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29515APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL t BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL. RIIILDING PROIF.CT IDENTIFICATION PERMITNO. n C rI C I G J 1 J BUILDING ADDRESS: zr6s.. • - C SANITARY NO. APPLICATION SUBMITTAL DATE OWNER'SNAME: - PHONE: e^� %` S3—• '+l CONTRA OR'S AM LIC NO: I Cb a NAC ❑ -CONTROL# .. RCHITECDENGINEER: - LIC NO: ADDRESS: - /r CONTACT, PHONE: ❑ Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG ELECT PLUMB MaEECC�H ❑ ❑ - ❑ ISI LICENSED CONTRACTOR'S DECLARATION I hereby affirm that I am licensed under provisions ax Cove, 9 my Because Lwit Section ]000)ofDivivlon3of the Buslnew and ProRsdlnns Coda and my licensolx is in full force and effect _ �, �J License DareCmntacmr n. ARCHITECP'SDECLARATION I under.... d''} � hall sed as public reroNs s QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION .RESIDENTIAL - ❑SFDWL ❑ KITCHEN REMODEL ❑ADDITION • ❑PLUMBINGRE-PIPE ❑MULTIUNIT' ❑STRUCTURAL -MODIFICATION. ❑INTERIOR "' El CHIMNEY REPAIR IMPROVEMENT ❑ BATH REMODEUREPAIR •D DEMOLITION , iQi1THE ` kbi'�� % PERMIT ISSUANCE. APPLIANCES -RESIDENTIAL PANELS UP T021q AMPS - LmensedProfessoonal -. � ccal OWNER- UILDER DECLARATION 2 1 hereby affirm that I am exempt room the Contractor's License Lew for the J following reason: (Section 7031 .5, es , Busins and Professions Code: Any city or county which requires a permit to construct, alter, improve, demolish, or repair any dmcmre 'fire m its issuance, also requires the applicant for such permifto fideasignedslaromem that he is licensed pursuant o the pmvisions of the Conductor's License Law (Chapter 9 (commencing with Section ]000)of Division 3 of the Business and Professions Cade) or `that he is exempt therefrom and the basis fur the alleged exemption. Any violation of Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of not more than five hundred dollars ($5(m), ❑ 1, as owner of the property, or my employees with wages as their sole compensation, will do the work, and Ne,tructure is not intended orolFered for sale (Sec. 70000. Business and Professions Code: The Convector's License Law does not apply ns an owner of Property who builds or improve,, thereon, and who does such work himself or through his own employees, provided that such improvements we not intended or offered for sale. If, however, the building or improvement is sold within one year of compledinn.the owner -builder will have the burden of proving that he did not build or improve for put, pose outside.). ❑ 1, as owner of the property, am exclusively contracting with licensed contractors toTOTAL: construct the project (Sec. ]846, Business and Professions Code:) The Contrectora Li- Cause Law does not apply to an owner of property who build, or improves thereon, and who contracts for such pmjems with a Caroni licensed pursuant to Ne Contractors • License Law. ❑ 1 am exempt under Sec. , B & P C for this reason 2BI-1000 AMPS OVER 1000 AMPS SIGNS ELECTRICAL SPECIAL CIRCUIT/MISC.f"!4 TEMP. METER OR POLE INST. COMMERCIAL - ❑ ❑ NEW BLDG/ADDITION • DEMOLITION []TENANT ❑ FOOD SERVICE - IMPROVEMENT , 116 OTKA - ,. POWER DEVICES SWIMMING POOLELECfRIC OUTLETS -SWITCHES -FIXTURES NEW RESIDENTIAL ELECTR $Q I SQ. FT. FLOOR AREA - - " $/SQ. FT , , .. QTY PLUMBING PERMIT FEE PERMIT ISSUANCE Owner Dare - ALTER -DRAIN &. VENT- WATER (EA) ( i' VALUATION I ' •STORIES WORKER'S COMPENSATION DECLARATION 'I hereby affirm under Penalty ofNrjury,one of the following deductions: ❑ I have and will maintain a Certificate ofComent m self -insure for Workers Cmnpem sadden, us Provided for by Section 3]00 of the Lahr Cade, for Ne performance of the work for which this permit is isened. 