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S 0436 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-El F'C1'RICAL TWIT"°. 0436 CAL BUILDING DIVISION APPLICATIONIPERMIT PING PROJECT IDENTIFICATION BUILDING PROJECT IDI:NfIFICATION SANITARY NO. AI'1'LICAI'ION SUBMII'I'AI.UNIT BUILDING ADDRESS: OWNER'S NAME: PHONE: CO RACI'OR'S NAME' �6 C1)^� NIC CONTROLp ARC RE TEN (NEER: LIC NO: ' ADDRESS: / V JJ dd � ❑ LDINIG TINIFID CONTACT:�dZ Nly,a 8 ❑ Consultant Fees Paid by Applicant(Initial) NL�q UI ELErCs LRPLUMB MECH MZ f SLICENSED CONTRACTORS>DECIARATIO�NN- QTy ELECTRIC PERMIT FEE 1 hereby affirm that 1 am licensed under provisions or Chapter 9(commencing JOB DESCRIPTION OKO with section](XX))of Division 3 of the Buxinessand Professions Code,and my 11 cense is RESIDENTIAL; IDENTIAL; LL1 O PERMIT ISSUANCE. F full force unJ attest �"3 Lt� ❑SFDWI. �CI'fCHEN REMODEL UE License Cl s Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE FF Z til Datc C.nlraclor tna6 ARCHITECTS DE ATION ❑MULTI-UNIT ❑STRUCTURAL F�Z I umlersand my plans shell he used na tic records PANEW MODIFICATION _ UPT02MAMPS C3 INTERIOR El CHIMNEY REPAIR w�FW Licensed Professional 201-1000AMPS IMPROVEMENT []SWIMMING POOLS .•..11 OWNER-BUILDER DECLARATION OVER IINN)AMPS ❑BATH RKMODEUREPAIR [IDEMOLITION a.1 1 hereby riirnt that 1 am exempt from the Contract or's License Law for the lye,06`7 following reason.Section 7031.5,Business and Professions Coda:Any city or countySIGNS ELIiCI'HICAL [10THEIt 4v 3 LL 1"' which requires v permit to ceramics,alter,improve,demolish,ar repair any structure t_�:y0� Proem it issuantt.,uso raceires Me applicar,l 11 such permit to file a aigned summers SPECIAL CIRCUIT/MISC. C o'1y6f that he is licensed pursuant the previsions of the Contractors License Law(Chapter 9 "PERMIT COMMERCIAL W..,2C (commencing wish Smile.7000)of Division 3 ofthe Business and Professions Cale)or OR POLE INST. 0. c that he is exempt therefrom and the basis for the alleged esemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION m Section 7031.5 by any applicant for a permilsubjecu the applicant m a civil penaltyaf ES El TENANT ❑FOOD SERVICE H not more than five hundred dollars($500). I OVEMENT QI,es uwn<r of she property,or my anpinyas with wages us their role compensation, OOL ELECTRIC wJl do she work,end she smicwre is not emended orollcrd for wle ISa.]p44,BusinessIIt and Professions Gde:The Contractor's License law does not apply to an owner of ITCHES-FIXTURES property who builds or improves thereon,and who docs such work himself or through his own employees,provided that such improvements ore net intended or offered for TIAL ELECTS SQ FT. sale,If.however.the building or improvement is sold within one year ofeomphaion,the �1 SQ.pTm A S/SQ.Fr. owner-builder will have the burden of proving that he did not build or improve for pur- S4rp pow.faide), TOTAL: h is 1,a owner of the Smfoecy,.B exclusively contracting with licensed comrction i- D canstrvct We project(Sec.]O4a,Business and Professions Csdcp'De Cantrannr'x Li- - ciV cense Law does nm aply to an owner of property who builds or improves Merton,and QTY. LUMBING PERMIT FEE who contracts for such project with a contradngL s)licensed pursuant to the Commerce, ~`,i 7iry0 Licence Wes. PERMIT ISSUANCE I am exempt under Sm. .B&P C for this reason ALTER-DRAIN&VENT-WA'T'ER(EA) VALUATION Owner Date WSCOM PIiNSATTON DE CLARATTON BACK FLOW PROTECT.DEVICE 1 hereby affirm underKER under penalty of Perjury one of the following Worimes Car Ij ❑Ihave mid will maintain aCemificateuf Conunno.