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B 0500 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUIIAING-ELECTRICAL PERMITO 0500 BUILDING DIVISION APPLICATION/PERMIT DING PROD CTusESUTFIC. S0001 BUILDING PROJECT 1UEN'1'IfICATIUN BUILDING ADDRIiss SANITARY NO. APPLICATION SUBMITTAL DATI OWNER'S NAME: �� NE: CONTRACTOR'S NAME: ` CN©� NIC CONTROL` t mIRACI F) Ron 1�4 AR 1 d.TIENGINF.F.R: LIC NO: QDR6.SS: e 1 ❑ l0 31 CONTACT: PHONE: �"� BUILDING PERMIT INFO f—� / 6­16/ 0 � ❑ Consultant Fees Paid by Applicant(Initial) BLS. ELECT PLUMB MECCH 2-7 LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEET rLl7�r JOBDESCRIPTION I hereby aRmr that I am licensed under provisions of Chapter 9(commencing O�Z with Section]UOB)ofDivision3ofthe Rusinessand Professions Cod e, dm mentors RESIDENTIAL' WOO PERMIT ISSUANCE p� Fly in full mrecanden�e g J ❑SFDWL ❑KITCHEN REMODEL aUu License Class—J(�2J--I-ic.N gpPLIANCFS-RPSIDENTIAL ❑ADDITION El PLUMBING RE-PIPE F Z W Date Can rvcm sn6q ❑MULTI-UNIT ❑STRUCrURAL ARCHITECTS DEC A ATION (.L Z O'4 I undersand my plan,laill teased as publia meords PANELS MODIFICATION OZ UP TO 2W AMPS C]INTERIOR ❑CHIMNEY REPAIR P,H)F-WWOW Licensed Professional 201-IOOIIAMPS IMPROVEMENT E]SWIMMING POOLS g,R£ OWNHR-BUILDER DECLARATION OVER Food AMPS ❑BATH REMODELiREPAIR ❑DEMOLITION N fL a 1 hereby affirm that I um exempt from the Contractor's License I.e.for tine Yp5.O6 U following reason.(Sari..7031.5.Business and Professions Gde:Any city or county SIGNS ELECTRICAL �tyl'HI W W es, which¢quids a Permit to construct,alter,improve,demolish.or repair any structure prior m'its issuance,also requires the applicant forsuch permit to file a signed armament SPECIAL CIRCUIT/MISC. , ,y, y tbm hem lie sedpumvam mite provisions of the Commctors License Los(Chapter 9 COMMERCIAL w�po (commencing with Section]010).fDivium 3ofthe Bminesamd Professions Code)m TEMP.METER OR POLE INST. 6 p,m oC that he is exempt therefrom and the basis for the alleged esemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION at 4. Section 703 IS by any applicant fora accord subjects the applicant to u civil penalty.r POWER DEVICES ❑TENANT ❑FOOD SERVICE FZi not more than five hundred dollars($50E. IMPROVEMENT Spa ❑Las owner.(the property,.,myemployees with wages as their sole compensation, SWIMMING POOL ELECTRIC a ❑OTHER willd.the work,and thesrrumumisnot intandedoroRered for sale(Sec.]fHq Business Y7`a�n and Professions Code:The Contractors License Law does not apply to an owner or OUTLETS-SWITCf{ES-FI%TURES Q - t '•k property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or oRercl for NEW RESIDENTIAL ELEM SQ FT sale.It.however,the building or improvement is sold within one year ofcompletion,the 5 ,Q RF.A -LSQ.FT. o vuervhuilder will have the burden of proving that he did not build or improve for pun-pose V \s f aa ro boas owner of the Mopeny,am exclusively contracting with licensed contractors m construct the projen(Sec.]044,Business and Professions Codc:)The Commemr's Li- cense law does not apply in an owner at proprty who builds or improves thereon,and QTY, PLUMBING PERMIT FEE wm contracts for such projects with a nmbactor(s)licensed pursuant to the Contractors License Law. PERMIT ISSUANCE i ❑I sent exempt under Sec. .H&P C for this reason ALTER-GRAIN&VENT-WATER(EA) owner Dare WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby uIll.under penalty of prjury ono of the following due laratlons: ❑I have and will maintain a Cenifcare.f Consent to self-insure for Worker's Camper. DRAINS-FLOOR,ROOF,AREA.GOND. STORIES 'TYPE CONSIRUCI'10 station,os provided for by Section 37W of the Labor Code,fur Ne pc.."I n n".of the work ho which this permit is issued. FIXTURES-PER TRAP ❑ I have and will maintain Workers Compensation Insurance,as required by Section 37Midde labor Cede,for the perfourear,.Dha work for which Nis permit is issued GAS-EA.SYSTIiM-I INC.4 OUTLEFS OCC GROUP APN My Workers Compensation Insurance carver and Policy number me: GAS-EA.SYSTtiM-OVER 