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S 3121 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE ITNO. BUILDING DIVISION APPLICATION/PERMIT PLUMmNG.MECHANICAL. 3121 BUILDING PROJECT IDENTIFICATION ❑I1ILDING ADI7RPSS: SANITARY NO. APPLICATION SUBMITTAL DATE oZtlo Hl �Iereat G W1 1&(0 g OWNBB�SNy E: I( ,eqILW zo`Enk CONTRACTORS NAME: LIC NO: NIC CON TROL# ARC��IVVirECf/ENGINEER: LIC NO: ADDRESS: ❑ CONTACT: - PHONE: H ILDING PERMIT INFO ❑ Consultant Fecs Paid by Applicant(Initial) HLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONfRAC'POR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby octm an N 1 can licensed under provisions of chapter 9(commencing JOB DESCRIPTION ADZ with Section 70018.I'Dismird 3ofthe Businesmal Pndession,Cldeand an,license is Iy 05 PERMIT'ISSUANCE FLIn- fusemideffmt. UWL ❑KITCHEN REMODEL li Llmnxe Class Lic.# full APPLIANCES-RESIDENTIAL ❑AUDITION [I PLUMBING RE PIPE Z N a Date-Conlmcmr ARCHITECT'S DECLARATION ❑MULTLUNIT ❑STRUCTURAL. F to PANELS Z O to Z 1 understand my plans shall be IoW as iolibe records MODIFICATION OZ4� UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR P3t:w Licensed Pmfessieral 201-RXMAMPS IMPROVEMENT 0SWIMMING POOLS L6'Y OWNER-BUILDER DECLARATION C Q 1 hereby affirm that I am exempt from the Contractor's License Law for the OVER I"AMPS ❑BATH REMODEUREPAIR D DEMOLITION q(06 U following reason.(Section 70315,Business and Protrusions Code:Any city or county SIGNS ELECTRICAL ❑OTHER W 34 y which requires to permit to mnstnep It,,improve,demolish.or repair any..cm. F.LL40Q prior to its is.......Is.marines theapplicam for such remain file.signet swtemem SPECIAL CIRCUIT/MISC, 14096112, a Olt that he is licensed pursuant to the provisions of the Contractor a Limove Law(Chapter 9 LL]y.6 (commencing with Section 7001)or Division 3 of the Business and Pmfcsom.Code)or TEMP.MLT ER OR POLE INST. L q a Ihm he is cumpl therclmm random basis for one alleged escmption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION tiRC 4. Section 7031.5 by say applicant for a permit subjecu the applicant to a civil penally of POWERDEVICLti ❑TENANT ❑FOOD SERVICE � <y not none,ban five hundred Italian,($500). Las owner of the n,nrm em to res with wa es vs their sole rote tion. SWIMMING POOL ELECTRIC IMPROVEMENT Q prose Y Y P Y 6 pens. ❑OTFiF.R Sym wi dothe wons Carle,and structureommitoti Licensoraffered wdoessot apply to an Business and Professions Cnde:The Contmcmr's License law does not apply m an owner of OUTLETS-SWITCIIFS-FIX'fURFS property who builds or Improves thereon,and who does such work himself or through his own employees,provided that such improvenwros are not intended or offered for NEW RESIDENTIAL ELEC."R SQ ET. sale.If,however,the buildingor improvement is sold withinone year ofcompletinn,the / pSQ.IT.PLOORARI3A E/SQ.IT. caner-builder will have the burden of paving that he did urn build Err improve for par- l/L1� O paw of sale.). ❑ 1,as owner of the progeny,am exclusively contracting with licensed contractors m I'O'fAl_ comarud the pup,"(Sac.7044,Business and 1'mfesslom,Coda:)The Commerce.,Li- trust,Law dries not apply to an owner of timpany Is ho builds or improcca deviation,and QTY, PLUMBING PERMIT FEF. who contracts for such projects with a conlrwmgs)licensed Pursuant o the Commmor'x License law. PERMIT ISSUANCE ❑I am exempt under Sm. .B&P C for Nis micame ALTER—DRAIN&VENT—WATER(EA) VALUATION ODate WORKER'S CO of PENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penally