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S 4304I� hoz WF �ZLL +Wv Oaz's PG�`¢ g,gDyU a�3Wl— F-�Oa sn o� =Za C oz Z2 • 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 S 4304 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: 3 LIC ►o.,4. SANITARY NO. APPLICATION SUBMITTAL DATE — �, P OWNER'S NAME: PHONE: CONTRACT(R'S NAMH:CIt LIC NO: NIC ❑ CONTROL If ^� Z_ ` l ARCHITECT/ENGINEER: LIC NO: ADDRESS: tog b4 CONTACT: PHONE:rr BUILDING PERMIT INFO OY J ❑ Consultant Fees Paid by Applicant (Initial) BfL�DG//ELECT PLUMB MECH LN ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION 1 hereby affirm Not I am licensed under provisions of Chapter 9 (commencing with Secsion TKp)of Division Sof Ne Businessand Professions Code.andmylicemeis Licenfull fomc sada t. L�Z.S :Ul'9�_ LicenseC sv Lic.M Dam ` Cnnormon, tel%G 1! s QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION RESIDENTIAL: ❑SFDWL ❑ KITCHEN REMODEL F1 ADDITION El PLUMBING RE -PIPE []STRUCTURAL MODIFICATION PERMIT ISSl1ANCli APPLIANCE - RESIDENTIAL ARCHITECTS DECLARATION trade . tend my piens sball tae used as public m<oMs PANELS❑MULTIUNIT UPT02WAMPS ❑INTERIOR El CHIMNEY REPAIR IMPROVEMENT SWIMMING POOLS C3 BATH REMODEUREPAIR El DEMOLITION Licensed Professional DECLARATION OWNER-BUILDERexempt 1 hereby affirm Nat I ton exempt from the Cummcmr's License Law for the 201-1000AMPS OVER 1000AMPS SIGNS ELECTRICAL. following reason. (Section 7031.3, Businessand Professions Code: Any city or county which requires a permit rt construct, aIle,, impave, demolish, or repair any vorembe ❑OTHER 451 poor to its issuance, also requires the applicant for such Permit o file a signed statement Nti at he is licensed pursuant the provisinna of the Contractors License Law LChap cr 9 SPECIAL CIRCUIT/MISC. TEMP. METER OR POLE(NST. COMMERCIAL: (commencing with Section WIN) of Division 3 ofthe Business and Professions Case)or that he is exempt therefrom and the basis for the alleged exemption. Any violation of Section 7031,5 by any applicant for a permit subjects the applicant to u civil penalty of not more than five hundred dollars ($500). El 1, as owner ofthe palmy, or my employees with wages as their sole compensation, NEW BLDG/ADDITION ❑ DEMOLITION (]TENANT ❑FOODSERVICE IMPROVEMENT POWER DEVICES SWIMMING POOL ELECTRIC will do the work, end the swcare is not intended mitfle ed for sale (Sm. 7014, Business ❑ OTHER �-- -- " and professions Cole: The Commerce, Liceme taw does not apply m an owner of OUTLETS -SWITCHES -FIXTURES property who builds or improves thereon, and who does such work himself or through his own employees. provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale. Jr. however. the building or improvement o wild within one year ofcompletion,the .FL. RAR ownerbudder will have the burden of proving that he did not build or improve for pur- pose"f �wn ❑ e if,if owner of the profanity, um exclusively nmtmcting with licensed contractors to JUN 21 19 9 TOTAL: economy the project (Sec. 7044, Business and Pmfesians Code:) The Confiscates Li - QTY, PLUMBING PERMIT FEE came Law does notapply it, onownerofprogeny who builds or improvesthemmn,and who contracts for such projects with a mntractrood licensed pursuant o the Contractors License ense Law. I]Jerry exempt under Sec. ,B& P C for this reason +' J PERMI3' ISSUANCE ALTER -DRAIN & VBNT- WATER (EA) BACK ROW PROTECT. DEVICE Owner Dae VALUATION x-. O O 5-00 J WORKER'S COMPENSATION DECLARATION I hereby aftrm under penalty of perjury one of