4(E Carrier: Polity No: A) CERTIFICA]'E OF EXEMPTION FROM WORKERS' GREASF/INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION IMES (This section need not he completed ifthe permit is former hundreddollats(8100) GREASETRAP orles'.) PLANCHECK FE-F. Icenify that in the performance ofthe work for which al l is issued,I shall SEWER-SANITARY-STORM EA.200 PT. our employ any pe n m any manners us m beco -bjecI the 'atoms'Compen. ENERGY FEE zZ satin.Law Cu ia.D.I,c WATER HEATER WNENT/ELECTR GRADING FEF. Applica9� NOTICE'•TO APPLICANT:If,after making this Ce - te ofof a�ou should WATER SYSTEM/IBEATING ry-t must SOIIS FEE become subject io the Workers Compemamon provisions of tin tabor Gde,ran �i Fat forthwith comply with such p wools nr this pewit shall he deemed revoked. WATER SERVICE iQ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID z m Receipt g V Q hereby which this there isettmswcti.nlending agency Tante performance of Qn (•. he wt Lenders Name ch this permit is issued(Seo.3097,Civ.CJ TOTAL: )U Lenders Name L[l lenders Address TOTAL: fy 1 certify that 1 have read this application and state that the above information is BUILDING FE V1 eomael.I agree to comply with.11 city and coontynahmaces send state cows rearing to QTY. MECHANICAL PERMIT FEE SEISMIC FEE V Z building construction.and hereby authorize representatives of this city m enter upon the above-mentioned property for inspection per,xi PERMIT ISSUANCE ELECTRIC FEE (We)agree m save,indemnify and keep harmless the City.f Coattail.against r liabilities,judgments,costs and expenses which may in any way seems against said City ALTER ORADD'TO MEC". PLUMBING FEE in omsel oro nfthe granting of this permit. APPLICANT UNDERSTANDS AND W�yk1. IT i ON-POINT AIR HANDLING UNIT(10 10.000 CFM) MECHANICAL FEE SOURC t REEK @N. pl AIR HANDLING UNIT(OVER 10,00 CFM) CONSTRUCTIONTAX ign a ant ommcmr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MAQkRIALS DISCLOSURE Willdniallicant m furore buildingsceapant store orhandlehuwdous mounal HEATING UNIT 00 I W,(NNI BT U) as dtftned by the Capetian Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,000 BTU) Code,Section n5532(a)+ ❑Yes VENTILATION PAN(SINGLE RESID) PAID Umc ReceiptM L 1 the applicant of forme building occupant use equipment or devices which BOILER-COMP(3NP OR 101,0111 PTU) .m air contaminants as defined by the Bay Arca Air Qualify Management TOTAL: District! / BOILER-COMP(OVER IW,00(IRTI1) Yes ve mad the baLacous maarids requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE lth ffi Safety Gds.Secnov25505.853]tart] J4.I ondenmidthat if the NLW RESIDENTIAL MECH. SQ.FT.es.tthrom.yin veatenant,that it ism spans' ility to nmify the acupant' pwhich a borne s avec of 'i at of Occyu .tlzm age. m TOTAL: ISSUED BY: OFFICE ADDITIONAL FEM9`7 FEES BUILDING PROJECT IDENTIFICATION VALUATION BUILDING aoo Eu 0 CW EPS NAME m FEESUMMARYI CONTRACTOR BUILDING AN1..a/5o2� uc No PLAN CHECK r.ONTRACTORI FEE ADDRESS PRONE SEISMIC FEE CITY. ELECTRIC PERMIT FEE UTLETS-SWITCHES-RECEP ELECTRIC LIGHTING FIXTURES PLUMBING APPLIANCES-RESIDENTIAL PANELS MECHANICAL SIGNS TOTAL 3 E a SIGNS TRANS. SPECIAL CIRCUIT PERMIT VALIDATIONEMP.METER OR POLE INS. MOTORS SEE FEE SCH. O SERVICE CHANGE Z 2 F LD TOTAL M T ISSUANCE DAT LU > OTY. PLUMBING PERMIT FEE BLDG. ELECT vLcf AAECN. O_ o =) 2 ALTER-DRAIN&VENT-WATER IEA.) J H- V O BACK FLOW PROTECT.DEVICELL p O IU DRAWS-FLOOR,ROOF.AREA,COND. Y H FIXTURES-PER TRAP F z GAS-EA.SYSTEM-I1NCAOUTLETS () GAS-EA.SYSTEM-OVER 4(EA.) INDUSTRIAL WASTE INTER. LAWN SPRINKLERS-1 INC 5 V.B. LAWN SPRINKLERS-OVER 51EA.) WASEWER-SANITARY-STORMHEAEW/VENEA.ZOOft/ WATER HEATER W/VENT WATER SYSTEM / WATER TREATING EQUIP. // OTY. MECHANICAL PERMIT FEE �• ALTER OR ADD TO MECH. APPLIANCE AIR HANDLING UNIT(TO 1Q000C.F.M.) AIR HANDLING UNITIOV ER IOJX OC.FM.) EXHAUST HOOD(WITH DUCT) HEATING UNIT(TO 100.000 B.T.U.) HEATING UNIT IOV ER IOODOO B.T.U.) VENTILATION FAN(SINGLE) BOILER-COMP13 H.P.or 100,000 B.T.U.) BOILER-COMP IOwr r W.00O erul SEE FEES CH TOTAL