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99110063 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN O K7 4v� CITY OF CUPERTINO BUILDING-ELECTR ALtei—i— I PE IT O. BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECIA ICAI. BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE It' ed2 OW SNAME. O CO CTOR' E:PHONCLIC NO: N/C CONTROLb iCHITECT/ENGINEEN: LIC NO: ADDRESS: 3 b © t� Ii a �A _i E3CONTACT. PHONE: p C BUILDING PERMIT INFO ❑ Consultant Ftxg Paid by Applicant(Initi ) BLDG ECT PLUMB MF,CH `❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION PAZ with Seniors]gxp ofDivision3of the Business ane Processions Cafe,and mylinnsc is RESIDENTIAL: H WU b in full force and effect. PERMIT ISSUANCE y. rElSFDWL [I KITCHEN REMODEL U License Class Lic.M L�i<a Dam Contracnn APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM BING RE-PIPE F,>,Vt ARCHITECTS DECLARATIONPANELS ❑ IT []STRUCTURALMULTI-UNSTRUCTURAL Z p(2 Z 1 understood my plans shall battened as public maonls MODIFICATION OZ-0 UP TO 200AMPS ❑INTERIOR ❑CHIMNEY REPAIR 1-�E•'W Licensed Professional 201-1000AMPS IMPROVEMENT EjSWIMMING POOLS OWNER-BUILDER DECLARATION OVER RKIFAMPS ❑BATH REMODEUREPAIR [I DEMOLITION SLS st I hereby affirm that I am exempt from the Contractor's License Law for the '31 jyF following 91U ...n.(Scction 7031 S.Rosiness and Professions Code:Any city []OTHER or county SIGNS ELECTRICAL which requires a Formal to construct,alter,improve,demolish,or repair any structure I. pmater issuwce,ala,rcquirestheapplicamfo...ch peva ted file.signed,hmmeat SPECIAL CIRCUIT/MISC. ydoes he is licensed pursuanuofire provisionsanheCommiLicense Law(Chapter 9 �OCpO Icotmnencing with Smion 70fp)of sion 3 ambo Businessand Professions Code)., TEMP.METER OR POLE INST. COMMERCIAL: a L eC that be is exempt therefrom one the basis for the allcgW exemption.Any violation of ❑NE DG/ADDITION El DEMOLITION X m 4. Section 7031.5 by my acidic.,has poicand objects the voplicarl to a civil penalty of POWER DEVICES ItJ—linANT (FOODS CE t more man five hundred dollars(ESm). 1I IMPROVEMENT _6 n Laso,mil,and pmpemy.or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC � will dotbewmk.Care: he Cia snotlnmeded Lu.does of apply taco mmorof ❑OTHER ncis and Professions CuJc:The Convacmrs License Luw docs not apply m im asvner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who docs such work himself or through his awn employers,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ ET. rode.ILlsommathebuildingoricepervencm is anti within one year ofrompletion.the SQ.FT.FLOOR AREA $/SQ.PT. ser builder will have the barden of proving that he did not build or improve fin pur- pose of sale} ❑I,as owner of the props.%am exclusively common,with licensed contractors to TOTAL: ome,ames the pm ess(Sec.70a 1,Business and Professions Code)The Convectors Li- cense Law does not apply to an owner of property who builds or impmva Nemon,and QTY. PLUMBING PERMIT FEE who contracts for such projects with aconuamods)licensed pursue,m the Contmemrs License Law. PERMIT ISSUANCE O l am exempt under Sec. ,B&P C for this mason ALTER-DRAIN&VENT-WATER(RA) VALUATION r Dam WORKER'S COMPENSATION DECLARATION BACK FLO Cr.DEVICE 1 hereby affirm under penalty of perjury one or the following declarations: l have mal will maintain a Cerafcam of Consent msclf-insure for Worker's Center. DRAINS- ,AREA,COND. If union,as provided for by Section 37M of the Lahor Code,for the performance of theftLACV TYPE CONSTRUCTION work for whichthis permit is issued. FIXTURES-PF, R P ❑1 have and will maintain Worker's Compensation Insurance,as respired by Section 37W of the Labor Coda,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTE NC I OCC.GROUP ,,,�U•N My Worker s Compcamlim Inspmnce caller and Policy number are: Carries Policy Nod GAS-EA.SYSTEM OVER EA �(� CERTIFICATE OF EXEMPTION FROM WORKERS' CJ 3 COMPENSATION INSURANCE GREASF/INDUSTRL WASTE INTERCEPTOR BUILDING UI VISION M (This when need not W completed if the Permit is for one hundtd dollars($100) GREASETRAP or less.) PIANCFIECK FEE I certify that in the performance ofthe work for which this permit is issued,Ishii] SEWER-SANITARY-STORM EA.2W FT. not employ any person in any mans so as to become subjecno the Wriflu 'Compen- ENERGY FEE Z sation Laws of California.Date WATER HEATER WNENT/ELECTR Z Applicant GRADING FEE p h NOTICE TO APPLICANT If,after making this Certificate of Exemyo plion, u should WATER S YSTENUFREATING abecome subject In the Workees Compensation penvisions of the Labor Cale,you must SOILS FEE W foMsaith comply with such provisions or this permit shall be deemed revokes]. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F[ PAID U 0 Ihertby nftlrm Nenhere is aconswnion lending agency for pcAonnonce of Dam Rtteipta H the work for which this permit is issued(Sec.3097,Ci,C.) ULender's Name TOTAL: W Lcndcfs Address I certify that 1 have read this application and sate that the above infimmmion is BUILDING FEE i-r correct.l agree to comply with all city and county ordinances and state laws Mating m Q L U Z building construction,and hereby authariu representatives ofthis city to enter upon the SEISMIC FEE ab.vomentioned property for inspection purposes. (We)agree to save,indemnify and keep homeless the City of Criteria.againstELECTRIC FEE liabilities,juegmen¢.cuus arts]expenxs which may in ens wey scene agoinn said City ) onsequenee of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT 1411,HAN ING UNIT(t0 I C'M) SOURCE REGULATIONS. MECHANICAL FEE NDI-I kTTDV 1 )CphA_ CONSTRUCTION TAX Signature of Applicant/Cmanattor Date EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Willtheiptilimat or future building oecipanlsmm or handle hayed..,mamrod (TO 100, U) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(01 HEATING UNIT -R 191),M BTU C3 Yes []No E Date ReceiplN Will us air cicum,furore building by the B use Area Air Qu or Marta which BOILER- tit hssardoua air contaminants as defines by the Bay Ama Air Quality Management CDMA(JHP OR IIXI,IXxI RTU) tOTAL: D¢ma7 BOILER-COMP(OVER IIXI,INYJ BTU) ❑Yes ❑No I have mad the hasnrtlous mamnak naromarams under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE forma Hcalm&Safety Cede,Seembor 25505,2553]and 25530.1 understand that if the NEW RESIDENTIAL MECH. SQ,FT. ^ Q building does rot currently have a meant,that it is my responsibility m notify the cecupanl of the tryuireawnts which most M met prom to issuance of a Certificate of Occupancy. / Diarist in authodsW agent Date TOTAL: ISSU(((ED BY. OFFICE