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S 4391 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING ADDRESS S 4391 BUILDING PROJECT IDENTIFICATION - 10103 &Y1ZNC A� CuPe nn/ar CA gSolLf SANITARY NO. APPLICATION SUBMITTAL DATE OWNER' AME:: HONE: " CO TRACTOR'S E: LIC NO: AR A DoRI HU 40g_R96-19 �l wLa a Co. 568298" NIC CONTROL It ARCHITECDENGINEER: LIC NO: ADDRESS: '3*'Iq bUlA cRLE ST. ALO RLTsfiitgb 0, ❑ coNTACT exoNE: BUILDING PERMIT INFO G� p I 9 2-3 ❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLUMB NIECE ❑ © ❑ ❑ LICENSEDCONTRACTORS under DECLARATION QTY ELECTRIC PERMIT -.FEE I hereby affirm that In.i3 licensed i under provisions or Chapter 9(commencing JOB DESCRIPTION ��Z th Section 9000)ofDivisionJ ofthe Business and Profeeslons Code,and my limnse is F0.,WZ nrfull force and effect ,I�/ pZOQ PERMIT ISSUANCE RESIDENTIAL aU0 License Class Lic.# OG O / O r ❑SFDWL El KITCHEN REMODEL PZWDate Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE Fprn ARCHITECT'S DECLARATION PANELS ❑MULTI-UNR ❑STRUCTURAL O ZN.Z I understand my plans shall he used as public records ' Z O UP T0200 AMPS MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR Q Licensed Pmfessronal 201-1000AMPS IMPROVEMENT rya ,'2j OWNER-BUILDER DECLARATION ❑SWIMMINGPOOLS ?Wy dE 1 hereby affirm that 1 am exempt from the Comractur's License Law for the OVER 1000 AMPS ❑BATH REMODEIJREPAIR (]DEMOLITION U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER W a Lc y which requires a permit t.consumer,alto,improve,demolish,or repair any swaare aF,0.-,06 prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. C that leis licensed pursuant to the provisions ofthe Contaxors License Law(Chapter 9 00 (ec'mmensing with Section 7")ofDi,isiOa3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST, COMMERCIAL' 0.km that he is exempt therefrom and the basis for me alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION W,yy Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES not more Nan five hundred dollars($500). ❑TENANT Ll FOOD SERVICE .F.Z< 0 Las owner ofthe property,or my employees th wages st p SWIMMING POOL ELECTRIC IMPROVEMENT will do the work,and the structure is not intended oroffe a Rnsaler(See704q Business []OTHER 6 a and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FlXTURES Eminent who builds or improves thereon,and who does such work himself m through his own employees,provided that such improvements are not intended It offered for NEW RESIDENTIAL ELECTS SQ FT. sale.If,however,the building of improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $ISQ.ET. owner-builder will have the burden of proving that he did not build ar improve for pur- e fp '--Cas the p r er properly,oro Business elyand contracting ng with licensed ilutcu's m TO � conswm the project(Sec]044,Business and Professions Cade)The Canwemr's Li-- cens,,Law does not apply 10 an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE who contracts for such projects with o comractar(s)licensed pursuant to the Contractors License Law. ❑1 am exempt under Sec. ,B&P C for this reason PERMIT ISSUANCE r Date ALTER-DRAIN&VENT-WATER VALUATION WORKER'S COMPE ATION DECLARATION cone l hereby affirm under penalty of perjury one of the following declamations: BACK FLOW PROTECT.DEVI ra ❑I have and will maintain.Certificate of Consent toself-insure for Worker's Compen- DRAINS-FLOOR.RO(3F,AS A. In ion,as provided for by Section 37M of the Labor Cade,for the performance of the STORIES TYPE CONSTRUCTION work for which this permit is issued FIXTURES-PER TRAP ❑ I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN My Worker's Compensation Insurance carrier and Policy number are: Carver: Policy No.: GAS-FA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR (This section need not be completed If the permit is focone hundred dollars($Hi ft BUILDING DIVIb10N FEBB or less.) GREASE TRAP PLANCHECK FEE I certify that in the perrnnninceof the work for which this permit is issued,l shall SEWER-SANITARY- not employ any person in any manner so as to become subject to the Workers'Cnmpen- STORM EA.200 PT. Z tribal Laws of Calicum..Data ENERGY FEE Z Q Applicant 1 WATER HEATER W/VENT/ELECfR GRADING FEE y NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEMNIZEATING a become subject to the Worker's Compensation provisions of the Labor Codc,you must SOILS FEE forthwith comply with such provisions or this permit shall be deme ed revoked WATER SERVICE 0. Q .�. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB, SQ.ET. PAID I hereby affirm that ns hem is a construction lending agency for the performance of Date Receipt# I, P the work for which this permit is issued(Sec.30)],Civ,C.) Lenders Name WLender's Address ,TOTAL. TOTAL: HL1r 1 certify that 1 have read this application and state that the above information is BUILDING F H V) correct.I agree to comply with all city and county ordinances and state laws relating m=UNIT ECHANICAL PERMIT FEE V Z building construction,and hereby rubmar,representatives of this city m enter,upon theSEISMIC FEE above-mentioned property for inspection purposes. ANCE (We)agree to save,indemnify and keep harmless the City of Cupertino againstELECTRIC FEE liabilities,judgments,costs and expenses which may in any way rearm against said CityDD TO MECH. in nsequence ofthe granting of this permit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINTNG UNIT DO 10.000 CFM) SOURCE REGULATIONS EGULATI�.� 1 7-7^/J� HANDLING UUNIT(OVER Ift"CFM) MECHANICAL FEE_/ CONSTRUCTION TAX SlgrmmrenfApplicant/Conmacmr Date OD(W/DUCT)HAZARDOUS MATERIA SDISCLOSUREHOUSING MITIGATION FEE Will Nenpplicunt or future building oceopam smreor handle hazardous material HEATING UNIT(TO 100.00)BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(.)? HEATING UNIT(OVER 100,1100 BTU) E]Yes No VENTILATION FAN(SINGLE RESID) PAID -- Will the applicant ter far..building cecupa d use equipment or devices which Data Receipt# emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) r„ District? TOT U ❑Yes NO BOILER-COMP(OVER 100.000 BTU) s 1 have read the hazardous materials reAIR CONDITIONER ISSUANCE DATE 825533 and Chapter 695 of Ne Cali- Health A,Safety Coda,Sections t,that,2553]and 25534.1 understand d that if the rte NEW RESIDENTIAL MECH. SQ.ET. M1vilding does not cutrcn0y have aterant.tMtit is my respnnsrbllity to notify the occopam of the rWuiremems wyeh West be�Iprlan Donee ofa Cenife�MOccnpvm Ownero mhmized.gem Dam ISSUED BY: OFFICE