¢If-insure for Workers Comporo DRAINS-FLUOR,EDGE AREA,COND. - STORIES TYPE CONSTRUCTION w don, provided for by Section 37W of she Labor Code,for the perfammnce of the which this porous is issued. WXTURES-PER TRAP 1 have and will mamuin Worker's Compensation Insurance,as required by Section 37W of she Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 Go LEI'S WC.GROUP APN CMy areer: 'sp mpensation lysu �eam}�ani Policy nu Cartier: `' �,sI 7r-�ars^'ad licya , GAS-P,A.SYS'fF,M-OVF.Ri(EA) CERTIFICATE OF FX,"ION FROM WORKERS' GREASF%INDUSTRL WASTE IM'1?RCEFfOR COMPENSATION INSURANCE BUILDING DIVISION FEES (This section redoes becornpleted Rosea.it is for.hundred dallarx(EIIXB GREASETRAP PLANCIIECK FEE or less) �Iversify that in me performance of the work for which this Permit is issued.lshall SEWER-SANITARY-STORM EA.2W FE . not employ any Person in any manm:r so as to become subject to the Worker'Campers ENERGY FEE O ,Z nater,Laws of California.Date WATER HEATER WNENTtELECfR GRADING FEEa Appham 4 NOTICE TO APPLICANT:E after making this Certificate of Exemption,you should WATER SYS'I'IiM/IREATING became subject to the Workers Compensation previsions of she tabor Code,you must NOR_%WEE Wforthwith comply with such provisions or this permit shall be deemed revoker. WATER SERVICE 7 � CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL VLMB. SQ.FT PAID Date Receipt is V Q If which by reffirm that them is..cd(Sm.30lending agency for she performance of she work for wbch this permh Olssued(Sea JW],Civ,CJ U Lender's Name 'f0'I'AL: V Lenders Address TOTAL: 1 certify Nat I have mad this application and state that the above information is BUILDING PEE 1 y correct.l agree to comply wish all city and county ordinances ondsure laws minting to QTY, MECHANICAL PERMIT FEE V Z building mmuuaion.and hereby authorise representatives ofthis city to enter upon the SEISMIC FEE ateve-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harandess she City of Capsicins against ELECTRIC FEEL. Imbilisies,judgments,costs and expenses which may in any way accrue against said City ALTERORADDTOMECH. PLUMBING FEE in nsequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Id,0mb CFM) MECHANICAL FEE SO CE F,GULATIONg q AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION'TAX Si tere.f Applican Contmctsr 7 Dare EXHAUST HOOD(W/DUC) 14OUSING MITIGATION ME HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building evcupamsme a handle hazardous material HEATING UNIT(TO IW.W)BTU) us defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532bo? HEATING UNIT(OVER 1110,(1011 B'I'Ud�AL� ❑Yes ­1 No VENTILATION FAN(SINGLE RISIDPAID Date Raeiro# Will she applicant or future building removal use equipment or devices which :mit harafdeus air contaminants ss defused by the Bay Area Air Quality Management BOILER_COMP OHP OR I 00.0IB TOTAL: DrstncR BOILER-COMP(OVER 100.000 BT ❑Yea 0N I have read the hazsrdous materials nafirma s under Chapter 6.95 r,1'this Cul l- AIR CONDITIONER ISSUANCE DATE forma Health&Safety Code,Swions 25505,25533 and 255:X.1 understand Thal if the NEW RESIDENTIAL MECH. buil ' does nm curremly aea temal.Ihot it is my responsibility to notify the occupant of menlgwhi matt be map en¢ofa Cenifi a f panty. 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