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S 0230APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE SALL POINT PEN ONLY CITY OF CUPERTINO - I I BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL _ //1�,� { BUILDINNaG;PROJRCT,IDENTIFIC, BUIINDRE ,S: V?. V.� /'L/�� OWNER'S NAME:,/X-1 •1 � /—/ PHONE: CONTRACTORS NAME: �• ARCHITECT/ENGINEER: - LIC NO: I I ADDRESS: n v v ❑ Coilsultaot Fees Paid by Applicant (Initial) `J ` .f' -7r APPLICATION 'LICENSED CONTRACTORS DECLARATION s QTY ELECTRIC PERMIT I hereby aiRm that I a licensed d provisions f Chapter 9 (common ng s - C) with Section 7070) ofDivision 3 of the Business and Professions Carlo, and my license PERMIT ISSUANCE; in full force and effect. fW,)F License Class LiaN ❑CHIMNEY REPAIR Date Contractor APPLIANCES —RF.SIDF:MI'IAl. GZ ARCHITECT'S DECLARATION - PANELS - 1 understand my plans shall he used as public ceNs - y 7a re� ❑ ❑, ❑ ' Licensed professional UP'10200 AMPS ' 201-IMOAMPS OWNER -BUILDER DECLARATION OVER IOINIAMPS _ I hereby off rte [hat atIam am exempt Tram the Contractor's License Law for the 6 U El TENANT - following reason. (Section ]031 5, Business and Professions Code: Any city or county F SIGNS ELECTRICAL - Ii which require,. o permit to consumer, alter, improve, demolish, or repair any suve um Ll OTHER prlorm its issuance. also requires the applicant for such nm file a signed panni gne SPECIAL CIRCUDIMISC: Qthat he is licensed pursuant to the provisions of the Cnnlnuim's Licence Law (Chapter 9 Section 9008) Division 3 Business Professions 00(commencing with of of the and Code) or TEMP. METER OR POLE INST. o that he is exempt therefrom and the basis for the alleged exemption. Any violation of .m. Section 70313 by any applicant for a permit subjects the applicant to a civi l Penalty of POWER DEVICES not more than five hundred dollars ($500), OOLELECTRIC SWIMMING POO'-ELECTRIC Sp ❑ I. as owner of the Property, or my employees with wages as their sole compensation. do will F will the work, and the sumre Isom intended oroffered forsale(Set. 7044. Business 3m nit Code: The Contranor's License Law does not apply to an owner of OUTLETS—SWITCHES —FIXTURF,S property who builds or Improves Ihearn m and who dot such work himself or through �. his own employees, provided that such improvements are not intended nr nffercd fur NEW RESIDENTIAL ELECPR SQ FLJ sale 11; however, the building or Impmvemenr is sold within one year of completion, the owneomilder will have the burden of proving that he did not build or improve for pur- pose ] I. as owner of the pmperty, am exclusively contracting with licensed contractors to construct the prm art (Sec. 9044, Business and Professions Code:) The Cmartwo rx Li- wuseLt. due' nottimlymanowarefpmperty who hulas or improves thereon,and QTY. ho contracts for such projects with a contmcor(a) licensed pursaant tet he Gnntre lm', License Law.' PERMIT ❑ ]am exerppL under Sec. B & P C for this reason WORKERS COMPENSATION DECLARATION • I 1 berehy alarm under Penalty of perjury one of the following declarations: Fl have end will maintain a Certificate of Consent to selbinsure for Workers Compen- sation, as provided for by Section 37M of the Labor Code, for the performance of the work for which this permit is issued. ] 1 have and will maintain Worker's Cornpcn ation Insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My Workers Compensation Insurance carrier and Policy number am: . Cornea - Policy No.: ` CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not he completed If the permit is for6no hundred dollary ($100) or less. certify that in the performance of the work for which this permit is issue(], l shell not employ coy person in any manner so as to Fecomo eupiect m the WorkersCompen- sation Laws of California. Date Applicant t NOTICE TO APPLICANT: If, after making this Certificate of Bxempdon, yen should become subject to the Worker's Compensation provisions of the Lahor Code, you must forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hereby