1 have and will maintain Workers Compensation Insurance, as required by Section 370t) of the Labor Code, for the performance of he work for which this permit is issued. My Work scion reason lnsurp acartlu nod Policy numbe are: Cartier. M '{� Policy No.: Iwv I4Sl(-CM916C 'CE BACK FLOW PROTECI'.'DEVICE DRAINS- FLOOR, ROOK AREA, COND. ' 'TYPE CONSTRUCTION. PIXTURES - PCR TRAP i GAS- EA. SYSTEM- I INC 4 OUTLETS OCC. GROUP APN GAS -EA. SYSTEM-OVER4(EA) ,. IHCAM OF EXEMPTION FROM WORKERS' OI sr COMPENSATION INSURANCE (This section need not heCo. mpleted iflhe permit is for one hundred dollars ($100) or less) I certify that in the performance of the work fn which [Instrument is issued, Ishak not employ any person in any manna as to beoom j n Wurkers' Compen=' sadianlawaof Culifomia.Data iso ,fie%4 / Applicant , , . CREASEIINDUSTRL WASTE. INTERCEPTOR - GREASETRAP BUILDING DIVISION FEES PLANCHECK FEE SEWER -SANITARY -STORM EA. 20d FT. ,ENERGY FEE WATER HEATER WNENIVELEC R GRADING FEE. 'NOTICE TO APPLICANT. f, aft making This ificare of Exemption, you should become subject I. the Worker's Compensation prnsmiters of NhCastle,e LarCastle,m e, you ust, forthwith comply with such Provisions or Box Permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a construction lending agency for the Performance of Ne work for which Nix permit Is Issued (Sec.309T, Civ. CJ, WATER SYSTEM?REATING SOILS FEE' WATER SERVICE - PAID NEW RESIDENTIAL PLMB. SQ. FT. _ Date Recupt p Lenders Name Lendaex-Addres,TOTAL: I Certify that 1 have read m this application and state that the above information is correct. I agree to comply with all city and country oniinences and slate laws relating to building construction, and hereby authorize representatives of this city to enter upon the above-mentioneA properly for inspection purposes. (We) agree to save, indemnify and keep harmless the City of Common against 'liabilities,judgments, Costs and expenses which may in any way accrue against said City in consegocnce of the granting of this partial, APPLICANT.UNDERSTANDS.AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. TOTAL : BUILDING PEE - QTY. MECHANICAL PERMIT FEE SEISMIC FEE " PERMIT ISSUANCE - ELECTRIC FEE ALTER ALTER OR ADD TO MECH. FEE AIR HANDLING UNIT (TO 10,0110 CFM) MECHANICAL FEE W.• AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX Signature m(Appicant(Convuctor ' Date HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store orhandle hazardous material as defined by the Capetian Municipal Code. Chapter 9.12, and the Heart end Safety Code, Section 25532(x)7 ,. Dyes INo , .. - Will the applicant or future building occupant use equipment or device, which emit hazardous it Contaminants as defined by the Bay Area Air Quality Management District? [I yes DN. I have reud the haiurdous mamnda requirements under Chapter 6.95 of the Cali- heads Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand that if Ne .building deer nod currently have a tenant, that it is my iesprreadebly 10 notify are occupant of the requirements which must he met prior in issuance of a Certificate of Occupancy. EXHAUST HOOD (INDUCT) HOUSING MITIGATION FEE HEATING UNIT G70 100.006 BTU) , „ HEATING UNIT (OVER 100,000 BTU) z -20 - PAID VENTILATION FAN (SINGLE RESID) - BOILER- COMP f3HP OR 100.000 BTU) , Data Receipt # TOTAL: - L BOILER- COMP (OVER 100,1100 BTU) AIR CONDITIONER ISSUANCE DATE • 1 ' ISSUED BY: NEW RESIDENTIAL MECH. SQ. FT. - Owner or authorized agent .Dale TOTAL] OFFICE '