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S 3277 -APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE SAL_L POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PF, IT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 3277 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE IOy Bonn d�• � 2 - g OWNS 'SN EC7 ONE: COjJTkACf0R'N M� Te ,5 LIC NO: N/C CONTROL# • ARCHITECT/ENGINEER: LIC NO: /DDRESS: ❑ o F` cT, gsiao CONTACT: PHONE: BUILDING PERMIT INFO n © ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MELD 6 El52-- ❑ f5� LICENSEDCONI'RACTG 'S DECLARATION QTY. ELF,CTRICPERMIT FEE 1 hereby affirm that 1 am licensed under pt l,mm of Chapter 9(commencing JOB DESCRIPTION - 1"1� Z wish Section 900E off ividan 3oflha Buslaessvnd Raresanus Code,and my license is FOO in full force and \}, PERMIT ISSUANCE O RESIDENTIAL: 4FUZU License Class d Lim.p O% ❑SFDWL [_1 KITCHEN REMODBI. NQS Dam Conexmr ' .rpm APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE F5h ARCHITECTS DECLARATION -PANELS DMULTI-UNIT DSTRUCTURAL z O understand 1 undend my plans shall be used as public records � MODIFICATION OZ-O UP TO 200 AMPS ElINTERIOR ❑CHIMNEY REPAIR F4,F„M Licensed Profcrsimml 201-I1100AMPS IMPROVEMENT LI SWIMMING POOLS gC MOVER IWOAMPS C:1 BATH REMODEUREPAIR DEMOLITION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the U following reason.(Section 7031.5,Brains,,and Professions Code:Any city or county SIGNS ELECTRICAL D OTHER �F '�; ¢n which regmree a permit to cnnstuct,Ater,improve,demolish,or repair any structure �. ..] prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. G that he is licensed pursuant to the provisions ofthe Contactors License Law(Chapter 9 Y]�66g0 (commeudng wifir Section l0(0)of Division3afthe Bminessvnd Erdtxinns Code)m TEMP.METER OR POLE INST. COMMERCIAL: Yy c C that he is exempt therefrom and the basis for 0e alleged exuntption.Any violation of W BLDG/ADDITK)N D DEMOLITION X m la. Section 10315 by any applicant for a pernm adapters the applicanl In acivil penalty of POWER DEVICES 4411�+m TENANT C1FOOD SERVICE FZ eg ^m than at five hundred dollars($500), IMPROVEMENT sd0 D1.as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC ya- will do the work,and the structure is not intended proffered forsale(See.1044,Business DOTHER 0. and Professions Code:The Contractor's License Law does nm apply to an owner of 7 OUTLETS-SWITCHES-FIX'NRF,S D progeny who builds or Improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT SQ PC sale.If,however the building or improvement is sold within one year al'complchred,the SQ.IT.FLOOR AREA $ISQ.ET owner-builder will have the burden of proving that he did not build m improve for par- pmo of sale.), D 1,as no,of the properly,am exclusively commerce,with licensed contractors to T(jTAL: construct the project(Sec.9044,Business and Professions Cade)no Career, Ij- cerm Law docs not apply to an owner of property who builds or Improves thereon,and QTY, PLUMBING PERMIT Q who contracts for such project with a contractors)licensed punuam to the Contractor's License I.. PEk MI'T ISSUANCE D I am mre exempt under S . ,B&P C for this ason Owner Date ALTER-DRAIN&VENT-WA'rM EA) V ON • WORKER'S COMPENSATION DECLARATION BACK FLOW PROIRCE DEVICE I hereby affirm under penalty of perjury one of the following declarations: D I have and will maintain a CenificateofConxat to self-insnrc for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION action,as provided for by Section 31(X1 of the Labor Code,for the performance of rhe work 1'or which this permit is issued. FIXTURES-PER TRAP 1110 have and will maintain Worker's Compensation Insurance,as required by Section ofthe Unfair Code,for the perforromme tithe work for which this permit is issued. GAS-EA,SYS"TEM-1 INC.4 OUD Fre OCC.GROUP APN My Wear r'x pe satitnlnstmnet carrier and Policynytnpp Carzief. Policy No.:T�l .3l�Y����Qrr GAS-EA.SYSTEM OVER 4(EA) CERTIFICATE F EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASPJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This onion need not Ise complaint if the permit is to' no hundred dollur-s($100) or Ices) GREASETRAP PLANCHECK FEE I certify that in the pmrfmmanceoDbe work for which this permit is issued.lshall SEWER-SANITARY-STORM EA.21X1 FT. not employ any penou in any manner,vn as ,,become xahj,c(nvhe Warkeru Colarn- ENERGY FEE Z saritn Laws of Cabftmia.Date - WATER HEATER WNENT/ELECTR � Applicant GRADING FEE N NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMffREATING abecome abject m the Workers Compensation pmvis rues time Labor Code,you most SOILS FEE LL7forthwith comply with such provisions or this permit shall be deemed revoked. WATtlR SERVICE Q ppp❑..sift CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH SQ.FT. PAID U Q I hereby affirm lhat the.iso constareton lending agency for the perforronee of - D Rewlpt# w F the work for which this permit is issued(Sec,3097,Civ.C.) p Lender's Name TOTAL: r LUkI Lender's Address TOTAL. 1t 1 certify that I have rend this application and stale that the above Infer n ors.is BUILDING nHi Vf correct,d agree to comply with all city and county ordinances and state laws relating m QTY, MECHANICAL PERMIT FEE building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE above-meminned property for inspection purposes. (We)agree to save,indemnify and keep hatmlese the City of Copernicus against PERMIT ISSUANCE ELECTRIC E liabilitles,jare of the costo and expenses which may in any cony amcme against said City ANTER OR ADD TO MECH. PLUMBINGFF- in onsequenceofshegmmingnfthis mit. APPLICA DE 'TANDS WIL R1I'L HALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) SOI MECHANICAL FEF. Z, Q " AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signatureof ApplicanUCuarace, Date EXHAUST HOOD(W/DUCry HOUSING MITIGATION FEB HAZARDOUS MATERIALS DISCLOSURE. e� Will the applicant or future building wearpantsmre or handle hazuNous material ` HEATING UNIT(M 100,000 B'DO) Z.IV as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safely Gude,Section 25532(a)1 — HEATING UNIT(OVER IWAY)BTU) DYet, 211/ VENTILATION FAN(SINGLE RESID) PAID Date Receipt If Will the ilrecaammor fining occupantuse .Air unt or Maces nagement BOILER-COMP(3HP OR 1(X1,000 BTU) emirict? us air monmminanta dcPolcd by the Pay Arca Air Qualify Management T(PT L: Linder? ❑Yes BOILER-COME(OVER IIXLUOU BTU) t AIR CONDITIONEk (__11`0 l I have read the zallous atrial requirements under Chapter 6.95 of the Cut- - ISSUANCE DATE I'nmla Henhh&S n>&,S tions 2 0 533 and 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.F1'. building does oily have I n of tis my responsibility to notify rhe Deco am - / Q of the requir a hkh url m pr' [a instancExi-e of a c H oh0au Ownert sed agentL� D c 1/i OT ISSUED BY OFFICE