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S 0780 r APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - CITY OFCUPERTINO RUILULNG-ELECTRICAL P IT NO. 7 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0780 HO BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION$UBMI'ITAI,DATE # q - I - q� OW E S I PHONE: CO R ORWS MP. LIC NO: !Gf'(_ t © NIC CONTROLM �• ARCHITECP/IiNGINEER: LIC NO: DDRES ' „�f ❑ CONTACT: PHONE: x90Ve --7 BUILDINGPERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) nLOG EhF.LT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION 1 hereby nfrom that I um licensed under provision.of Chapter 9(commencing OWZ with Section llKKOnfUivision3ofthe Business and Rnreasino.Codc,nnd my license is RESIDENTIAL' W O PERMIT ISSUANCE MODEL Fly full farce andel e 3 ❑SFDWI. ❑MODKITCHEN FICATRE; ON �U j Liccnae Chis Lw-0 APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RB-PIPE Z{y Date •LL,0 - Contac I•n6y y A�Cf-SD t I1 ❑MULTI-UNIT [I STRUCTURAL ~m 7, 1 understand my plans shall be used as puhlic records PANELS MODIFICATION ZOrn,.- UPT02MAMPS [I INTERIOR [I CHIMNEY REPAIR OyFW Licensed Professional 201-1000AMPS IMPROVE SWIMMING POOLS pQ�Y OWNER-BUILDER DECLARATION OVER Fiat AMPS ❑BATH REMODF.URF.PA]R El DEMOLITION `C t I hereby a1B,m that I am exempt from the Contractor's License Law for the NQ.U rollowingreason.(Section 1031.5.Businesa end Professions Cale:Any city or county SIGNS ELECTRICAL [I OTHER ,F" which requires a permit m mnswct,alar,improve,demolish,m repair any swnure p,I.,tela isammea,iii-ne,micathe applicant Eminent 1.11[ofile.signed statement SPECIAL CIRCUIT/MISC. �y that he is licensed pursuant aw(Chapter9 Iy,Y,�p (cummgw encinith Sec1km700)ofDividrm3ofthes c Bminsand Patax,rns Cowkm P.) TEMMETIR OR POLE INST. COMMERCIAL, 0,tL M y that he is exempt therefrom and the hesis for the olleged earavown.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION �LL11 4• Section 7031.5 by any applicant fora permit subjects the applicant tnacivil pewhy of POWER DEVICES ❑TENANT ❑FOOD SIiRVICE y not morethan five hundred dollars($500). IMPROVEMENT SQ CL SWIMMING POOL ELECI'RIC ❑OTHER ill Bothe work,sod the he Co a is to.%Lneede Law do for tale(Sec.n ant owBriner if W and property who Gisler The Contactors License law does not appy a an owner or OUTLBfS-SWITCHES-FIXTURPS d property who builds or improves thereon,and who lora such work himself or through his own employeese provided that such annisvoidimprovements aro nn intended or offered Int NEW RESIDENTIAL ELECTR SQ t1'. sale,If,however.Ne building wintpmvemem is sold within one yearof completion,the SQ.Ff.FLOOR ARLA SISQ.FT. nwner-builder will have the burden or proving that he did not build or improve for put- - pose of saleJ. TOTAL: ❑1,as owner of the property,am exclusively contracting with licensed conaacton to 10, construct the project(Sec.1044,Business and Professions Code:)The Commena's Li- cause Lew does not apply to an owner of property who builds or lmpmves thereon,md QTY PLUMBING PERMIT FEE V/ who emancts Eminent projects with a cmmmCtor(a)licensed prop mum the Contractors V License Law. PFRMIT ISSUANCE 1 an exempt under Sea. .B&P C for this reason ALTER-DRAIN&VENT-WATER(EA) I VALUATION Owner Data WORKER'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE 1 hereby affirm under penalty of Perjury one of the following declar tions: • F1 I have and will maintain a CeniOcate of Consenuo self-insure for Worker's Cnmpen- DRAINS-FLUOR.ROOK AR E- .COND. STORIES TYPE CONSTRU6TION action,as provided for by Section 3100 of the Labor Code,for the pm brmance Of the walk for which this Permit is issued. FIXTURES-PER TRAP 1 have and will maintain Worker's Compensation Insurance,as required by Section 3100o1f1he Labor Crude.for Ne performance nfthe work L+rwhich this perm it is issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP APN My Wary C m enwr Ins move carrier and Policy GAS-EA.SYSTEM-OVER 4(EA) Carrier.,(,+�', Policy No: - CER FICA OF EXEMPTION FROM WORKERS' GRLASFJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION PETS (This action need not he completed if the permit is for ane hundrcddnllnrs($I(Xll GRFASB'fRAP or lean.) PLANCHECK FEE leenifythat in thepednrmmceofnhewark fnrwhich thispenaitis isaued.lshall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any none,so os ,,become subject the W.Awris Cnmpen- ENERGY FEE Os� sation Laws of California.Date WATER HEN]ER W/VENTMLECTR O GRADING FEE 0 Applicant t G y NOTICE TO APPLICANT.If,aper making Otis CaniGcate of Exemption,you should WATER SYSTEM/I'RFATING SOLSIME H become suhjecno the Workers Compensation provisions of the labor Code"YOu must tri foMwirh comply with such provisions or this penult shall b,deemed revoked. WATER SERVICE IgJ Q d CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN. SQ,FF. PAID Doe c I hereby affirm fund is a construction lending agency for the performance of ip {U F the work for which this permit is issued(Sec.3091,Civ.C.) TOTAL: 0 Lenders Name Lenders Address TOl'AL: 0 1 certify that 1 have read this application and nam Nut the uhovc information is BUILDING PEE W N creel.las=to comply with all city and county Ordinances and state laws orating to QTY. MECHANICAL PERMIT FF,E SEISMIC FEE V z building construction.and hereby authorize representatives of this city to enter upon the aMve-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE (We)agree to save,indemnify and keep harmless the City of CuMmuto against Iiabilinien.judgments,costs and expenses which may in any way same against said City ALTER OR ADD TO MECH. PLUMBING FEE in consequence of the gnntimg Of this Perttit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO E L)00 CFM) MECHANICAL.EES OURCEREGULATIONS. AIR HANDLING UNIT(OVER 10.0110 CFM) CONSTRUCTION TAX Sig re of AppiwirviComm r More EXHAUST HOOD(WIDUCO HOUSING. ION HAZARDOUS MATERIALS DISCLOSURE Will the epplicamnr future ImIdingoccupuntstorcor handle hamrdous material HEATING UNIT GO 1(0,000]ITU) as defined by the Ctiper0m Municipal Code.Chapter 9.12,and the HeuOh mad Safety - Code,Section 25532(x)? HEATING UNIT(OVER 1Do"BOD ❑Yea []No VENrll.AFIOa ESID) PAIDDote Receiptp Will the applicant or future building Occupant use equipment ser devices which BOILER-COMI BTU)mit hamrdoua air,mnaminer.as defined bythe Bay Area Air Quality Management TOTADistrict? BOILER-CO0 BTU) _❑Yes ❑NoI have Head the hamrdons maraia[a namrsa ares under Chapter 6.95 of the Cali- AIR CONDIT - ISSUANCEDATE fom Health&Safety Code,Sections 8505,25533 and 25534.1 understand that if the NEW RESIDSQ.FF.but ding does nm currently have a tenant.that it ix my responsibility mostly thesx�cu.ntmentawlt h ¢pror suanceofaCenificat fOceu ancy.pe Owner 11bodzed agent alb _ TOTAL: ISSUED RY: OFFICE