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31544 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO I BUILDING-ELECTRICAL PERMI'FNO. XIS BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. J{ BUILDING PROJECT'IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE /�Et6i a . / OWNER'S NAME: PHONE: CO .AG 'S NAME: LIC �� NIC CONTROI.k ARCHITF.CT/ENGINEF.R: LIC NO: All 5: ❑ CONTACT: - //- � PHONE: M - BUILDING PERMIT INFO • KJ�s� Q6P t��V ❑ Consultant Fees Paid by Applicant(Initial) BLDGr ELECT ^3B MECH LICLNSEDCONTRACfOr....Moroni CON Q1'Y. ELECTRIC PERMIT FEE I hereby affirm that I.m licensed ander provisions of Chapter 9(commencing OD ASCRIPTION tLZ with Section TWO)of Division 3 of the Business and Professions Code,amdan1'c �� in full force and cff ynenuis _ PERMIT aU License Class Lic,M Q7 ❑SFOWL .(]KITCHEN REMODEL �,�W Uam Connector' APPLIANCES—RIiSIDF.Nf1AL ❑ADDITION ❑PLUMBING RG-PIPE pq ARCHITECTS ECTS DECLARATION - ❑MULTIUNIT El STRUCTURAL Z 1 understand m lens shall h used as public rtcorda PANUS FFFO... YP pts MODIFICATION O`�� UP TO,200 AMPS ❑INTERIDR [I CHIMNEY REPAIR PON Licensed Professional OWNER-BUILDER DECLARATION 2111-IgXLAMP$ IMPROVEMENT f� '� X 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I"AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION k 3 S V following reason.(Section 1031.5,Business and Professions Code:Any city or countySIGNS ELECTRICAL see 0 OTHER u]LLO which requires a Permit m connrucl,alltt,improve,demolish,or repair any swcmm ffnn priana its issuance.abo requireadmit,plurma I.,such permit e'file.signedmmemem SPGCIAf.CIRWIT/MISC. y that he I.licensed pur..ant to the Pro mums at the Comes, rs License Low(Counter9 CO (commencing with Section 1000)of Division Sot the Busawsoand Professions Cork)or TEMP.METER OR POLE INST. COMMERCIAL: that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION M rn Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE nal more than five hundred dollars($5(q). IMP 3MENT C� ❑.Lasowner.lor prnPerry.or toy employee,with wages us turnstile compens.tion, SWIMMINGPOOLEI.ECfRIC will do the work,and the structure is not intended or offered for sale(Sec.10/4,Business HER 3 R and Professions Code The Convectors License law does not apply to an owner of OUTLETS—SWITCHES—FUTURES Q p' property,who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements arc not intended or oflcral for NEW RCSIDENTIA I.ELECT SQ FT. sale.If,however,Ne building or improvement is sold within one year of completion,the SQ,FF..FLOOR AREA $/SQ.I'll owner-budder will have the burden of proving that he did not build or improve for pur- pose.fele.). ❑h as owner of the propeny,ten exclusively contracting with licensed contrarian to TOTAL construct the project(Sec.Muhl,Business and 1'rofeWm x Code)The Commaor'.Li- nse,Law does not apply man owner nfprnpmy who builds or improves thereon.and QTY, LUM PERMIT FEE who contracts for such projoeta with a contmcmr(s)licensed Dursuanpo the Cammcmr'.x License law. - PERMIT ISSUANCE [3I em exempt under Sm. ,B&P C for this reason Owner Date ALTER—DRAIN&VENT—WATER LEA) AVIV AVa, 'ION - WORKER'SCOMPENSATION DECLARATCT ION BACK FLOW PROTECT.DEVICE it I hereby affirm under Penalty of perjury one of the following declarations: •❑ l have and will maintain a Certificate of Consent to self-insure fnr Workcea Comper- DRAINS—FLOOR,ROOF,AREA,COND. PC CONSTRUCTION' sation,as provided for by Section PALO of the Labor Code,for the perliamunee of the BEV walk for which this permit is issued, FIXTURES—PER TRAP ❑1 have and will maintain Workers Compensation Insurance,as required by Section 3100ofthe Labor Code.for the parommorce aflhe work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS ,plRp APN My orkers Compensation Insurance carrier and Policy mamhcr are: lar, Policy Nn.: GAS—HA,SYSTEM-OVER 4(EA) CERTIFICATE OP EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFANDUSTRL WASTE INT CEPTOR (This section need not be comple ad Katie permit is for one hundred dollars($IOD) - BUILDING DIVISION F[il!S an less.) .1 GREASE TRAP PIANCHECK HE I certify that in the perinrmuncc of the work fnr which this permit is isaucJ,lehall SEWER—SANITARY TORM EA.21111 FU not employ any person in any manner so az to become subject to the Worker.'Compete ENERGY FEE 0Z sabot laws of California.Data WATER HEATS NCNT/ELECTR y 0 Applicant GRADING FEE NOTICE TO APPLICANT:If,after making this Cenifcate of Exemption,you should WATER SY P.M/1'NI?ATING a [fit become subjection the Worker's Compensation prolkions of the Ltdv r Cude.you must SOILS FEE forthwith comply with such provisions orthis permit shall be Jeemod revoked Wq SERVICE �r CONSTRUCTION LP.NDIN(1AGENCY :W R13SIDPNTIAI,PLMB. SQ.PI'. PAID V0 kforw .ffirm lhermiticed(Sect30 l7,Crn .ganey fnrthe performance of IAne RmeiPIN !-X the Lerwork for which this panus is issued(Sec.3091,Civ.Q) Q t` Lender's Name TOTAL: W Lembf,Address - TOTAL: Lls 1 cenify that I have read this application and sham that the above information is BUILDING FEB h comet.I.gree m comply with all city and county mrinuncesamd smm laws relating to QTY. MECHANICAL PERMIT FEE. V 9builJing conswdion,and hereby uuMarize reprcsentutives a on.ca,menter upon be SEISMIC FEE ahave-mentioned property for inspection purposes. PERMIT ISSUANCE'. (We)agree m save,indemnify and keep hornless the City of Cupmino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way occurs against said City ALTER OR ADD TO MECH, in asequence of the granting of this permit. PLUMBING HE APPLICANT UNDERSTANDS AND W COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) SOURC .GULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER K.0010 cpfrCONSTRUCTION TAX S azure of ApplicandComeracmr I D EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEC HAZARDOUS MATERIALS ISCLOSURE Will the applicant arfumre building occupant store or handle harardous material HEATING UNIT LTD 100, TO) as defined by the Cupanina Municipal Code,Chapter 9.12,..it the Health and Safely Core,Section 255321.17 HEATING UNIT IDV' IBO,000 BTLE ❑Yes, ❑Nn VEtsHLATIO N(SINGLE RESID) PAID Will the applicant tbuilding occupant use equipment or devices which Dam Receipt# BOILER OMP(PHP OR 100,0(18 BTU) emit haraNaus air contaminantsininaants a os defined by the Pay Are.Air Quality Management District? B0 .3K—COMP(�VI?R 100,000 HTU) TOTAL: Yes ❑No -.S ax have read the burardous amensda Madomieals under Chapter 6,95 of the Cali- IR CONDITIONER ` ISSU DATE forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if dte NEW RESIDENTIAL MECH, SQ.IT. building does not currently have n[cont,that it is my responsibility to notify the occupant of the requirements which mush he met prior to issuance of a Cenilicam of Occupancy. Owner m rmfl orzW agent Dom TOTAL: SSUED Y. OFFICE