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29379APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPF,R'1'INO BUILDING - PD.ECTE BUILDING DIVISION APPI.ICA7TON/PERMITPLUMBING-MECHA BUILDING PROJECTIDEM ID3z-7 M AP -4 Add_ Opium IIIfMH"A ❑ Consultant Fees Paid by Applicant (Initial) 2al80 Y Q U U Z W 1 hereby alum that I am licensed under provisions of Chapter 9 (commencing with Section ]000)of Division 3 ofthc Business and Profcssians Cade. and my license is in full Ione and effect. License Class Lic. # Dae Cameroon SIGNS ELECTRICAL APPLICATION SUBMI ITAL DATE SPECIAL CIRCIADMISC. L_ Z ARCHITECTS DECLARATION I understood my plan., shall be used us public recoNs NIC ilE aal Licensed Professional SWIMMING POOL ELECTRIC C ,,4 w OWNER-RUILDER DECLARATION C RATH RF.MODEUREPAIR C DEMOLITION B 6 D Q. U O F Gthat 1 hereby effrr a that I am exempt fano the Commam's License Law for the following reamer (Section 703 L5. Business and Professions Cole: Any city or county which requires a permit to common, alter, improve, demolish, er repair any structure primo, it, issuance alimeN es,]at applicant farsuch formiOo tile.eguedware ent he is licensed privateln the provisions ofthe Contractors License Low(Chapmr9 EI.{:Cr PLUMB 6q /N 1:1M L Qo K 3I or, SSC p., i 3 m (commencing with Section 9000) of Division 3 of the Business and Professions Code) or that he is exempt therefrmn and the hats for the alleged exei iplina Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of t more than five hundred dollars ($500). I, as to, metal 'ihe propery,ornty employees with wages as lhit irsoJo, rempcn,ation, will do the work. and the structure is not intended oroffcred for sale (Sec. 701c, Business and Professions Code: The Contractor's License Law does not apply to an owner of property who builds or improve therum, and who does such work himself or through WATER SYSTEM/TREATING SOILS FEE WATER SERVICE PAID NEW RESIDENTIAL PLMB. SQ. IT. his own employees, provided that such impersonates arc .nt intended or offered for TOTAL: sale. If, however, the building or improvement is and within one yea ofeempletion, the owearbuilder will have the burden of proving that he did not build or improve for pur- pose of 'dr.), C 1; ars owner of the property, am exclusively comtmaed ing with licensed contmcurrs ns construct the project (Sec. ]044, Business and Professions Code) The Contracwrs Li- rvscLawdoesnetapply to on ow our of property who builds or improves thereon. moil Ql Y. who contracts for such projects with a cummeror(s) licensed personal to the Conraaor's \ Lice.. law. C 1 �mpt under Sec. . B is P C for this reason xncr Dem WORKER'S COMPENSATION DECLARATION under penahy of Wit one of the following 1 hand Worker's CaI have and will maintain a Ccnificae ofConam a self -insure for Worker's Commcn- will saion, as provided for by Section 3900 of the Labof Code, In, he performance of the work far which this permit is issued. C 1 have and will maintain Workers Compensation Insurance, as requited by Section 3900 of the Labor Code, for the performance of the work for which this permit is issued. My Worker, Cninpensad I Insurance curia and Policy number ufe: Carrier: Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE onto section need not becensplcted II the peirrit is for one hundred dollars ($TIP) or less.) I cenify that in the performance of the work for which this permit is issued. I shall not employ any person in any munnef so as m becomes.hjccto, the Workc,,Conopen- O z z a; Wforthwith 7 z U 0 W F .tion Lar—of Cairomio. Dae Applicant NOTICE TO APPLICANT. If, a0er making Ibis Cenitiewc of Hsenption, you should become subject to the Workers Compensation provisions of the Labor Codi you must comply with such musicians or this panto shall b<deemed revoked. CONSTR GUT [ON LENDING AGENCY l hereby sffrm that there is a construction lending agency for the performance of the work for which this former is issued (Site 3097, Civ. C,) Lenders Name 0 U W 2611 Lenders Address cenify that 1 have read this application and state that the abuse information is t,I cr.,. 