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S 0539
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO Bull DING-ELECTRICAL PERMIT ND. BUILDING DIVISION APPLICATIONMERMIT PLUG IS;.-MFICHANICAI, S 0539 BUILDING PROJECT intur'IF'ICATION BUILOADRF-SS: SANITARY NO. APPLICA'TIONSUBMI'TIALDAE P0VA y cS � v 0lS©/ �-� ' q7 OWN PyONE: CONTRACTOR'S NAME: LIC NO:U CONTROLN ARC ; LIC NO: / ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ T-� ❑ LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION I hereby affirm But 1 am licensed under provisions of Chapter 9(commencing Qwz with Section 7MH of Division 3 ofrhe Business and Profession Cade,and my license is R SIU NTIA W p C PERMIT ISSUANCE. EWSi D in full force and eRuct. ❑SFDWL [I KITCHEN REMODEL. C U F License Class Lic.M [ Zm Date Contractor APPLIANCES-RESIDENTIAL []ADDITION PLUMBING RE-PIPE. rn<y ❑MULTI-UNIT ❑STRUCTURAL. I.M H ARCHITECTS DECLARATION PANELS MODIFICATION- 9JZ l understand my plans shall he used as public records UP 702118 AMPS OZ 11 INTERIOR (_1 CHIMNEY REPAIR l,W Licensed Prof,xionul 2111-I000AMPS IMPROVP.MENT 0SWIMMING POOLS •.I OWNER-BUILDER DECLARATION OVER IM)AMPS [D BATH REMODFL1 REPAIR [I DEMOLITION p�,Y Q I hereby affirm that I am exempt from the Contractors License Law for the isj 3 F hdlowing reason.(Section 0031 s,Business and Pime..sians Code:Any city or county SIGNS ELECTRICAL ❑GTHER PLO W O r� which tryussu n petmn requires the eller,improve,demolish,or rtWiany statement a7 phiormhscensece,insane to res prevision o for Contrauch ctors Limnssigneda (Chapter SPECIAL CIRCUIT/MISC. -T Q 2 } that m is withr Section 7")ffic provisions of the eBusin ss nd Prof Law lC ode)9 Q. <f (untie iscixemiNSeisiicl(100)of Diaiiinn3of theeged Business and Professions Code)orTEMIt METER ON POLE INS?. COMMERCIAL, Q.ly c that he i.exempt any applicant and the nasi.for the alleged exemption.Any it violation of ❑NEW RhDG/ADDITION ❑FOOD SERVICE^m LITION $uci 7031.5 by hundrelicantfmapermit suhjucts the applicant uracivil penalty of POWER DEVICES ❑IMPROV El FOOD SIiRVICIi re than Five hundred dollars($5(X0, IMPROVEMENT FSp I,ssowncr of the properly,or myemployees with wages es their sole compensation, SWIMMING POOL ELECTRIC pS� will do the work,and the structure is not intended or offered for sale(Sm.1014,Business []OTHER W and Professions Code:1'he Contractor's License Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who docs such work himself or through his own employees,provided that such itnprovemenk are not intended or otfemd for NEW RESIDENTIAL ELECTR FT. sale.If,however the building or improvement is sold within one year incompletion.the SQ.IT.FLOOR AREA $/SQ.FE wnerbuilder will have the burden of proving that he did not Wild or improve for pur- l awne r of the propertyam exclusively contracting with licensed contractors to T AL nsnactthe project(Sec.1044.Business and Pmfessinas Code:)'fhe Contractor's Li- cense law docs not apply to an owner of property,who builds or improves thereon,and QTY, PLUMBING PERMIT FEE who contracts for such projects with o commands)licensed pursuant to the Contractors License law. PERMIT ISSUANCE ❑ I am exempt under Sec. ,B&P C flnhis rcasan ALTER-DRAIN A VENT-WATER(EA) VALUATION Owner Date X WORKER'S COV Ti A'DON DECLARATION r x / BACK FLOW PROTECT.DEVICE 1 hereby affix under penally o