the following dcclaretions: DRAINS- FLOOR, ROOF. AREA. COND. have and will maintain a Certificate of Consent taxelf-insure for Worker's Compete as provided for by Section 37M of Nor e labCale, for the performance of the work far which this permit is issued. STRI %O TYPE CONSTRUCTION FIXTURES -PER TRAP F -1I have and will maintain Worker's Compensation Insurance, m required by Section ` 37M of the Litany Cade, for the performance of the work for which this permit is issued, My Werke s ...Ligy Insyutncc c d Policy myrom yr�,� Cnnier:� a�'' L Policy N".:"L09�/9C�Y� GAS- EA. SYSTEM. I INC. 4 OUTLETS OCC. GpOUP 2 APN y ©� GAS- EA. SYSTEM OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' VhyC/_ COMPENSATION INSURANCE (This section need not he completed ifthe pamdt is for one hundred dollars DI 00) or less.) GREASf%INDUSTRL WASTE INTERCEPTOR BUILDING DIVISION GREASEIRAP PLANCHECK FEE SEWER - SANITARY - STORM EA, 200 FL Loy any thatin the pinfivirryouany asbe kforwhije this the Wrkers'Comps issued, rll not employ say person in any manner so ac to bmnme subject m the Workers' Cnmpen- ENERGY FEE WATER HEATER WNENTBLEC R sationlaws of Califnmia. Dae Applicant Applicant GRADING FEE NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should become subject to Ne Workers Compensation precision., of the or Codc, you man WATER SYSTEMITREATING SOILS FEE O forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY L hereby affirm that here is o construction lending agency for the performance of PAID a Receipt If NEW RESIDENTIAL PLMB, SQ. FT the work for which this permit is issued (Sec. 3091, Civ. C.) TOTAL: Under, Name Lender's ANleass TOTAL: BUILDING :E I certify that 1 have read Nis application and some that the above let ..no. is QTY. MECHANICAL PERMIT FEE corect.l agree to comply with all city and coomy ominunces and state laws relmingm building construction, and hereby auNnrite repmsenmtives of this city Incineration the SEISMIC above-mentioned property for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE It ELECTRICFE liabilities,judgments, costs and expenses which may in any way acrnc against said City in n.sequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBLNGEEE AIR HANDLING UNIT (TO lq(100 CPM) MECHANICAL FEE APPLICA UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT ROURC. EG ATIONS. It AIR HANDLING UNIT (OVER 10,0110 CFM) CONSTRUCTION TAX _ at atell'Al,,tyrial/Gelfiniefor Date HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(WR)UCI') HOUSING MITIGATION HE HEATING UNIT TO IN." BTU) Will the applicant or future bailiingnce-pont store or handle hnoalous material as defined by the CuPer ino Municipal Cale, Chapter 9.12, and the Health end Safny Code, Section 25532(-)1 HEATING UNIT (OVER 1 WON BTU) ❑Yes CIN. Will the u licant or pram building mcu tent use ant t or devices which PP 6 1 q i e" emit M1azallous air contaminants as defined by the Bay Aren Air Quality Management District? PAID ..' Date Receipt W AL: VENTILATION PAN (SINGLE RESID) BOILER -COMP LHP OR 100,0110 BTU ( ) ❑Yes ❑No BOILER- COMP (OVER 100.(100 BTU) ! AIR CONDITIONER I have read the bmuNous materials re uitements under Chapter 6.95 of he Cali 9 p (antis Health & Safety Code, Sections 5505. M533 and 255]4. I understand Net if the huilding Acesna eurtently huvw tenant, that it is my rccpnnsihility mnatify Neoccupont ISSUANCE DATE /- a/ —� NEW RESIDENTIAL MECH, SQ. F1'. of q mems w r t 'fi toe" Oecu cy. 6 ! C/Y (P ISSUED BY: r or authorized agent D m TOTAL: OFFICE