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29089 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO, O BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL. ^ BUILDING PROJECT IDENTIFICATION BUILDING AD RESS:- O�jf - SANITARY NO.. A 89 PLICATION SUBMITTAL DATI powk& OW11i NAME: t l' j�tU)IF' '�y II CO OR'S N ^ a 77 OV N/C CONTROLtl AR ITECT/E (NEER: LIC NO: AD ❑ CONT PHONE: - BUILDING PERMIT INFO //� /f ❑ Consultant Fee9 Paid by Applicant(Initial) BLDG ELECT PLUMB MEC / ,!/f),t ❑ ❑ ❑ LIC SED CONTRACTOR'S DECLARATION Qyaz QTY, ELECTRIC PERMIT 1 hereby affirm at 1 tem licensed under provisions of Chapter 9(commencing 'JOB DESCRIPTION { with section'IUW)of vision3 o1fleBusiness and Professions Codu nd 'ansa is Ir afullf.e. .'al, .PERMIT ISSUANCE RESIDENTIAL F+ O' U V L¢ense Cla s myl -Lic.# - ElElSFDWL. KITCHEN REMODEL ' rF�a Date "Cmmmmpr APPLIANCES-RESIDENTIAL - ❑ADDITION [I PLUMBING RE-PIPE Fpm ARCHITECTS DELLA ❑MULTI-UNIT ❑STRUCTURAL yy I understand m 1 hall be used us public records PANELS O Z Fi Y.plans s MODIFICATION UPT02M AMPS A El INTERIOR ❑CHIMNEY REPAIR jLicensed Professional 201-I000AMPS IMPROVEMENT OWNER-BUILDER DECLARATION Q 1 hereby affirm that 1 ami exempt from.the ContractorOVER IOW AMPS's License Law for the 11D VR BATH REMOEPAIR DEM LI IO {ii5 O as U following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER FWO to which requires a pemut rte construe,aline improve,demolish,or repair any stricture - ) I lots, QQ prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/Ni e' _ Ithat he is licensed pursuant to the provisions ofthe Contractor's License Law(Chapter 9 I �M (commencing with Section 9000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST - COMMERCIAL:' ` dq c that he is exempt therefrom and the basis for the alleged cxarraui n:Any violation of i5 u• .5 by any applicant fora pp [ITEWBLDGIADDITION ❑OEMOLIRVICE Scene.7031 Worry permit subjects the applicant penalty of POWER DEVICES El ❑FOODSEVICE pz not mom than Bve hundred dpllam($500). IMPROVEMENT ; G ❑Lo the work, Ne property,r intended with agefor rsale(Sole 0FEBu anis SWIMMING POOL ELECTRIC WWR will doth¢work,Craand t:The Cure istors License Law does rot apply Loan Business ❑OTHER L and Professions Cade:The Contractors License dodoesnesapply himself of ` OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through - own employees,buire lding that such improvements anot hoarded or offered for NEW RESIDENTIAL ELECTR SQ FT sale. owns L however the have fee bur improvement issoldhe within one build or improve the SQ.FB FlpO AREA ASQ:FT. ewner-builder will have the hunks of proving that he did not build ur improve for Pur- 0 pose of sale J. , t ❑L as owner of the property,am exclusively contracting with licensed contractors to TOTAL: , consumer the project(Sec.7044,Business and Professions Code:)The Contractors Li-, 190VJAN ry 190L cense Low doesnot apply to on owner of property who builds or improves thereon,and Q Try, PLU IN PERMIT FEE `, J ' who counncu for such projects with a amilecmr(s)licensed pcame n [.,he Contractor's License Law. PERMIT ISSU CITY Uf UUPL l V ❑,I am exempt under Sec ,B&P C for this reason. LIN Owner - Date ALTER-DRAIN .NT R A) VALUATION 0 WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. VI Y �-�/`p�/ 1 hereby afftrm under penalty of perjury one of the following declarations: ❑Ihave and will maintain a Certificate ofCe