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30441 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - - BUILDING-ELECTRICAL PERMITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 7 0 o A /I44Z BUILDING PROJECT'IDERFIFICATION J .BUILDING ADDRESS: SANITARY NO. APPLICATI NSU ITTALDATE io19Co 'Cary .-e-r�uia Cry, �50� y %a y 9�-- OWNER'SNAMB: PHONE: J©� C ACfO SIJA rL, NIC CONT L p O NRCHITE /HNGINEER: LIC NO: - ADDRESS: - CONTACT. PHONE. i'/1 BUILDING PERMIT INFO DO� as�O3 / Y Applicant(initial) BLDG BUILDING PLUM ❑ Consultant Fecs Paid'b A Iicant Initial LICENSED CONTRACTORS DECLARATION -ffmFEC El ELECTRIC PERMIT 1 hereby an that I am licensed under provision,of Chapter 9(commencing JOB ESC [ONION OO with Seconn7000)ol Division I mile Business and Pro&sviryt,Code,nn dm Ilcenaeir fy in full force and e A (_// ( I/_ PERMIT ISSUANCE R - ID NTIA a Q V Licen Cla l-J Lic.p -I �I lY ❑SFDWL ❑KITCHEN REMODEL C:u mem APPLIANCES-RESIDENTIAL ❑ADDITION 7v. ARCHITECTS DECLARATION EJ PLUMBING RE-PIPE OII.. PANELS - ❑MULTI-UNIT ❑STRUCTURAL OZ.�1 Q I uMcrstand my plans shall he used as public rtcoNa MODIFICATION P41t,R.Il Licensed professional UP TO 200 AMPS CINTERIOR ❑CHIMNEY REPAIR yg 47,,,,) OWNER-BUILDER DECLARATION 701-IMM)AMPS IMPROVEMENT {s,O W G I hereby affirm that 1 am exempt from the Co.,., x License Law for the OVER HCUAMPS ❑BATH REMODP ElD L pS a 6 F following mm-a.(Section 7031.5,Imine..and Pmfero.to Code:Any city or county SIGNS ELECTRICAL ❑OTHER fsl O y which requims a perms m,.mm,,t,alta,improve,Demolish.nr repay any swewre m Jit priorm its issuance.also requiresrhe applicant forsuch permit file a signed statement SPECIAL CIRCUIT/MISC. 00 that he is licensed pursuant m the provisions of the Connucmr's License Law(Chapter 9, _ y (commencing with Section 7000)of Divism.3 Of Ne Businessaod Professions Code)Or TEMP.METER OR POLE(NST. a y o that he is exempt tMrefmm and the basis for the alleged excmptim.Any violation of C1 NEW BLDG/ADDITION DEMOLITION .wry Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ,mora than five hundred dollars(SSoh. ❑TENANT ❑DEMOLI FOOD ION C Q 01,as owner of Ne properly,or my employees with wages as their sole eompensmim, SWIMMING POOL ELECTRIC IMPROVEMENT C2C2.' VICE will do the work,and the structure is not intended.rolTemi for sale(See 70,14,Business ❑OTHER 6 a vnd p ilicaonm Codo,The Contactors License Law does not apply to un owner of OUTLETS-SWITCHES-FIXTURES Property who builds or improves thereon,and who don such work himself or through his own employee,providd that such improvements are not inmmkd or Ply, for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however,the building or improvement is sold withinonic'e. f'ampletioatheQ.FT.FLOOR AREA S/SQ.FT. owner-builder will have the burden of proving that he did not hold Or improve for par- ❑1,as owner of the Property,am exclusively convecting with licensed contractors.- TOTAL: P conswn the project(Sec,See,700044,Business vnd Professions Coda:)no Conuncmrs Li- a' cense Law does not apply loan owner m properly who hullds or improves thereon,and QTY. PLUMBING PERMIT FEE R�/� m who contracts for such pmjecu with o contortions)licensed pursuant m the Contractors License Law. ❑lent exempt under Sec. & �-as Y � ,BPCfor Nie rca On PERMITISSUANCB l+'3yu Owner Date ALTER-DRAIN&VENT_WATER(EA) CITY L WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECE DEVICE .OI hereby affirm under penalty of perjury one of the following deelaadions: - ❑I