1 agree to comply with all city and county ordimoner, and sem Ines relining e QTy. U z building constriction. and hcnbyauthome repre,whilives ofthisaity menterurym the abuvamemianed progeny for inspection purposes. (We).,me ter ove, materially and keep humdcss the City of Copeman. against liabili(ies,jodgme mcosts andexfoenmswhichmaymany way accric sgram,sail City in asequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURCE REGULATIONS. Signamre of Ap,heanbCommaor Date HA]ARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant tore or handle ha>rrdous material as defined by the Cupertino Municipal Code, Chapter 9. 12. and the Health and Safety Code, Section 255320)9 CYes Fl No Will the applies.( nor future building oecup.nt use or,yerent ter devices which emit hazardous air conmminants as defined by the Bay Area Air Quality Management District E] Yes Fl No 1 have real the hazallous natcriuh requirements under Chapter 695 of he Cali- fomia Health & Safety Care, Sections 255115.25533 and 25534, 1 understand that if thc ELECTRIC PERMIT FEE PERMIT ISSUANCE APPLIANCIS - RESIDENTIAL. PANELS UP TO 20D AMPS OVER lots) AMPS 29379 SIGNS ELECTRICAL APPLICATION SUBMI ITAL DATE SPECIAL CIRCIADMISC. 2� l TEMP. METER OR Pol INST. NIC POWI7R DEVICES CON 'I'Roil N SWIMMING POOL ELECTRIC IMPROVEMENT OUTLETS—SWITCHES—FIXTURES C RATH RF.MODEUREPAIR C DEMOLITION NEW RESIDENTIAL ELECTR SOFT. JOB DESCRIPTION 29379 UNITARY NO APPLICATION SUBMI ITAL DATE IC D PLOMBING RE -PIPIT ❑MULTI -UNIT 3 % -AG NIC MODIFICATION CON 'I'Roil N C CHIMNEY REPAIR IMPROVEMENT GAS- EA. SYSTEM OVER 4 (EA) C RATH RF.MODEUREPAIR C DEMOLITION BUILDING PERMIT INFO BLDG EI.{:Cr PLUMB 6q /N 1:1M JOB DESCRIPTION RESIDENTIAL: C SFDWL CHEN REMODEL ❑ADDITION IC D PLOMBING RE -PIPIT ❑MULTI -UNIT []STRUCTURAL DRAINS- FLOOR, ROOF, AREA. COND. MODIFICATION C INTERIOR C CHIMNEY REPAIR IMPROVEMENT GAS- EA. SYSTEM OVER 4 (EA) C RATH RF.MODEUREPAIR C DEMOLITION DOTTER GREASETRAP L// 6q /N COMMERCIAL: C NEW BLDGIADDITION C DEMOLITION ❑TENANT ❑ FOOD SERVICE ^IMPROVEMENT SQ. IT. FLOOR AREA p� P Al C PLUM BING PERMIT FEE T�yMAR 51996 CiTUr writ h l INL SEISMICFEE PERMIT ISSUANCE ALTER -DRAIN& VENT- WATER (EA) VALUATION BACK FLOW PROTECT DEVICE DRAINS- FLOOR, ROOF, AREA. COND. STORIES OCC. GROUP TYPE C( FIXI'URFS - PER TRAP GAS - EA. SYSTEM -1 INC.4 OUTLETS GAS- EA. SYSTEM OVER 4 (EA) GRF.ASEIINDUSTRL WASTE INTERCEPTOR RUILUINC DIVISION FIiFS GREASETRAP PLANCHECK FEE SEWER -SANITARY -STORM EA. 200 FT ENERGY PIT 7. WATER HEATER WNENDE'LECTR GRADING FEE WATER SYSTEM/TREATING SOILS FEE WATER SERVICE PAID NEW RESIDENTIAL PLMB. SQ. IT. Date Receipt# TOTAL: - MECHANICAL PERMIT FEE BUILDING FEE SEISMICFEE PERMIT ISSUANCE ELECTRIC FEE ALTER OR ADDTO MECH. PLUMBING FEE Llkr MECHANICALFEE AIR HANDLING UNIT (TO Flood CPM) AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCTION TAX EXHAUST 11001)OVIDUCT) I'• HOUSING MITIGATION FEE HEATING UNIT (TO 100.000 BTU) HEATING UNIT (OVER 100.0N)BTU) PAID VENTILATION FAN (SINGLE RESHn Dam Realer p BOILER -COMP (3HP OR 1011.00) BTU) H)1'AL BOILER - COMP (OVER 100,00) BTU) AIR CONDITIONER ISSUANCE DATE, p NEW RESIDENTIAL MECH. SQ. IT. woV.,:l /t/ TISSUED BY:� OFFICE SISQ. FT.