affirm that there is a construction lending agency for the performance of the work for which this permit is issued (Sec. 3097, Civ. CJ , Lender's Name _ Lmderls Address I certify that I have read this application and state that the above information is corer I agree te comply with all city and poorly inifirandes and xlate laws reading to building construction and hereby authorize representatives ofthrs city to enter upon the mrsom-mentioned property far inspection purpoxes. ' (we) agree to save, indemnify and keep harmless the city of Cupertino against Ilabllilies,judgments, costs and expenses which may in any way accrue against said City in onsequemce of the graming of this permit. APPLICAN UN ER$TANDS AND ILL COMPLY WITH ALL NON -POINT SOURCE TI S. - ...�....._.....rr vote HAZARDOUS MATERIALS DISCLO handl Will the applicant no Muni building occupant store or and t e Health anmaterial as defined by the Cupertino Municipal Code, Chapter 9.[ 2, cod the Health coil Safety Code, Section 25532(a)9 , ]Yes ]No Will the applicant or future building occupant use equipment or devices which emit bsardnus air contaminants as defined by the Bay Area Air Quality Management District? ]Yes Fl No I have =it the hoarders materials requirements under Chapter fi 95 of tomcat, human heCali- fmmia Health & Safety Cede, Sections 25505, 25533 and 25534.1 understand that if the building does not currently have a tenant, that It Is my responsibility to amity the occupant of Ne mqulremenls which must ho met prior to Issuance of a Certificate of Occupancy. JOB DESCRIPTION "S"'_ 0 2 3 0 ,NITARY NO. APPLICATION El KITCHEN REMODEL ❑ADDITION QUIiMIfI'Ai. Y NIC ❑STRUCTURAh CONTROL# MODIFICKHON El INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT BUILDING PERMIT INFO BLDG ELECT PLUMB MF.CH ❑ OTHER ❑ ❑, ❑ JOB DESCRIPTION RESIDENTIAL, OSFDWL El KITCHEN REMODEL ❑ADDITION 1:1 PLUMBING RE -PIPE ❑MULTLUNIT ,' ❑STRUCTURAh MODIFICKHON El INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT ]SWIMMING POOLS ❑ BATH REMODEUREPAIR ❑ DEMOLITION ❑ OTHER COMMERCIAL ] NEW BLDG/ADDITION ❑ DEMOLITION El TENANT - ❑ FOOD SERVICE IMPROVEMENT Ll OTHER ALTER — DRAIN & VENT — WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS— FLOOR, ROOF, AREA, COND, FIXTURES — PER TRAP GAS — HA. SYSTEM -I INC. 4 OUTLETS GAS — EA. SYSTEM ON ER 41EA) GREASFAINDUSTRL WASTE INTERCEPTOR GREASE TRAP SEWER—SANITARY—STORM EA. 200 FT. WATER HEATER WNENUELECT, WATER SYSTEM/TREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ, Pf. - tMEGHANJCALPERMITr., , PERMIT ISSUANCE ALTER OR ADD TO MSCIL AIR HANDLING UNIT ('1'O 10,000 CFM) AIR HANDLING UNIT (OVER 1G.00I CPM) EXHAUST HOOD(W/DUCT) ' HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER fili BTU) VENTILATION FAN (SINGLE RESID) BOILER—COMP(3HPOR 100,00i = BOILER—COMP (OVER 100,000 BTU) . _ Ip SQ. FI. ' TOTAL ISSUEDBY: NEW RESIDENTIAL MECH. PLANCHECK FEE ENERGY FEE GRADINGFF.F SOILS PP.Ii PAID Data Receipt# TOTAL: BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Raceipt# $Q, Mf. FLOOKAbA IP P. q JUL rrrly 01 - TOTAL: IT t ' FEE ALTER — DRAIN & VENT — WATER (EA) BACK FLOW PROTECT. DEVICE DRAINS— FLOOR, ROOF, AREA, COND, FIXTURES — PER TRAP GAS — HA. SYSTEM -I INC. 4 OUTLETS GAS — EA. SYSTEM ON ER 41EA) GREASFAINDUSTRL WASTE INTERCEPTOR GREASE TRAP SEWER—SANITARY—STORM EA. 200 FT. WATER HEATER WNENUELECT, WATER SYSTEM/TREATING WATER SERVICE NEW RESIDENTIAL PLMB. SQ, Pf. - tMEGHANJCALPERMITr., , PERMIT ISSUANCE ALTER OR ADD TO MSCIL AIR HANDLING UNIT ('1'O 10,000 CFM) AIR HANDLING UNIT (OVER 1G.00I CPM) EXHAUST HOOD(W/DUCT) ' HEATING UNIT (TO 100,000 BTU) HEATING UNIT (OVER fili BTU) VENTILATION FAN (SINGLE RESID) BOILER—COMP(3HPOR 100,00i = BOILER—COMP (OVER 100,000 BTU) . _ Ip SQ. FI. ' TOTAL ISSUEDBY: NEW RESIDENTIAL MECH. PLANCHECK FEE ENERGY FEE GRADINGFF.F SOILS PP.Ii PAID Data Receipt# TOTAL: BUILDING FEE SEISMIC FEE ELECTRIC FEE PLUMBING FEE MECHANICAL FEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Date Raceipt#