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30120 APPLICANTTO FILL IN INFORMATION,WITHIN RED LINES-USE BALLPOINT PEN ONLY „ CITY OF CUPERTINO BUILDING ELECTRICAL PERMIT NO BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL - O n O BIROJECT IDENTIFICATION G BUILDING ADDRESS: - con'.ING PSANITARY NO. APPLICATION SUBMITTAL DA" D OWN NAM& / .e7�1 'HON _ CJWUCTOR'S NAME: LIC NO: _' ,/ ( �V l../< z 7z�{) L(J E' �� "� c3�' N/C CONTROLN ' AR T/ENGINEER: - LIC NO: p Pq; s ❑ CO/NTIACrTy .PHONE: BUILDING PERMIT INFO ,,f SID _Z�-�� E] ConSWtanfFeesrPaid by Applicant(Initial) BLDG ELECT PLUMB METH e MCENt I a CONTRACTOR'S DeGons Of Chapter Q TELECTRIC PERMIT FEE _ I hereby affirm but I nm licensed under and Pefee of Chapter 9(commencing JOB DESCRIPTION {iO O,Z with Scotian 7000)of Divisian3ofthe Business end Professions Code,end mylicense is RESIDENTIAL F in full force and elle )-„�' © T ISSUANCE UZ U License C ss Co k ❑SFDWL ❑KITCHEN REMODEL h6G Dam '� Contractor - - NCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE [�.rOrn A ELTS UECLARAt10 S' ❑MULTI-UNIT ❑STRUCTURAL Z O y Z " t understand my plana shall Iscariot-sed as public records " MODIFICATION O Z 0 s 1X1 AMPS ❑INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT OWNER-BUILDER DECLARATION AMPSI herebyaffrm Nat I am exempt from the Contractor's License Luw for Ne000 AMPS El BATH REM EPAIR DEMOLITION >(O d U following reason(Section 7031.5,Business and Professions Code:Any city or county OTHER which requires.a permit to construct,alter,improve,demolish,or repair any stature SIGNS ELECTRICAL y�oe prior to its issuance,also requires the applicant for such permit to file.signed statement SPECIAL CIRCUIT/MISC. "1yG� that he is licensed pursinat to the provisions of the Contractor's License Law(Chapter 9 G�CO (emananeingwlthSection]OUO)ofDlvisioo3 opheBusiness.nd Pro[eselons Cade)or TEMP.METER OR PoLE INST. COMMERCIAL, - 0. e K that he is exempt Nerefmm and he basis for Nc alleged exemption.Any violation'of ❑NEW BLDG/ADDITION [I DEMOLITION Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of PoWER DEVICES F Z P not mom than five hundred dollars I$51p). - ❑TENANT ❑FOOD SERVICE 6Ca Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECT RIC IMPROVEMENT o will do Ne work.and thesWnure is not imemdedo offend for sale(See.7044,Rosiness - ❑OTHER and Professions Code:The Contractor's License Law does not apply m an owner of - OUTLETS-SWITCHES-FIXTURE /_ property who builds or improves thereon,and who does such work himself or through his own employees,provided deficient impmvemema are not intended m offered for NB W RESIDENTIAL ELELTR SQ sale.If.however,the building or improvement is sold within one year of completion,the'' SQ.FE FLOOR AREA $/SQ.FT. er-builder will have the burden of proving that he did not build or improve for par- s f4 R �. p scix aakJ. C ❑I,as owner of the property,am exclusively contracting with licensed'emaracues to TOTAL: construct the project(Sec.7(004,Business and Professions CWc:)The Conwchs''s Li- cense Law does not ripply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE JUN 1996 who contract for such projects with a convactor(s)licensed pursuant to the Contractor's License Law, m PERMIT ISSUANCE ' I sexempt under Sec. ,B&P C for this reason (.IIP VF VV!'LIT IRVIJ l Owner Dare ALTER-DRAIN&VENT-WATER HEA) VALUATION - WORKER'S COMPENSATION DECLARATION s I hereby affirm under penalty of perjury one of the following declansrations: BACK FLOW