Labor Code,for the Workersce of the DRAINS-FLOOR,ROO REA, ON STORIES TYPECONSTRUCTION moron,as provided for by Section 37W of the Labor Code,for the performancebf the work for which this permit is issued. p1XTURES-PER TRAP ❑1 have and will maintain Worker's Compensation Insurance,h required by Section ° ' 3]W of Ne Lab Co afar eperfonnnnce of lM1e work fo which this pe d. GAS-EA.SYSTEM-I INC.40D TS ` DEC.GROUP APN My War kat'sC no drier and Pollc, IifY Cartier: Policy No. -� a GAS-EA.SYSTEM-OVER4(EA) - - CERTIFIC EOE XEMPTIONFROMWORKERS' COMPE SATION INSURANCE GREASEANDUSTRLWASTE INTERCEPT (This section need caths completed ifthe permit is foronehundred dollars($I W) BUILDING DIVISION FEES or less.) - GREASETRAP PLANCHECK FEE (certify thatinthe any awtobecomewhichthis the Workers SEWER-SANITARY-STORM EA.2W FT. shall not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE ' O z intim,Laws of California.Date WATER HEATER WNENT/ELECTR - z O Applicant - GRADING FEE rte NOTICE TO APPLICANT.If, outranking this Cenificate of Exemption,you should WATER SYSTEM)TREATING abecome subject to the Worker's Compensation provisions of the Labor Code,you must _ SOILS FEE W forthwith comply with such previsions or this permit shall he deemed revoked. WATER SERVICE sci 'Q UO _ !, CONSTRUCTIONLENDINGAGENCY NEW RESIDENTIAL PLAID. SQ.FT. PAID - Iherebyaffirmthatthere is a construction lending agency for theperl'ormanceof Data - Receipt# (L H the work for which this permit is issued(Sec.3119],Or.C.) O U Lender's Name - TOTAL: w Lender's Address - TOTAL: - 1 certify that 1 have rated this application and state that the above internist on is BUILDING ME Tap correct.I agree to comply with all city and county ordinances and state laws relating to QT MECHANICAL PERMIT FEE U 7 building construction,and hereby authonre representatives ofthis city to emeropon the SEISMIC FEE above-mentions roperty for inspection purposes. PERMIT ISSUANCE (We)a e o save,indemnify and keep harmless the City of CUFlenim against ELECTRIC FEE Iiididities.jad a casuandexpensesw), hmay in nn wry accrue guinst said City -ALTER OR ADO Ib MECH. Inconsequem of a n'ngofdaspermit. PLUMBINGFEE AT LICANI UN t NDS AND ILL C PLY WITH ,1.1110 V JN-POINT AIR HANDLING UNIT(TO 10,0(X)CFM)' rte^ SOURCERE UL 10 - 1 MECHANICAL FEE AIR HANDLING UNIT(OVER 10,0011 CFM) CONSTRUCTION TAX Signature ofA cony o actor U DaEXHAUST HOOD(W/DUCT) - HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOS Well the applicant or future building occupant stere or ban I -e hamNous material HEATING UNIT GO I W."BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532001 HEATING UNIT(OVER 1 W."BTU) - ❑Yw C]No - VENTILATION FAN(SINGLE RESHy' PAID - Will Neu applicant or future building t use equipment or devices,which Date fi Receipt# PFl gby the quipr Qu BOILER_COMP(3HP OR IW,WO BTU) emit homrdous air contaminants as definetl by the BayArea Air Quality Management District19 BLER-COMP(OVER 100,000 BT(1) TOTAL: ❑Yes tL]No OI .1 have read the harerdeus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCEDA forme Healg data ar Safety Code,Sections.that i 25533 and 25534.1 understand out file NEW RESIDENTIAL MECH. SQ.FT. building drcs not cutren0y hav<h tenanWhnt it is my responsibility mortify the eceupon of the requirements which most he met prior m issuance of a Certificate of Occupancy. Owner or authoured a send - Date TOTAL: ISSUED BY: OFFICE