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30309 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.ELECTRICAL, PERMUTING. BUILDING DIVISION APPLICATIONPERMIT PLUMBI30309 ING-MECHANCAL BUILDING PROJECT IDENTFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE sou z F3�-v►o. sTE . 7 3,° g OWNER'S NAME:GGCC IJ PHONE: ��DO ro ONTRACR'S NAME: LIC NO:VL1as� NIC CONTROL \RCHRELT2NGINEER: ADDR LIC NO: &SS: 5 ❑ S [!{ It G X31 li3 oLVN5t-N S CONTACT. PHONE: BUILDING PERMIT INFO pampa IW W'f 5AV\/A C-A0 3 664-5 ❑ CoRSWtanl Fees Paid by Applicant(Initial) BLDG ELECT PLUMB M LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE t4T Z 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION with Section]01bof Division Sof the Business and Professions Code,and my license is ` - /� RESIDENTIAL: 00 in full force and effect. PERMIT ISSUANCE L� pg ul �SFDWL ❑PLUMBINREMODEL aU License Chas Com APPLIANCES-RESIDENTIAL ❑ADDMON (3 PLUMBING RE-PIPE Data-- contmrmr LL ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL F5y - PANF.IS Z Or-Z ////7777 WWB0yyrrrr pions shall be used as public rernMs MODIFICATION Oy-. ! �NJiN Pt UPTO 200 AMPS O �, [I INTERIOR El CHIMNEY REPAIR u.4l L enxJ l'rofese nal 201-1000 AMPS IMPROVEMENT OWNER-BHILUER DECLARA'fIUN OVER I"AMPS ❑BATH REMODEUREPAIR [I DEMOLITION G I hereby union Not I am exempt from the Contractor's License Law(."he (iS506U following ren n(Section'T03 LA Business and Ptafessions Code:Any city or county SIGNS ELECTRICAL []OTHER which requires a Permit to construct,alcor,improve,demolish,or repair any Svucmre prior it)its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. Lisr �� P thin he is licensed pursuant pursuano the Previsions of the Contracmfs License Law(Chapter 9 p0 (commencing with Section 11100)of Di vision 3 of the Business and Pmfe..trm Code)ar TE MP.METER OR POLE INST. COMMERCIAL: d y m C that he is exrefr exempt therefrom ad the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION iC Y. Section 70313 by any applicantfor a permit subjects the applicant o civil Penalty of POWER DEVICES W^ria TENANT ❑FOODSERVICE �y0not mote than❑f thundrtdty,or (SSW). /�1PROVEMF.NT 17 Lmowmrk and property,r myemployees dwith wages mtheir Sole 0cal,B sines SWIMMING POOL ELECTRIC E and dothework,amlthe he Contractor's roti License La does rad for apply to Business ❑UTHF.R and Professions Cale:The Conwcreo License Law docs na apply toll owner of 3UTLETS-SWITCHES-FIXTURES 3 his own who builds or improves thereon,and who does such work himself or through his awn employeeprovided that such improvements ore not intended or offered for NEW RESIDENTIAL ELEGTR SQ FT. sale.If.however, , building orimve promem is said within one year of complttiuna.on.the - /)SQ09,FLOOR AREA S/SQ.FT. ..,,bell&,will have the burden of proving that he did not build nr improve for part poseofsalc.). - 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: /!'1/ n construct the Project(Sec.T(W,Business and Professions Cale:)The Contractors Li- \V� •�� cense law does not apply to an owner of pmpeny who builds or improves thereon,and QTY, PLUMBING PERMIT FEE who contracts for mien projects with u cnmracmra)licensed pursuant o the Contrmmr's License law. 11 PERMIT ISSUANCE G L ❑ I am exempt under Sec. ,B&PC for this reason V Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECC DEVICE D� �^ 1 hereby affirm under penalty of perjury one of the following declarations: ❑ l have and will maintain it Certificate of Consent to self-insure for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND, TO IiS 11 TYPE CONSTRUCTION sation,as provided for by Section 37M of the Labor Code,for the performance at me work for which this pewit is issued. 97 FIXTURES-PER TRAP ❑ 1 have and will numboon Worker's Compemsaion hormones,us required by Section 3]Wbo oflhclarCsdefo the performance of the work for which this Pewit ixisowd, l GAS-EA.SYSTEM.I INC.4 OUTLETS /i OCCGROUP APN My Worker's Compensation Insurance another and Policy number ma: GAS-EA.SYSTEM-OVER4 Carries (EA) Policy Nu: ( CERTIFICATE OF EXEMPTION FROM WORKERS' GHEASEIINDUSTRIs WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FITS (This sec,ionnecd not b,completed ifthe pc.it is ftronehundrcddollans(5100) OREASETRAP or less.) PLANCHECK FEE e I certify that in the performance of the work for which this permit is issued,i shall SEWER-SANITARY-STORM EA.2W FT. rs rad employ any peon in any manner no as to become subject to the Worked pe Cnmn- ENERGY FEE 0 N zz sation Laws of California.Dam WATER HEATER WNENT/ELF.CTR O Applicant GRADING FEE Lay NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING a became,subject to the Workers Compensation Provisions of the Labor Code,you most SOILS FEE - forthwithcomplywithsuchprovisionorthispewitshallhedeemedrevoked WATER SERVICE a UO CONSTRUCDONLENDINGAGENCY NEW RESIDENTIAL PUNCH. SQ.PT. PAID ,p,p Dae 1 hereby affirm the,Inert is a construction lending agency for the perfPerformancePerformanceof W. r•t the work for which this permit is issued(Sec.319],Civ.C.) r. he Name TOTAL: {U Lender'.Add.. - TOTAL: w I certify that[have read Nis uppliestion and sore that the above information isorBUILDING v Ln crect.]agree to comply with all and county ordinances and state laws renting to QTY, MECHANICAL PIiRMIT FEC V z building canswaion.and hereby authorise reproxamsives ofthis city to enter upon the SEISMIC PE above-mentioned praperty for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Contain,,.,.,a., ELECTRIC FEE [is bililies,judgments,costs and expenses which may in any way aceree against said City ALTER OR ADD TO MECH. %� in cmen,uence of the granting of thio pmnin. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,01Y)CFM) SOl CERCI 1. ONS. MECHANICAL FEE 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX - Siurere ofAp licaMCum cmr tae EXHAUST HOLD(W/DUCD HOUSING MITIGATIONF F. HAZARDOUS MATERIALS DISCLOSURE Will the pplicam or furore building occupant store or handle hvzmdrms material HEATING UNIT CFO 100,000 BTU) as defined by,he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? ''JJ • HEATING UNIT(OVER 100.00)BTU) ❑Ye. Nn PAID VENTILATION FAN(SINGLE RE51D) ate p Will No uppiiwm n furarc builtling wcupmt use equipment nr devices which emit hazardous air contaminants as refund by the Bay Arca Air Quality Management BOILER-CAMP LHP OR 100.000 BTU) a , Disuiaa IOTA ❑Yes No BOILER-COMP(OVER IaI.(Xp BTU) a Ihave read the hwoarfmlcrvalx requirements under Chapter 6,95 of the Cnti- AIR CONDITIONER t ISSUANCE DATE front Health&Safety Code,Sexual,25505,25533 and 25534.1 mtdemend than if the NEW RESIDENTIAL MECH. SQ.FL mss.. //tt� �•s building does not cumntly have v tenant,than it is my resryasibility to notify the aacmpum hick nun be met prion,issuance nlaCeNti um of cu racy. ( !f [[[[ !I .armauh rizedegent Date TOTAL: 1 OFFICE