PROTECT.DEVICE - ❑I have and will maintain a Certificate ofCoenOo self-insure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,CONE. cation,as provided for by Section 37W of the Labor Code,for the performance of the , STORIES TYPE CONSTRUCTION wodc for.which Nis permit is issued. FIXTURES-PER TRAP " 1 have and will maintain Workers Compensation Insurance,as required by Section of the Labor Code,for the penumbrae of the work for which this permit is issued. GAS-EA.SYSTEM- INC.4 OUTLETS OCC,GROUP ' APN MY Wnr 's Cu aeo Insurance carrier and Po)Icy numberp Cm'e: -tp a Policyl�r_. INhl1� � GAS-EA.SYSTEMOVER4(EA) E LOCATE OF EXEMPTION FROM W(1RkCR51' COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (this section need not be completed if the permit is future huodreddollars($IW) GREASE TRAP or less.) - PLANCHECK FEE Toy any Pal in the performance of the wo for'whic�tthis itisisauCrimpe - SEWER-SANITARY-STORMEA.2W FT. not employ any person in any manners m 9g t v rkers'Crimper- ENERGY FEE O Z satApplicant ants of Cal y'DalZ^� � J u IT' WATER HEATER WNENT/ELECTR O Applicant ^�I / 'Z H NOTICE TO APPLIC after making this(7 dma4 o GRADING FEE L-S �empmn,you should WATER SYSTEM/TREATING �i � becomesubject comply the Worker's Compensation provisions of the cod Labor Cade,you must SOILS FEE W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB.. SQ.FT. PAID U 0 Thereby affirm Nat there is a construction lending agency forthe perfmmbnre of Dare Receipt If - {L the work for which this perm is issued(Sec.3097,Civ.C.) Lender's Name O U ' TOTAL: ' Lender's Address- _ TOTAL: I certify that 1 have read this y and coup and state Pm the above information rmating is BUILDING FEE h bonen.l agree ro comply withal[city and county ordinances and state laws relining e QTY. MECHANICAL PERMIT FEE V ,'� building consuudtion,and hereby authorize represematives of Nis citymenmr upon the SEISMIC FEE ' a0sive-mentioned property for inspection purpe.sea. - We indemnify p yo pe gains PGRMIT ISSUANCE ( )agree to save,Inde xpe and hi c harmless the Cit 'f,against s i t " ELECTRIC PCE liabilities;judgments,costsandof this expenses which may in any way eccme against said City PETER ORADDTOMECH. A consequence of the graining of this D WILL PLUMBING FEE ' SOURCE RENT GULATIONS. ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQ000 CFM) SOURCE REGULATIONS. � � MECHANICAL FEE AIR HANDLING UNIT(OVER 10,0100 CFM) CONSTRUCTIONTAX Signature of Applicant/Contmcmr Date EXHAUST HOOD(W/DUCT) - HAZARDOUSMATERIALSDISCLOSURE HOUSING MITIGATION FEE Will Ne applicant orfumre building necupant store of handle hazardous mateaal HEATING UNIT(TO 1001000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(-)' HEATING UNIT(OVER 100.000 BTU) ❑Yes I I I]No _ VENTILATION PAN(SINGLE RESID) - PAID Will the air contaminants or Intra building occupant use ea Air a or devices which Date Receipt k Distict? us air nmmminen[s es defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,00(i - Dirtdcfl - TOTAL: ' 7 Yea No , BOILER-COMP(OVER I00.0100 BTU) I Y I have rend the hazardous materials requirements under Chapter 6.95 of Ne Cali- AIR CONDITIONER Health ISSUANCE DATE fomiagdoes&Safety Code, ea tens 25505,is my and 25534.I m o6tifand that if Ne NEW RESIDENTIAL METH. SQ.FT. of thengdoesnot currently hich huveemtul that it is rriyresof.Cilitytme of Nepo.y.m s of Ne requirements which most be mat prinnoissuance ofe Ceritieme o[Occupancy. Owner m ierfl mrized agent Date TOTAL: ISSUED BY: OFFICE "