efperjury one of the following Jeclarationr. I have and will maimainn Cenificnm of Cnnsenno self-i...m or Worker's Comren- DRAINS—FLUOR.ROOF AREA,COND. ST R S TI(PF.CONSTRUCTION .dun,as provided for by Section 37M of one Lehr Come,for the pvrfa marm of the work for which this permit is issues. FIXTURES—PER TRAP ❑I have vnd will maintain Worker's Compensation I....maroons requited by Section 37M.fthe Labor Code,for the performoureof the work far which this remit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCC GROUT' APN My Worker's Compensation Insurance carrier and Policy numhcr are: Canter: Policy Nu.: GAS—EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION MOM WO KERS' COMPENSATION INSURANCE Q AREAS STRL WAS"I'B IM'T:RCti1'fOR BUILDING DTVI. )N FE RS _ (This section necl not hennnplelm if the permit is faro read, REAS P or IdsJ PLANCHECK PEI3 I cerifyidat home perfnmtancenfthe work forwhich III r 'tisicucdlsltall E ITA not EA. FT. not emplayany record in any manner so as ter become subject We ©l�mp�n ENERGY FEE Z satin.Laws of Califmni..Dale ,ii E j4ER W/VENT/ELF.CTR z0 Applicant GRADING LLE r y NOTICE TO APPLICANT:IL after making this Certificate 14 Exemption,Yen should WATER S M!1'REATING a Necome subject.,he Workers Compensation provisions of I e ayr Code,you must SOILS FEE comply with such provisions or thus perit shelf mbe tB0 WATER 9F+ICE A CONSTRUCTION LIiNDING AGENCY NEW RESIDENTIAL PLMB. SQ,Ff. PAID V O Thereby eOirm lhm lhcri Smmm lendin6 vgcncy forth,rerfommnce of 'm Receiplp F the work for which Nis permit is issued(Sec.3097,Civ.C.) Q ULender's Name TOTAL"' W Lender's Address TOTAL" Lyn, Lku I certify that 1 have read this applic.0on am state Nm the above Information is BUILDING P E i.r or IZI Crearee m.l a gcomply with a 11 city and county mminances and state lawn rclatingm QTY. MECHANICAL PERMIT FEE SEISMIC FIE (,) Z mildiall,im mesion,vad hereby ammonia,representatives ofthis city to enter upon the above mentioned preamy for inspection purposes. PERMIT ISSUANCE (We)agree to cave,indemnify and keep humorless the City of Culmina against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way acemcagamse said City ALTER OR ADD TO MECIL PLUMBING FEE in rorecerance of the granting of this remrit APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10,00x1 CFM) MECHANICAL FLE SOURCUrItEGULATIONS. AIR HANDLING UNIT(OVER MIRK CFM) CONSTRUCTION TAX Signature of Applicare/Contrucmr pxJ Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future bidding occupantstom or handle havNous material HEADNG ON I r U 0100.000 BTU) as defined by the Cugcnino Municipal Cnde,Chapter 9.12.and the Health and Safety Code,Section 25532(.)? 1HiATING UNIT(OVER 100,000 BTU) E]yes ❑No PAID VENTILATION FAN(SINGLE RISID) Date Receipt# Will he.rplicanl or future huilding accupanl use equipment or devices which BOILER-COMP Little OR 100.000 BTU) emit haeardoua air ronaminnms as defined by the Bay Area Air Quality Management pL: District? BOILER-COMP(OVER 100,11(0 BTU) ❑Yen No I have read the hdardousnwteriAsmquiremems mare,Charter 695 of the Cut,- AIR CONDITIONER ISSUANCE DATE. Tome.Health&Safety Code.Sections 25505,25533 and 25534 I understand that if the NEW RESIDENTIAL.MUCH, SQ.FT A building does not currently have u tenant,that it is my respmsibRay m nosily me compound // / 01 W of the requirement,which mull hson e grin,msom isomeric of v Cenificcte of Decupancy. (/ Owner or anthoneed agent Data TOTALI ISSUED BY: 77� 9 OFFICE