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30652 APPLICANT TO,FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO t'• BUILDING-ELECTRICAL _ PERMIT NO. O BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: - SANITARY NO. APPLICATIONSUBMITTAE DATI 7335; /3a OW ERS NAME: PHON -CONTyRA-C�TOR'S NAME: LIC NO H SD �•-fya /�� f[' / g� S�� i.N/C CONTROL# , SRCHITECTI GINEER: ✓4Cry CND: �Q/ ^a I V)/ aq ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB , MECH ❑ ❑ ❑ , LICENSEUCONTRd code,SDElime.f hap QTY, ELECTRIC PERMIT FEE I hereby affirm that 1 nm licensed Bu under provisions er Chopper 9(commencing - JOB DESCRIPTION �OOCZ with Sedion'/000ffeal. ision 3afthe Busine.us anJ Professions Cade,and my license,.s - RESIDENTIAL: O PERMIT ISSUANCE l" in full toren end affiant.. U F License Claes Lic.# ❑SFDWL - El KITCHEN REMODEL vFZ Date Contracinr APPLIANCES-RESIDENTIAL ❑'ADDITION ❑PLUMB[NGRE-PIPE FDan - ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT OSTRUCTURAL OZ y 74. 1 undersand my plans shall be used as public records MODIFICATION :-7 UP TO 200 AMPS �.,�„ Licensed Professimal El INTERIOR El CHIMNEY REPAIR fq�sai .OWNER-BUILDER DECLARATION 201-IIHlt1AMPS IMPROVEMENT I hereby affirm that I am exempt from the Computer's License Law for the OVER IOWAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION fiSS, pW.U following reason.(Section 7031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL ❑OTHER W I"' which requires a permit to construct,alter,improve,demolish,or repair any structure _ prior to it,issuance,also rcgmre.,the applicant Formal permit o file a signed statement SPECIAL CIRCUTUMISC.., that he is licensed pursuant to the provisions of the Contractors License Law(Clamor 9 100 (commencing with Section 7")of Divimm3 of the Business and Professions Code)or TEMP.METER OR POLE.INST. A, COMMERCIAL: that he is exempt therefrom and the basis for the alleged exemption.Any violation of - EW BLDG/ADDRION ❑DEMOLITION �+ ANT ❑FOODSERVICE Section 703 IS by any applicant for a permit subjects the applicant m a civil pemhy of POWER DEVICES - I oat mora than five hundred dollars($500). IMPROVEMENT p. ^'�•6 [1 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC t� will do the work,and the swcture is not intended or offered forms,(See,nal Business ❑OTHER and Professions Code:The Contractors License Law does not apply to as owner of OUTLETS-SWITCHES-FIXTURES �' property who builds or improves thereon,and who does such work himself or ptuough his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however,the building or improvement is sold within one yeurofcompicpion,the SQ.PT V0 $/SQ.FT. owner-builder will have the burden of proving that he did not build or improve for pur- pose of selene TOTAL: ®pi� ❑ I;as Owner anile property,am exclusively contracting with licensed eonwemrs m u�� _ �� construct project(Sea.7044,Business and Professions Code:)The Commemrs U- cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE �x,Tyj who contracts for such projects with a eoutmdCorporatesr(s)licensed pursuant to theCorporates �I// Uj- c. License Law. PERMIT ISSUANCE N to l IlVU ❑ 1 am exempt under Sec. ,B&P C for this reason - ALTER-DRAIN&VENT-WATER(EA) ° VALUATION Owner - � �Dete ,' Qr - WORKER'SCOMPENSATION DECLARATION BACK FLOW PROTECT DEVICE �. 51 10 ,1 hereby affirm under penalty of perjury one of the following declarations: I haveand will maintain a Certificate of Consent mself-insure for Workers Compete DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION sation,as provided for by Section 37M of the Labor Cade,for the performance of the' - work for which this permitisissued. FIXTURES-PER TRAP ❑ I have and will maintain Worker's rap nsabon Insurance,es required by Section 3'/00 idlh Code,for eperfom rte f0 _or for which this permit is issued. GAS-EA.SYSTEM-1 INC.40U'ILETS, OCC.GROUP APN M�y 'kC nsati n5yr4c cr o my Nn: roc/iJ /Q GAS-EA:SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' C -COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR This section neednm be completed Hato permit ix farina hundred dollars($100) - B C ISIONFEES GREASETRAP or leas) � PLANCHBCK FB (certify that in the Performance ro the as to k for this Permit is the Workeue rs' Campech I r- SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner so as m become subject m the Wnrkcri Compren- ENERGY FEE- - z Salman Laws of California.Da¢ I T/WATER HEATER WNENELECIR ' Q O Applicant � GRADING FE FN-r NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING F7 become subject to the Worker's Compensation provisions of Ne Labor Code,you must SOILS HE - WQ forthwith comply with such provisions or this permit shell be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ,FT. PAID `U 0 I herebyaffirm that there iso conswctan leadingigmey forthe performance of D Receipt If the work for which this pemdt is Issued(yea,3097,Civ.C) QU Lenders Name _ TOTAL: 4iI Lenders Address TOTAL: il— I rectify that l have read this application and spate that he above information is BUILDING TE F.V) corset.I agree to comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE U Z building construction,and hereby authorize represenatives ofthis city to enter upon the SEISMIC E move-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep hornless the City of Cupertino against ELECTRI liabilities,judgments,costs and expenses which may in any way accme against said City gLTER OR ADD TO MECH. PLUMBING FEE in onsequence of the granting of this permit. - APPLICANT UNDERSTANDS AND WILLCO LY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,001)CFM) - SOURCE REG ATT �ONS. - MECHANICAL FEE `�/v - AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTTONTAX - SignatureofApplicanoCnnaactor Dam EXHAUST HOLD(WMUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or thmre building occupant store or handle hamNous material HEATING UNIT UT,100j"BTU) • as defined by the Cuper im Municipal Cade,Chapter 9,12,and the Health and Safety " Cade,Section 25532(a)P . HEATING UNIT(OVER I W,000 BTU) ❑Yes No VENTILATION FAN(SINGLE RESID) PAID Does Be, VENTILATION - WilltheapplicamnrfumreM1uilding,ecupam use equipment nr devices which BOILER-COMP(3HP OR IOO,gIp BTU) mit hazardous air ammunimmts aa_defined by the Bay Area Air Quality Management TOTAL: Districts ❑Yes ❑Nm BOILER-COST(OVER 100,03,1)BTU) ' I have reed Ne hemadous materials requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE. forma Health&Safety Code,Sections 25505,M533 end 25534.1 onderspand that if be NEW RESIDENTIAL MECH. SQ.FT. building Ones top currently have a anent,Nm it is my responsibility to notify the occupant of the requirements which Must hMet labor 10 of Certificsa of Occupancy. Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE