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S 3941APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY lie z °z° a� a0 UO 0U W �z CITY OF CUPERTINO BUILDING DIVISION APPLICATION/PERMIT BUILDING - ELECTRICAL PLUMBING -MECHANICAL BUILDING PROJECT IDENTIFICATION PERMIT NO. S . 3941 BUILDINGADDRRSS: SANITARY NO. APPLICATION SUBMITTAL OATS 11130 ` ace, G 7�- 97 O NF,R'S AME: HONE: J J Sx qC q 0540 O TRACT R'S N � ADDR _, NIC ❑ CONTROL# ARCHITECTIENGINEER: LICNO: CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) BLU ELECT PLUMB / MOH LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing QTY. ELECTRIC PERMIT FEE t JOB DESCRIPTION with Section 7") of Division 3 oflhe Business and Professions Code, and my license is in full farce and effect. PERMIT ISSUANCE RESIDENTIAL: ❑SFDWL ❑ KITCHEN REMODEL APPLIANCES -RESIDENTIAL License Class Lich Dwe Contractor ARCHITECT'S DECLARATION 1 understand my plans shall k used as public records C1 ADDITION ❑PLUMBING RE -PIPE [I MULTI -UNIT [I STRUCTURAL MODIFICATION PANELS UP TO 200AMPS El INTERIOR [I CHIMNEY REPAIR IMPROVEMENT []SWIMMING POOLS Licensed Professional 201-1000AMPS OWNER -BUILDER DECLARATION I hereby affirm that am exempt from the Committee's License Law for the following reason. (Section 7031.5, Business and Professions Code: Any city or county ❑ BATH REMODEL/REPAIR ❑ DEMOLITION ❑ OTHER OVER RNIB AMPS SIGNS ELECTRICAL which "wines it permit to construct, alter, impmve. demolish, or repair any nrvaure SPECIAL CIRCUFUMISC. IV / prions its issuance, also requires the applicant for such Permit o file a signed.natement Nat he is licensed pursuant to the provisions of the Contractor's License Low (Chapter 9 TEMP, METER OR POLE INST. COMMERCIAL: (commencing with Section 7") of Division 3 of the Business and Professions Code)or Nal he is exempt therefrom and the basis for the alleged exemption, Any violation of ❑ NEW BLDG/ADDITION ❑ DEMOLITION POWER DEVICES Section 70313 by any applicant for a pavan subjects the applicant to a civil penalty of Out more than rive hundred dollars ($500). ❑ I, ns owner of the property, or my employees with wages as their sole compensation, will da the work, and the evocwro is not intended olmowd for sole (Sec. 7(004, Business []TENANT ❑ FOOD SERVICE IMPROVEMENT ❑OTHER SWIMMINGPOOLELECBIC and Professions Code: The Contnaors License Law dues not apply to an owner of OUTLETS -SWITCHES -FIXTURES property who builds or improves (hereon and who docs such work himself or through his own employees, provided that such improvements are not intended or offered for sale.If. however, the building of improvement is sold within one yew Of completion, due NEW RESIDENTIAL ELECTH SQ PE SQ. FT FLOOR AREA SISQ,FT. wner-builder will have the burden of proving that he did not hui Id or improve far par pose of sale). ❑ 1, ns owsler of the properly, am exclusively contracting with licensed co nancons to TOTAL: - construct the project (Sec. 7014, Business and Profemions Cale) The C.O.Ors Li cense Law does not apply in an owner of property who builds or improves thereon, and QTY, PLUMBING PERMIT FEE who contracts for such projects with a conuactons) licensed pursuantto Ne Comrncoms License law. ❑ 1 am exempt under Sec. . B & P C for this ¢anon PERMIT ISSUANCE 3 wneraZ Dote ALTER - BRAIN & VENT - WATER (EA) VALUATION BACK FLOW PROTECT. DEVICE WORK R'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of Ne following declarations: DRAINS- FLUOR, ROOF. AREA, COND. ❑ I havemtd will mwntaina Cerificateof Consento self-insurcfor Workers Compen- sation, as provided for by Section 37M of the labor Code, for the performance of the work Iia which this permit is issued, STORIES TYPECONSTRUCTION FIXTURES -PER TRAP O ❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section 3700o1fOr, labor Code, for the performancemthe work for which this permit is issued, GAS -CA.SYSTEM-I INC. 4 OUTLETS OCC. GROUP APN My Workers Compensation Insurance carrier and Policy number ase: Canter: Policy NO: GAS - EA. SYSTEM -OVER 4 (EA) GREASUINDUSTRL WASTE INTERCEPTOR CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE -�' BUILDWG DIVISION FEES (This seetirnneedr n becompleted if Ne permit;, nature huMaddolum SM) or less.) GREASE TRAP PLANCHECK FEE I certify that in the pedomance of the work for which this prrtdt is issued, I shall not employ any person in any manner so as m become subject as the Workets' Camper SEWER -SANITARY -STORM EA. 200 FT. ENERGY FEE WATER HEATER WNENTMLECTR GRADING FEE ration Laws of Cali forms. Date Applicant ` - NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Workers Compensation provisions Of the tabor Code, you must WATER SYSTEM/IREATING .SOILS FEE forthwith comply with such provisions orthis permit shall be deemed revoked WATER SERVICE CONSTRUCTION LENDING AGENCY here is a construction leading agency for the pmfonce of I hereby affirm Oat mm NEW RESIDENTIAL. PLMB. SQ. FLPAID Date Receipt# Ne work for which this Permit is issued (Sec. 3097, Ci, C.) Lender's Name TOTAL: Lendcr',Address AL' ` C) BUILDING FEE 1 certify that I have read this application and state that the above information is QTY, MECHANICAL PERMIT FEE SEISMIC correct, 1 agree to comply with all city rand county ordismnces and nate laws relming to building construction, and hereby authmire representatives of this city to enter upon the PERMIT ISSUANCE ELECT I .hove -mentioned properly for inspection parfaits, ( We) agree m save, indemnify and keep harmless the City of Cupertino against PLUMBING E et, liabilities.judgments, costs and expenses which may in any way accoe against avid City in consequence Of the granting of this Permit, ALTER OR ADD TO MECH. AIR HAN UNIT (T CFM) MECHA AL FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SO��C REGULATIONS. ��JJJ 21111 nom/ . A—�-� O AIR HAND UNI14Y ER � , CFM) EXHAUST OV CONSTRU ON TAX gnatumof Applicant ntnctor Date HAZARDOUS MATERIALS DISCLOSURE HOUSING MI GATION FEE Will theii,licuntof future building necup:mt score m handle haznrdom material HEATING (TO (1Q000 BTU) as deriaal by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 25532(x)? HEATING 10d," BTU) ❑Yes ❑NO PAID -- pp(�OVER VENTILATI Date Receipt# N! Will the applicant or future building occupant use egnipmem or devices which tent by the Bay Arca Air Quality Manageent et hazardous zards air contaminants as defined gen mi BOILER -COMP (3HP OR 10a,g111 BTU) AL. BOILER- COME 100.000 BTU) Dievict' ❑NO ❑Yes Z O AIR CONDITIONER requirements p I have read the hazardous materials Is under Chapter fi 95 of the Cali- ISSUANCE DATE NEW RESIDENTIAL MECH. SQ. FT. mania gHealthdoes & Safety Code. Sections 25505, 25533 and 25534) undemard Net if Ne buildingJcesma, cun have to notify the occupant / hi witheraward. aatitismunceaf.Ceriry of eikemenu hi set be sen Edon to iawonce ofa Certiricat of�WFICT D O ISSUED BY: efl T TOTAL: Or emhorie.e agent Umt U OFFICE