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30351 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - ' CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT ' PLUMPING.MECHANICAL 0 5 BUILDING PROJEcr IDENTIFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI i Oa 3S . D P_ OWNERS ME: - PHONE: CONTRACTOR'S NAME: - JI NO: SZAy1 a� /x ��a�� S e S d? N/C CONTROL# RCHITECT/ENGINEER: LIC NO: ADD�BSS: 4..� V / ❑ 0 E(„qaf_ �&j I-05r CONTACT: PHONE: BUILDING PERMIT INFO I ❑ Consultant Fees Paid by Applicant(Initial) B1L�O�G// ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing , JOB DESCRIPTION a'Z with Section 7037 fDivision 3afthe Businessand Professions Codaand my license is - , DO PERMIT ISSUANCE RESIDENTIAL• �r mfulIf ora an fat. � ❑SFDWL' ❑KITCHEN REMODEL lUpp License Class Lic. APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING R&PIPE y<a Dam Contractor 'V. ARCHITEM S DECLARATION - ❑MULTI-UNIT ❑STRUCTURAL .::)V. I understand my plans shall be used as public recoN.v PANEL'S _ MODIFICATION OZI.Q UP T0200AMPS ❑INTERIOR El CHIMNEY REPAIR [--,�1q"ul Licensed Professional 201-PaRAMPS IMPROVEMENT gad OWNER-BUILDER DECLARATION OVERIWOAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION RSR-' =M< 1 hereby affirm that 1 am exempt from the Contractor's License Low for the 6U following mason.(Section 7031.5,Business and Professions Cole:Any city or county SIGNS ELECTRICAL ❑OTEER —� Nta,Fm¢ which requires o permit to construct.alter.improve,demolish,or repair any structure 0J primo,its issuance,also requires the applicant nonsuch clot 1.fit easignWsmannent SPECIAL CIRCUIT/MISC. p., thin he is licensWponvointm the pcmixuaidt'the Convectors License Law(Chapmr9 00 (commencing with Section 7")dDivision 3 ofthe Business and Professions Cale)or TEMP.METER OR POLE INST COMAAi c pf that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION 4, Section 7031,5 by any applicant for a Permit subjects thoupbeant ma civil penalty of POWER DEVICES ern ❑TENANT ❑FOOD SERVICE Zy not teas thanowne five fthe poreddollars myepl IMPROVEMENT •wQ ❑Lothe wor , the pmpcny,or myemployces with wages red foralel(Sec. 044.Burnes SWIMMING POOL ELECTC F� will do the work,and the he Cot is not intended Livens orofw does nor apply to an Business ❑OTHER 0. and o,nom Cade:The Commnor's License Law does not apply s if owner of OUTLETS-SWITCHES-FIXTURES papery who builds or improves thereon,and who does such work himselffo through his own employees e provided that such mentis old w an not intended m oledon,for NEW RESIDENTIAL ELECTS SQ sale.If,however.the building or improvement is sold within one year of completion,the $Q.FT.FLOOR AREA 5/SQ.PT. owner-builder will have the burden of proving that he did not build or improve for pur- _ c of a . [sl.ass owner of the propeny,am exclusively cnntracting with licensed contractors to TOTAL: tP k^ Rr emommenhe project(Sec.7044,Business and professions Code:)The Contractor's Li- cense Law doo,not apply to an owner of property who builds or improves thereon.and QTY PLUMBING PERM IT FE AUG 9 1996 who contracts I'm arch projects with a contmm crta)licensed pursuanrto the Commums mr's n License Use PERMIT ISSUANCE 1 am exempt under Sec. .B&P C for this reason -f- ALTER-DRAIN&VENT-WATER(EA) v 'VALUATION ,\ Owner Dam WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE J DO 1 hereby dm fmunder penalty of perjury one of the following declamations: J I have and will maintain a Certificate of Cortaro self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. - S RIES TYPECONSTRUCTION F radon,m provided for by Sworn 3700 of the Labor Code,for the performance of the , 1 work for which Nis permit is issued. FUTURES-PERTRAP ' ❑1 have and will maintain Workefs Compensation Insurance,as required by Section 3700ofihe Labor Code.forthe performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC,4 OUTLIDS OCC.GROUP APN My Worker's Compensation Insurance carrier and Policy number art: Cartier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRRASEIINDUSTRL WASTE INTERCEFfOR BUILDING DIVISION FEES (This section r¢cd not bemmpletalifthe permit isfmone bundled Julian($lip) GRF.ASETRAP or less.) PLANCH[CK FF.F. Loy any that inthe any omonceuftI Iwork for which this thepournitWorkers' dlshu0 SEWER-SANITARY-STORM It.201(1 FT. not employ any person in any manner5py�imicfnry{nubject m the Wurkern'Camper. ENERGY FEE z ration laws of Califon 'o Dat a YY'' '''Y/`` WATER HEATER WNENf/ELECTR z� Applicant - GRADING FEL .n y NOTICE TO APPLICANT.If,ra making this Cernificam of Exemption,you should WATER SYSTEMfTREATING F' [' become subject to the Worker's Compensation provisions of the Labor Cafe,you must SOILS FEE {akI G forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. 5Q.FT. PAID Dam Receipt# L)Q Ihcreby affirm that them is acnnamcuon lending agency for the performance of - 'he work for which this pe(mt}ism ur�(Sec.3097,Civ,C.) 0 Fe Lender's Name N O Far TOTAL.: 0 V Lenders Address TOTAL: 1 certify(hut 1 have read this Indication and ame that the above information is BUILDING FEE fn correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE 'V z building consvuction.and hereby liamorim representatives of this city to enter upon the SEISMIC FEE tr above-mentioned pmpeny for inspersion purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE Iiabilioies,judgments,mists and expenses which may in any way acme against said City ALTER OR ADDTO MECH. PLUMBING FEE in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 10.000 CFM) MECHANICAL FEE SOURCE REGULATIONS. I9-46, AIR HANDLING UNIT(OVER 111,000 CFM) CONSTRUCf10NTAX Signal ofApPlic onuaau Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE AZARDOUS MATERIALS DISCLOSURE _ Will theapplicanl to future building occupantsmre ar handle M1nzadous materia110 l HEATING UNIT 100,0BTU) as defitmd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? �� HEATING UNIT(OVER 100.000 BTU) , v� _ ❑yes *Jtlo VENTILATION VAN(SINGLE RESID) PAID Came Receipt# Will the applicant or furore building Izcupant use equipment or devices which BOILER-COM('QHP OR 100,01X1 BTU) nit hazardmin ous air comtaants'as defined by the Bay Area Air Quality Management TOTAL: G Militia? ❑Ycs INo BOILER-COMP(OVER 100,000 BTU) _ I have read the hazardous materials re itursemnts under Chapter 695 of the Call AIR CONDITIONER ISSUANCE DATE foods Health&Safety Cam,Sectium 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FE - building does nm curtemly ha..meant,that in is my responsibility m unify the occupant ofthe taquim ms c must ha met aissuance ofa Certificate of Occuponcy. ..1 aL�t o Owner ore InRd ugc Gam - TOTAL: ISSUED BY: OFFICE