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S 4335 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO, BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4335 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE 7§-3s- wyawvw& OWNER' NAME: PH CONTRACTOR'S NAME: LIC NQ: - N/C CONTROL« i� ARCHITECT N /- GINLER: LIC NO: ADDRESS: �m O / a ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CBNTRd wader CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby affirm That 1 an Ifilbe Be under provisions of Chapter 9(commencing JOB DESCRIPTION W�Z with Secereaadc)of Divixi.nJ.f me Business and Professions Cade,and mylicenx is F+IyO ' full tome and eRea PERMIT ISSUANCE SFDWL El KITCHEN REMODEL I �U� °ireneeG w _ e-3 37 S IZZW Dam Commcmr APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE Z:)otiRCHIlECTS DF.CLARATIO ❑MULTI-UNIT ❑STRUCFURAL PANELS Z O�K I understand my plans shell M used av public accords MODIFICATION 'OZ`✓a UP T'02WAMPS [I INTERIOR El CHIMNEY REPAIR ; Licensed Professional 201-i"AMPS IMPROVEMENT 0SWIMMING POOLS C �_1 OWNER-BUILDER DECLARATION OVER If00AMPS ❑BATH REMODEUREPAIR [3 DEMOLITION 4' I hereby alLtm that I am exempt from the Contmcmr'a License Law for the 4 O a V following reason mi (Seon 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRI L A OTHER which requires it pewit m conswn,alae,improve,demolish,or mpvie nny awewm prior to its issuance.also inquires the applicant for such pormiuo file v signed sutement SPECIALCI UIT/MISC. all -L� 4$'' y thm he is licensed pursuammthe provisions of Ne Cnntruanrs license Lew(Chapttt9 W�� (commencing with Secti.n]IX0)of Division3 of the Business and ProPosxionsCode)Or TEMP. ER OR POLE INST. COMMERCIAL: 4 4 p a' that he is ex<mpn mercfmm and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION m,y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POW DEVICES O TENANT [IFOOD SERVICE �Zy not more thin five hundred dollars(550% IMPROVEMENT =a0 ❑I,as Owner of the property.or my employees with wages as thei...]a compensation, S IMMINGPOOLELECTRIC +gyp. will do the work,and theswcwreis notimended nr nnereJ for sale lstt.]M4,Business am and Professions Cade:The Contractor's License Law docs rat apply to an Owner Of OUTLETS—SWITCHES—FU(TUR property who builds Or improves thereon,and who does such work himself m throughe.v his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELECTR SQ sale.If.however.thebuilding or improvement issuld withinonc ye an femn'tttion,Ne Q.FT.FLOOR AREA i VSQ.FT. iser-builder will have the burden of proving that he did not build Or improve for aur- JUL1 (I •)(�(J(� ,oee.fade.l. UL 1 a7 1.7.7x7 l ❑ 1,as owner of Ne property,am exclusively contracting with licensed ridurwtors to TOTAL: construct the project(Sec.7014,Business and Profession,Code:)The Contractor's Li- meLaw does net apply,.an owner of property who builds or improves memos and QTY PLUMBING PERMIT FEE who convects for such projects with a contractors)licensed pursuant to the Contractorsv By License Law. PERMIT ISSUANCE J.S� Ism exempt under Sea ,B&P C for this reason Owner Date AFTER—DRAIN&VENT—WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BA',•',LOW PROTECT.DEVICE I hereby of rm under Penalty of perjury one of the following declarations: V I have and will maintain a Cenilicate of Consent to self-insud for Worker's Compen- DRAINS—FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION cation,as Provided for by Section 37W of die Luba Code,for the performance of the work for which this Permit is issued. FIXTURES—PER TRAP I have and will maintain Workers Compensmion Insurance,as required by Section ] of the labor Coda for the performance ofthe work for which this pewit is issued. GAS—EA.SYSTEM-]INCAOUTLETS OCC.GROUP APN My enrke gC rape oi..Jnsy pp«r�anie Policy NoYnuAlw&'S �,/ GAS—IIA.SYSTEM OVER 4 PA) Camec :S/IVTiG ILP// CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR - BUILDING DIVISION FEES ('otic section need oat he cnmplctN ifthe permit is forone hundred a ) 4 solta1 GREASE TRAP or IessJ PLANCHECK FEE I certify that in the performance.fthe work for whichth"trunt is issued,l shallSEWER—SANITARY—STORM EA.200 FT. ENERGY FEE not employ any person many manner Boae. mis 19bs,4*cwiliy.Vorkers'Contpen- - Z smi Lmasofctiorimiv.D♦q 7 �( 77 x - WATER HEATER WNENTELECTR ��1 C Applicant /i9 I A • ✓" GRADING FEE y NOTICE TO APPLICANT, this Cenificutc of Exemption,you should WATER SYSTEMITREATING a SOILS ME become subject t.the Workers Compensation provisions of the Labor Code,you must forthwith comply with such provisioner this Pewit shall he deemed invoked. WATER SERVICE L n CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID L) O work which thatPermit i iso issued lending agency for the performance of Da ceip,M U work fin which this pewit is issued(Sec.309].Civ.CJ U Lenders Name r, - aft TOTAL: O Leaders Address TOTAL: 1 acnify thin 1 have reed this application nod state that the above information is BUILDI G nor V correct.l agree to comply with all city and county ordinances and state lows relating to QTY. MECHANICAL PERMIT FEE V Z building convection,and hereby authorize representatives of this city to enter upon the SEISMIC FEE ti ab.e-rarcioned property for imiccumi purposes. PERMIT ISSUANCE of (We)agree to save,indemnify end keep harmless the City of Cupertino against ELECTRIC .E liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence ofdra,...fir,of this pewit. PLUMB FEE z APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IBIKO CFM) MECHANI LFEE SOURCEREGULATIONS. /j (,/I q �a� //_ //- ;1—/.j -4( AIR HANDLING UNIT(OVER IB,WO CIM) CONSTRUCTION TAX Signature.f.fLAplp^lic^o'7Connatorr Dau EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building Occupant store or handle hazardous materiel HEATING UNIT(TO IM."BTU) as defined by the Cupertino Municipal Code.Chapter 1.11.and the Health and Safety Code.Section 25532(x)? HEATING UNIT(OVER 100 DTU) ❑Yes ANn VENTILATION FAN SI/LEFS RID) � PAID Will thea applicator or future building t use equipment or devices which Dam 0.eceipt« pp gbytheBBOILER—COMP POR 100,(00 BTU) Ai emit District? us air contaminants as def sed by me day Mca Air Quality Management TOTAL: tJr District? E]Yet, aLS L No BOILER—CO (OVER 100,001 BTU) ' I have read the hvardouv trumrids rcyuircments undo Chuprer695 of the Cali- AIR CO ITTONER ISSUANCE DATE Puma Heabh&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NE ESIDENTIAL MECH. SQ.FT. building does not cuwntly have ate at,that it is my msponsibility to notify the occupant of the Man which most tp'n issuanceofa��/nifirsl fOcrytp y. /'til Ownermauthurizwlag t Data TOTAL: ISSUED BY: OFFICE