perjuryone of the following declarations: ❑Ihave and will maintain Certificate uf Consent toself-insure for WorkeYs Cnmpen- DRAINS-ItOON.ROOF.AREA,COND. STORIES TYPECONSTRUCIOI t cation,as provided for by Section n 31 W of the label Code, of rformce for the peanthe work for which this permit is issued. FIXTURES-PER TRAP EJ I have and will maintain Workers Compensation Insurance,as required by Section 3100 offle labor Code,for the perfomunce ofthe work for which this permit is issued. GAS-EA.SYSTEM-]INC.40UH.F,TS OCC.GROUP APN My Worker's Compensation Insurance Cartier and Policy number am: Carrier, Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION MES (Thnsuctinnncenl ambammplemd tithe pnmit is foronehundred dollars(SIM) GRP-ASETRAP or less) PW NCHF.CK ME Icenifytht,in the perfoommeof me work far which this permit is issued,l shall SEWER-SANITARY-STORM EA,2!111 FT. not employ any person in any manner so as to become subject to the Warners'Cnmpen- ENERGY FEE Z cation Lows of California.Dare ' WAl'ER HEA TER WIVENTIELECTR 1 z Applicant s GRADING FEE rp NOTICE TO APPLICANT:IL after nmking this Certificate of Exemption,you should WATER SYSTEMUREATING (•" became subject to the Workers Compensation provisions of One labor Cade,you must SOILS F[li at t'7„t forthwith comply withsmh provisions or this pemlit shall he deemed revoked. WATER SE RV ICE D A C'D CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT, PAID V� rDMC! R Q Iherebyaffion that there is a lomtructian lending agency for the performance of ccetptp Llsthe work for which this permit is issued(Sec.31191,Civ.CJ Lenders Name Ie� 1 VF �W( Lenders Address V G I certify that 1 have read this application and state that the above information is BUILDING FEE In commit.l agree to comply with all city and county ordinances and state laws relutingm QTY. MECHANICAL PERMIT FEE L) wZ-t building consuvction.and hauditionhy amhu reprommadves of this city menta upon the SEISMIC FBE above-mentioned property for'mspectiun purposes. PERMIT ISSUANCE ELECTRIC FEE �0 (We)agree to save,indemnify and keep harmless the City of Cupenino against liabilities,judgments,costs and expenses which may in any way accrue against said City AFTER OR ADD TO MECH. PLUMBING FEE in consequence of the granting M this permit. APPI T .RST AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010,000CFM) MECHANICAL FEE SOUL 'ION. AIR HANDLING UNIT(OVER 10.0(X1 CPM) CONSTRUCTION TAX gig ofAppllcen on0act Dine EXHAUST HOOD(W/DUCT) HOUSING MITIGATION TEP, HAZARD S ATTER DISCLOSURE. WUlLeappliic torfum ilding pantsmrc nr handle heruNous nmterial BEATING UNIT(TO ILMM1 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely Code.Suction 25532(a)? / HEATING UNIT(OVER I(H)-D%1 BTU) E]Yea No VENTILATION FAN(SINGLE RESID) PAID Dae Receiptk Will the applicant m futuredingrccupam use Woipmcm or devices which BOILER-COMP(3HPOR I(p,Oq)BTU7 emit haardous air contaminants a' efined by the Bay Area Air Quality Management TOTAL: District? BOILER-COMP(OVER 1(10,(X10 BTU) Yes 1 haveI vmdnus materials AIR CONDITIONER ISSUANCE DATE r5,2553 an uMer Chapter rsta othe iftli- fnmia He th ade,Sections 25505,2551)and 25514.1 ondemtand shot if the NEW RIiSIDENTIAI.MF,CII. SQ.FT. -- - -T oten' L onhkmyrespnms,mlymomifythe spam n bent brofaCmif -C"%— And! _Owner rr autnt Duc TOTAL' ISSUED BY. ...` x I OFFICE