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30640 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0- 30640 . O V/p�T O BUILDING DIVISION APPLICATION/PERMIT PLUMBING•MECHANICAL. ' BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: (p'3 /! /]Ch•( s K f 1\ O/ e v k ehl rI 0 om' SANITARY N0 APPLICATION SUBMITTAL DATE . C , OWNER;�NAIA S ` A PHO 37/_��� CONTRACTOR' N/C _ �a(� SNA I LIC NO: G CONTROL# RCHI n—riNGINEEE: LIC NO: ADDRESS: ❑ � 2- !� OG7 `/J91 coNTALT: PHONE: BUILDING PERMIT INFO ' ❑ Consultant Fees Paid By Applicant(Initlap BLDG ELECT ' PL{1MB p1ECH LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE 11 IHAII- JK jEa(l I hereby aRlrm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION 1g1yy�Z with Section]000)ofDivislon3oFlhe Business and Professions Cminand my license is F�� in full force and of cu,, PERMIT ISSUANCE -RESIDENTIAL + ;VU License Lick ❑SF'DWL .- ❑KITCHEN 'D. Dn[e Contractor - APPLIANCES-RESIDENTIAL ❑ADDITION DPLDMBING RE-PIPE -1„p,� AR TELTS DEC []MULTI-UNIT I understand my plans shall beusedas public cards PANELS ❑STRUCTURAL OZY Lsensed y MODIFICATION UPT0200 AMPS !� .(]INTERIOR °' OCHIMNP.Y REPAIR } t� Pofessmnal - LL 'Q v 201-1f100AMP5 IMPROVEMENT OWNER-BUILDER exempt h DECLARATION gy�4 1 hereby affirm then I am exempt from she Commences Co License Law for she OVER IfgpAMPS. C BATH REMODEVREPAIR (]DEMOLITION W 3 F fallowing reason.(Section]03 L5,Business and Professions Code:Any city car county SIGNS ELECTRICAL ❑OTHER which ragm xs o permit to construct,site,,Improve,dmmallsh,ar repair any succome F,aj Ot3 prior to its issuance,also requires the applicant for such permit m file a signed statement SPECIAL CIRCUIT/MISC. >. that he is licansed pursuant to the previsions of the Contractor's License Law(Chapter 9 GOA (commencing win Sec,ion]Wp)uf Division 3uflhe Businessamd Pmm,donsCWG., TEMP.METER OR POLE INST. - COMMERCIAL- that he is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.56 anye applicant fora EW BLDG/ADDITION [I DEMOLITION µlimy a re permit subjects the applicant to penalty of POWER DEVICES TENANT ❑FOODSERVICE F Z Y t more them five hundred dollars(SSW). , xQ ❑ I.as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will du the wark,and the curature is nor intended or offered for sale(Sea.]044,Business OTHER and Professions Code:The Counselor's License Law does not apply to an owner of OUTLETS-S WITCHES-FI%TURES O propeny who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements ora mat intended or offered for NEW RESIDENTIAL E6ECTR SQ FT. ' sale.If,however,the building or improvement is sold within one yaar ofcumpletim.the _ -"__--�SQ.FT.FLOOR AREA $/SQ.IT. owner-builder will have the burden of proving that he did not build or improve for put. poseof sale.). ❑Las owner of the propeny,am exclusively contracting win licensed amematers m TOTAL: YO consumer the project(Sec.7044,Business and Professions Code:)The Committers Li- cense Use does not apply to an owner of propeny who builds or improves thereon,and QTY, MBING PERMIT FEE who commits in,such projects with a cammnur(s)licensed pursuant sa the Contsemds License Law. ❑ 1 am exempt under Sec. ,B is P C for this reasonPERMIT ISSUAN Owner ALTER-DRAIN&V - TER(EA) Dare /t�VAOATI�C` Wm intenSCOMPENSATION OF,CLARATION c BACK FLOW PROTECT'. IC r//N hereby affirm intentionally of perjury one uf,he following declarations ' ❑Ihave anJ will maintains Ccrtifica,e of Consennoeeif-insure Yor Worker's Compen- DRAINS-FLO OP,AR ,GON,. sation,as provided for by Section 3701 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION walk for which this permit is issued. FIXTURES-P T P - ❑I have and will maintain WORm'e Compensation Insurance,as requited by Section 3700of the Labor Code,for the performance mfthe work for which this permit is issued. GAS-EA.SYSTEM- OUTLETS My Worker's Compensation Insurance artier and Policy number are: OCC.GRO11 UP APN Cowie': Policy Na.: GAS-EA.SYSTEM-OV I. ) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE - GREASFNINDUSTRL WAST I RCEPTOR or less.) - (This aactloa need not be'complered ifthepermit is for one hGREASE,TRAP undreddmlars($100) BUILDING DIVISION FEBS'�/� ' " .I employ any thut in the any manner of the become which itis permit is its'Conn M1all PLANCHECK FEE eraemploy any person in any manner so as to become subject to the Workers'Compen- SEWER-SANITARY-STORM EA.200 FT. station T/ELECTR Laws of CelifnmENERGY FEE ie.Date WATER HEATER WNEN • l� . C) Applicant Applicant -- GRADING FEE lA NOTICEbj APPLICANT.If,rs Commakingnit Cisions f of Exemption,You should WATER SYSTEM/T'REATING t f'! become Subject m the Worker's Coons or Compensation provisions of the Labor Code,you must SOILS PEE CfST+I forthwith comply with such provisions or this permit shall he deemed revoked: WATER SERVICE � CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID L)Q I hereby affirm that there is a construction lending agencyfat rte performancund Data Receipt# W F rte work for which this p,mut is issued(Seo.3097,Civ.C.) Lender's Name L) TOTAL: CendefI Address TOTAL: V) I certee tofy at co plyhavwith this city and c un y ordinances that me d samebasisout information is BUILDING FEE U fA builder 1 agree a amply win all city and county ntaiives f and state laws relating m QTY. MECHANICAL PERMIT eE U bhllding wnsumcrlon,and hereby authorize representatives oFlhis city menmr upon the SEISMIC PEE above-mamloned property for inspection purposes PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City ro Cupertino s against '� ECTRfC FEE in orbicostsand expenses thispermit. may in any way acemeegainsr said City ALTER ORADD TO MECH. inconsequence of rte granting of this permit. ' PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT SOURCE REGULATIONS. TO 10,000 CFM)) � MECHANICAL FEE AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX Signature of AnAicanisCommc,or Data EXHAUST HOOD OV/DUCT) r HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE Will the applicant or future building occupant store or handle Licentious material / HEATING UNIT TO 100,000 BTU) �y - as defined by the Cu su inu Murton and I Code,Chapter 9:12; the Health and Safety - Code,Section 25532(a)P HEATING UNIT(OVER I01L0 ld BTU) ❑Yes Nu VENTILATION FAN(SINGLE RESID) PAID Will the applicant or future building occupant use equipment or devices which Datep emit hazardous air contaminants as defined by he Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) District? / TOTAL: ❑Yee CWNO BOILER-COMP(OVER 100,010)BTU) I have reed the hozonlous martrlals requirements under under Chapter 6.95 of the Cali- AIR CONDITIONER ' ISSUANCE DATE fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. /� builiingJcesnot unemly a.on I use fy the occupant CITY WI CU( ERNNO oPnere whls� m t sofa Certificate of0 cup oy. q Owner or mumnzed onto, Date T AL: 9 S DBY: � OFFICE