECLAHA'DON BACK PLOW I'R[YI'[CI'.1 +VI ^ all 1 hereby anion under penalty of perjury one of the following declurminns: n I hareand will maintain aCenlficumofConsem to self-ionre fin-Worker's Comoro- DRAINS-FLOOR,ROOF,ARRA.CO 1. S'IY)RI TYPII C(lNS'I'RIJC'I'ItIN snlmn,us provided I...by Senior 37M of the[,shot Cole,Ill the per0rmancc or the ark Tr which do.permit is issued. FIXTURES-E'ER I RAI' ❑ 1 havc and will maintain Workers Comp rroa,ion Insurance,as rcquined by Section 370fol the lobar Cole.for the partpr.an ccof the work for 1whhichhtthis permit is i sued ah GAS-IIA.SYS'1'EMd INC.JOU'11,1:fS OCC.GROUP AI`N Cyiev ny�ll. inn T epoicy No.Yj ^a`/r'^ti�Z N GAS-flat.SYS]'HM-OVER 4(M) CEUURTIPICATE F EXEMPTION FROM WORKERS' GREASErNDUS'IRL WATIM NIIiRCEPPOR COMPENSATION INSURANCE ELI NG DIVISION FEF_S (Ttis cedim need..,becnmpleted ifur,Camara,is foronc handled dollars(SIM) ORMSETRAP or lcsxl PLANCIII-C ETI" h I venify that in the performance.fthe work for which,M1is permit Ls issued.]shall SEWER-SANITARY-STORM M.200 FT. n.,employ,any person in any manner m as to become subject the Workers'Compen- ENERGY I ,Z sadion laws of California.Date , WATER HEATER W/VE ts-DiLECSR GRADIN '.li Z Q Applicant - h NOTICE TO APPLICANT:If,after making this Certificate of Exempion,you should WATER FYSTEM/rREAI'I NG SOLI (•-' hecome subject to the Worker's Compensation prow,cons of the Lalxr Code,you muss ai forthwith oply with such pmvisinns or this pem,id shall be Jeented revoked. WATER SERVICE Q = z CONS'1'HIICTION LENDING AGENCY NEW RESIUENI'IN.PLMB, SQ.Pr. I'A1 hereby end Cthat there is.cnn9mcdinn lm,ding rgvncy for he perrnmunecol him Hecciptb CUL . t he walk it,,whichthis permit is is,ned(Set.3(97,Civ.C.) TOI'AI: Q Lender's Name V lender's Address A �' I sentry thm I havc read Nis application unJ sum thnl the aMrve inli,rmadion is 11UILIlINO FEE ern comect,lagree.comply withal]city and county ordinances and state laws mining uo QTY. MECHANICAL PERMIT SEISMIC Ins Uz building nm.mmetion,and hereby anthems,representnives of this city to enter upon the obovomenti...ed pmpeny for inspection prnwses. I PERMIT NSUANCEi ELECT CFEE (We)agree to ave,indemnify and keep hornless chic City of Cupertino against / Iiabili,ies,judgmems.cost%and expenses which may in any way accrue againstaid City ALTERORADDTOMI: 11. ELUMR,GFE in consequence of the Cumming of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-' INT AIR HANDLING UNITOO 10.000 CFM) MECH, ICAL ME S.tgOURCE Rf, AT( '. 6_I _ AIR HANDLING UNIT(OV ER 10.000 CFM) CONS'fRUCI'10 A% naure of ApplicuMContmact Ilam EXHAUST HOOD(W/DUCE') HOUSING MI If FLE I IAZARDOUS MATERIALS DISCLOSURE! Will,hc uppllcamm Comm buildingrecupamsmrenr handle hvaMoas mmerial HLADNG UNIT(IT, do,dod BTU) ns Jelinnl by dhc Culrnin.Municipal Code,Charyer 9.12,and the Health and Saredy Code,Seethe..255320x10 HEATING UNIT(OVER 00jXx)BTU) ❑Yes, No ('AID VENTILA'I'ION IAN(SIN(ll.li RIiSID) (Jute Recciptk WIII dhe apphema or fail.budding wsvpam use equipment nT devices which BOILBN-COME'131{P(lH IINLINNI B'I'U) mit hemrdous air contaminants as defined by the tiny Area Air Quality Management TOTAL: Villin'! BOILER-COME'COVER 10d000 BTU) E3 Vie, El No I have mad the hwaNrms materials mgWlemerts under Chapter 6.95 of the Cali- AI R CONDITIONER ISSUANCE DATE fomite Health&Safety Code,Sections 25505.8533 and 25534.1 uolcrsmml that if d,c NEW RFSIDENI'IAL NIECH. SQ.Ef. building does not Comedy have a tenant.Bat it is my responsibility to notify the occupant of then cci¢rmnu which must be met prior to issuance of a Certificate of Occupancy. Owner or audhorieed agent cwg ISSUED BY: OFFICE