have and will maintain a Cenificateof Comma wself-insure for Workers Compen- DRAINS-FLOOR,RODE AREA,COND. sation .as provided for by Senion,37fin of the Labor Coda,for the perfirmance of the STORIES TYPH CONSTRUCTION w rk for which this permit is issued. FI%TURFS-PER'TRAP have and will maintain Workers Compensation Insurance,as roll by Section 37W of the Labor Cole,for performance of the work for shich,hi,permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS My Worke' Co e•u' ,Insurysseconier and Policy . aro —GROUP APNi Cerriev�PON No.:� GAS-EA.SYSTEM.OVER 4IRA) CERTIFICATE EXEMPTION FROM WORCERS' COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR or less.) (This section need nen be completed bribe permGREASE TRAP dt is for one hundred dollars IS BUILDING DIVISION FEES I certify that in the perfomance of the work for which thistis issued, Jull PLANCHECK FEE perml STORM EA.200 PT. ' not employ Use any peaoniany manner so atm become subject to the Workers'Campen- SIiWCR-SANITARY- ENERGYFEE ,Z ,tion laws of California.aDale WATER HEATER W/VENT/ELECfR 7�0 Applicant GRADING FEE q y NOTICE 90 APPLICANT:If,after making Nis Cmificnla Of Exemption,you should - F^ become vubjauo the Waiters Compensation pmvisiom of the Lehr Code,you most WATER SYSTEM)TREATING SOILS FEE A forthwith comply with such provisions tr this permit shall be dremed mvoked. WATER SERVICE CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PLMB. SQ.17 PAID UQ 1herebyafftrm Nat Nem is a crosrnelion lendingxgency for the pMannamvof GA Date Rcceiptp H ,he work for which this permit is issued(See.3097,Civ.C.) O U Lender's Name TOTAL: y W Lender's Address TOTAL: L, ly I certify that I have read this application and state that the above informwion is BUILDING E fA cumn.I agree m comply wish all city..it county ordinances vndstate laws relating,. QTY. MECHANICAL PERMIT FEE U z building construction,and hereby manioae mpoesemaives of this city to enter upon the SHISMI 'CE above-mentioned property for inspection purposes. - (We)agree to save,indemnify and keep harmless,he City of Cupertino.,.in,, PERMIT ISSUANCE. ELECTRIC TEE Iiabilides,judgmers.evns and expenses which may in any waynceme&gain'said City ALTER OR ADD TO MECH. in consequence of the granting of this Penni. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQt100 CFM) SOURCE REGULATIONS. . M11CHANICAL FEE AIR HANDLING UNIT(OVER IQOnd CFM) CONSTRUCTIONTAX Signa'urcof Applicunt/Comrae'or Date 17XHAUST HOOD(W/DUCT) HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE Will the applicant or future building cecupem port or handle haanrduus materiel HEATING UNIT(TO IW,IXMI BTU) as defined by the Cupertino Municipal Cone,Chapter 9.12,and the Health and Safety Code,Section 25532(x)? HEATING UNIT(OVER 101LOCO BTU) ❑Yes ❑No VENTILATION FAN(SINGLE RESIDI PAID Will he applicant Of future building occupant use equipment Or devices which Date Receipt N ' emit haardousfie connotations as defined by the Bay Area Air Quality Management BOILER—COMPGHPOR IOO,000BTU) District? E]Yes ❑Nt BOILER-COMP(OVER IOO,)PORTU) TOTAL: I have mend the hazardous materials rtqui¢mm�rs under Chapter 6.95 of the Cali. AIR CONDITIONER form Health&Safety Cole,Sections 25505,25533 and 25534.1 understand that if the - ISSUANCE DATE build idg doe some madly have a mount,that it's��ryY' pomibillrym tify occupant NEW RESIDENTIAL MECH. SQ.FT. of the requirtme x 'hat o syanca3pf. nificm OfQ - " Owner.,m onsed.prit I toI NOTAL: ISSUE BY: OFFICE