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30549 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO' BUILDING-ELECTRICAL. PERMITNO. 11�� pp 9 BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING-MECHANICAL. 0'a1 /' 9 BUILDING PROJECT'IDENTIFICATION vv T �J BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATI 9 � EAo _ �. �3� G W NAME: r J )�� PHONE: CONTRACTOR'S NAME: LIC NO: R W R ZQ7f N/C CONTROL If ARCHTTECT/ENGINMR: LIC NO: '�+ ADDRESS: ❑ CONTACT: PHONE: - BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH LICENSEDCONTRACTOR'SDECLARATION QTY ELECTRIC PERMIT FEE - I hereby afriw that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION a with Sediun 70IXSI nl'Divisimn 3 nfthe Business and Professimns Code,and my license is : �-y in full farce aM effect. PERMIT ISSUANCE RESIDENTIAL WE, ❑SFDWL O KITCHEN REMODEL �U License Class Lica Date Co. APPLIANCESRESIDENTIAL OADDITION El PLUMBING R&PIPE l - ARCHITECTS DECLARATION DECLARATION ❑MULTI-UNIT ❑STRUCTURAL y p h Z undersand my plans shall b used u public PANELS ods MODIFICATION Oy..Q UPT0200 RAMPSAMPS ❑INTERIOR ❑CHIMNEY REPAIR €+'4�W-j Licensed Professional 201-IIXI0AMP5 IMPROVEMENT ' gga OWNER-BUILDER DECLARATION OVER IOOIIAMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION KK a 1 hereby affirm Nm I am exempt from the Communes License Law for the y a,F following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER W O Vs which myvires a permit m ennawet.altar,improve,demolish,or repair any structure 3 prior aid iss ntt.al o requires the applicant farevch Permitto file o signed immanent SPECIAL CIRCUIT/MISC. } that he is licensed pursuanuothe provisions of the Contrdcmre Littsu Law(Chapter9 , G� (commencing with Section 7000umf Division Sof the Bilines,and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: lto Y that he is exempt therefrom and Ne basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION O DEMOLITION mSection 7031.5 byanyapplicant for a permit subjects thenpplicant In.civil penaltymf POWER DEVICES ❑TENANT OFOODSERVICE Z p, not marc than rive hundred dollars($500). C1 ❑I,as ownerof the proemy,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT �.IC'•. will do Ne work.and Neswcmreis oat intended mothered for sole(5cc.704d,Business ❑OTHER W 3 and Professions Code:The Commommes License Law docs nm apply to an owner of OUTLETS-SWITCHES-FlXTURES p' properly who builds or improves thereon.and who does such work himself or through his own employees,provided Not such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ sale.IL howm cv,n the building or improveent is sold within one year of completion,the 'SQ.FT.FLUOR AREA SISQ.FT. owner i ilder will have the burden of proving that he did not build or improve for put- Fac of sale,). ❑I,ns owner of the property,am exclusively commcting with licensed ex nlmt9m s m TOTAL: construct Ne project(Sec.7610,Business end Profcasions Cede:)The Convector's U. - f cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE '• -� who contracts for such projects with a contractors)licensed pursuant o the Contractor'a �1�� License law. PERMIT ISSUANCE S ❑1 am exempt under Sec. ,B&P C for this reason 319 _ Dao ALTER—DRAIN&VI?NT-WA'fER(EA) , VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE � ('Jt�'-nsB••V hereby affirm under penalty of perjury one of the following declarations: ❑Ihave and will muinmine Cenifmum of Consenuoaelf-insure far Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. I RIES TYPECONSTRUCTION vadon,us Provided for by Section 37M of the Labor Code,for the parfmwance of the work hashish this permit is issued FIXTURES-PER TRAP ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 37W of the labor Code.for the performance of the work forwhicb Nis permit is issued. GAS-EA.SYSTEM-1 INC.S OUTLETS OCC.GROUP APN My Worker's Compensation Insurance carrier and Policy number am: Carrier: Policy Nu: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This section neednol he completed ifthe permit is forms,hundteddollara($100) GREASE TRAP or less.) - PLANCHECK FEE I cenifythatmthe pei-hromicof the work for which,hispermit is issued.i shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner su as 0 become saltier,m the Worker:Compen- ENERGY FEE ,Z sation Laws of Culifomin.Date WATER HEATER WNEISTMLECTR O O Applicant GRADING FEE NOTICE TO APPLICANT..If.ofine making Nis Cenificem of Exemption,you should WATER SYSTEM/TREATING abecome aubjecna the Winces CaanPensedon psovisimts of the labor Cade,you must SOBS FEE W forthwith comply with such provisions or this permit shall M1e deemed revoked. WATER SERVICE Q CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. - SQ.FT. PAID I7.Jn T hereby uRrm that issued Son.3097. agency for the perfomiwce of Date Receipt It W It'.+t Lbe embrek for which this permit is issued(Sec.3(197,Civ.CJ TOTAL: O U Canasta Name Lenders Address TOTAL: - G 1 certify that I have read this uppl'sation and state that Ne above information is BUILDING FEE fA c..,I agree,.comply with all city and county mdinances and state laws helium,to QTY MECHANICAL PERMIT FEE U7 building convection,and hereby auioriu representatives of this city to enter upon the SEISMIC FEE above-mentioned pmpemy for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep taintless the City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way creme against uid City ALTER OR ADD TO MECH. in con equentt of the granting of this peanut. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT OD 10,000 CFM) SOURCE REGULATIONS. MECHANICAL.FEE AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX Signsturc of Applimat/Conwcmt Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hommous materialHEATING UNIT OT)100.000 BTU) as definal by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely - Code.Scrumm 25532hH? HEATING UNIT(OVER IDEM)BTU) ❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID Data Receipt W II the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 11X1,000 BTU) emit hazardous air connotations amints es defined by the Bay Area Air Quality Management TOTAL: District? yes ❑Nm BOILER-COMP(OVER 100,000 BTU) ❑ I have rend the hazardous materm materials haphoents under Chapter 6.95 of the CanAIN CONI3ITIONER ISSUANCE DATE Burma Health&Safety Code,Sections 25505,M533 and 25534,1 understandthat if the NEW RESIDENTIAL MECH. SQ.FT. building does nrn currcn0y hove a tenant,the it is my rcaponsibility m notify Nc s<cupant of the requiremcnn which must be met prim m ismnnce of n Cenificvte of Occupancy. ' Ownernr au mimed agent Dat, O ISSUED BY: OFFICE