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30142 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTIN'0 BUILDING-ELECTRICAL: PERMIT NO, '3O1 a L 4 BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL JK BUILDING PROJECT IDENTIFICATION BUILDINGADDRPSS: SANITARY NO. APPLICATION SUBMITTAL DATE 7536 HOLLANDERRY -PLACE,CUP8kTEENo ? 31 OWNER'S NAME: PH ON is r` CONTRACTOR'S NAME: LIC NO: J/ 6 - ul O ES 8q I N/C CONTROL RCHITCCGENGINEER: LIC NO: ADDRESS'. ONTACT: PHONE: ' BUILDING PERMIT INFO �AM� As �}go v& ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MrE��CrH- LICENSEDCONTRACTOR'SDECLARATION OI 1 hereby affirm that 1 am licensed under provisions of Chalice 9 Bursts in QTY ELECTRIC PERMIT FEE p g JOB DESCRIPTION 7�n ith Section 7000)of0ivision 3 ofthe Business and Professions Ceda.andm license is y PERMIT'ISSUANCE RESIDENTIAL: full force and effect. 0SFDWL O KITCHEN REMODEL cense ClassLic.NpppL1ANCCS-RESIUENTIAI.ote Cncinnator ❑ADDITION ❑PLUMBING RE-PIPE [N[..DOtt ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT 0STRUCTURAL Z pv2 7,. •1 understand my plans shall he used as public records MODIFICATION HPT0200AMPS O Z=4� [I INTERIOR " ❑CHIMNEY REPAIR twit Licensed Professional - 201-1000AMPS IMPROVEMENT yy�•S� OWNER-BUILDER DECLARATION W Q 1 hereby affum that 1 am exempt from the Conlractor'a License Law for the OVER 1000 AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION $l3 LL V followingatom.(Senior 7031 5,Business and Profession.,Code:An y o y SIGNS ELECTRICAL IM.S ALL VTAf- YLL77 re' ycit or ❑OTHER 7 LL which requires a permit to construe,ellen improve,demolish,or repair any structure F1 R c PL AC•E yprior to itsissuance.elw requires theupplicum mrsuch permit 10 file u signed manmm SH,,A1.CIRCU1`VMISC. y`�} that he is licensed pursuant to the previsions of the Comment's License Law(Chapter 9 COG (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: y p{ that he is exempt therefrom and the basis for the alleged exemption.Any violation of ONEW BLDG/ADDRION 0 DEMOLITION full 4, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES m cwt mom than five hundred dollars($500). ❑TENANT ❑FOOD SERVICE pDl,as owner ofthe proper,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT!' will da the work,and destruction nte is nut inded oroffetcd for In(Sce.7011,Business E1OTHER and Professions Code:The Convector's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements ort but intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however,the building or lmprovenent issoldwithin one yearofmmpletion,the SQ.FI(FLOOR AREA .$/SQ.FT. ner-builder will have the burden of pmving that he did nm build or improve for pm- Cy pose of sale.). El 1,as owner of the progeny,am exclusively contracting with licensed contractors to nsuuct the projat(Sce.7044.Business and Pmfcemions Code:)The Contractor'I Li- apse Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE wh comma for such projecu withvcontneorts)licensed punuanun the Contmemrs ,it ansa Law. PERMIT ISSUANCE -/��C'Ut 9�6 I am exemXcicr ee. PCfmrthisreaso0 Z'/•J�j rs -11 ner ALTER-DRAIN&VENT-WATER(EA) VALUATION w X0RKER'SCO ENSATEONDECLARATION - BACK FLOW PROTECT, VICE I hmeby affirm under penal of perjury one of the following decorations: v O l have add will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOFK ,COND. STORIES TYPE CONSTRUCTION setion,as provided for by Section 37M of the labor Code,for the performance of the week for which this permit is issued: FIXTURES-PER TRAP 0 1 have and will maintain Workers Compensation Insurance,ex required by Section 37W of the labor Cade,for the performance of the work for which this pe mut isissued. GAS-EA.SYSTEM.I INCOIIT OCC GROUP, APN My Worker's Compensation Instant carrier wd Polity number are: Center: - Policy No.: GAS-EA.SYST 4(EA) , CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREAMEANDUS S CEPTOR (This suction need not be completed ifthe permit is instant hund�doll Giem) BUILDING Df VISION FISFS or less) GREASETRAP PLANCHECK FEE I cenify that in the performurce ofthe work for which this permit is issued,Isholl SEWER-SANITARY-STORM EA200 FT Out employ any person in any maasubject aer so as to become subjeco the Workers' .Compcn- ENERGY FEE Z suction Laws of Califamia.Date O Applicant WATER HEATER WNENT/ELECTR GRADING FEE s'7 NOTICE TO APPLICANT:IL afar making this Certificate of Exemption,you should WATER SYSTESUTREATING abecome subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEC LLl ti forthwith comply with such provisions or this Perot Wall be deemed revoked. WATER SERVICE Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID ' L1 0 l herebywhich this thtool i is u ed construction 7,Ci, agency for performance of Data Receipt M q.0 no workLerri for which chis permit is issued(gee.3097,Civ.CJ larders theme TOTAL: Lender's Address let ` 1 certify that I have rcud this application and some that the above information is BUILDING FEE '. In correct.l agree n comply with all city and county ordinances said shote laws reling to QTY, MECHANICAL PERMIT FEE L) Z building construction. it heathy audamiu rcprcsenmtives of this city to enter uponthe SEISMIC FEE above-mentioned property for inspection purposes. . PERMIT ISSUANCE (We)egret n save,indemnify end kap hamdess the City of Caperton against ELECTRIC FEE habicities,judgincels,costa and expenses which may in any way accrue against said City ALTER OR ADD TO MCC.. PLUMBING FEE in consequence rf the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE SOURCE REGULATIONS. AIR HANDLING UNIT(OVER HI000 CFM) CONSTRUCfIONTAX Sigrmture of ApplicantiConcrctor Date EXHAUST GOOD(W/DUCO HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will theupplicane or future building wati,mmoromhandle hazardous material HEATING UNIT(TO 100,000 B'1TU as darned by the Cupertino Municipal Code,Chapter 9.12,and the Health card Safety Cede,Section M53200? HEATING UNIT(OVER 100,000 BTU) ❑Yes ONo VENTILATION PAN(SINGLE RESED) PAID $ - - ate 'RuceipU Will the air Ounrt m funs building by the Bt ave equipment m devices which BOILER-COMP CHIP OR 100.000 BTU) it hezrudoue air cnmvminoms as dcrn<J by the Pay Area Air Quality Management TOTAL: )imrWO ❑Yes ❑No _ BOILER-COMP(OVER IW,WO BTU) - I have iced the hazardous materials tequlremcnts under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE (oras.,Health&Safety Code,Sections 25505,25533 and 255.4.1 understand Nat if the NEW RESIDENTIAL MECH., SQ,FT building does notcumently have a teneat,that it is my mspon ibiliry to notify the occupant of the requirements which mum be met prior to issuance of a Certificate of Occupancy. Owner ar authorized agent Dam ISSUED BY: OFFICE