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29392 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO. ^^ass Aad BUILL93JVL DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECTIDENTIFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE Ll 41 L LQ"-vIkd W 'S AME: N CO M' OU NAME: LIC NO: N/C COMROLp 4R ITECTIENG INE E : - IC NfY ADDRESS: ❑ !moi 'l ONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Feta Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby affirm that I am(doe Business under wood Pe ism of Chapter 9(commencing JOB DESCRIPTION COZ wiLo n]1l0))of Division Sof Ne Busineaa ooM Pmfmsions Code,and mylittnse is PERMIT ISSUANCE R SIDS FNTI�; F n fand fy QFU Lic .. J Li �� ❑SFDWI. ❑KITCHP.N REMODCI. WG eC, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPF.Z g,pw HI Dfi rARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL Z y spublic records MODIFICATION . OZ—Q UPT02MAMPS ❑INTERIOR ❑CHIMNEY REPAIR Lic cdP e.s' 201-1000AMPS IMPROVEMENT OWNER-BUILDER DECLARATION he y 1. ]let I am exempt fano the Contractor's License Law 1'or the OVER ION)AMPS ❑BATH REMODEI/REPAIR ❑DEMOLITION 30. folia mg lees .(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER LL C which requires a permit to consumer.alter,improve,demolish,or repair any rmcmrc ry. prior to its issuance,also requires the applicantfor such permit to file a signed statement SPECIAL CIRCUIT/MISC. that he is licensed pursuant to the provisions ofthe Contra is License Law lChaper9 -+ , g [MY a (commencing with Sedinn](NNB of Division3nf the Business and Pmfessions Cndejnr TEMP.METER OR POLE INST. COMM 0. LL that he is exempt therefrom maids,basis Radio alleged excision,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION m Section 7031.5 by anyapplicamCol.permit subjects the applicant to a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE 1- < not mom than Five hundred d.11ars($500). I,os owners the norm IMPROVEMENT willO ❑ pest ct yemeoithwageaosalei(See.c0m,Bintiien, SWIMMING POOL ELECTRIC and do the work,and rbc he Cont is not intended Lice .r offered for sale(See.70W,an Business ❑OTHER 3 and Professions Code:The Contractor's there's License Law fires not apply to if owner Of OUTLETS-SWITCIiF.S-FIXTURES property who builds or improves t thereon,and who does such work himself or through his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECfR SQ PT. sale.If,howevee the building.,improvement is sold within one yearo(completion.the SQ.FT.FLLv9ORAREAf�--5�mm I/%FT. .anal-builder will have the burden of proving that he did not build or improve for put- p.m of sale.). _ ❑1,on none,of the propeny,oto ead mivcly 1-olow1 ng wilt licessod aanraatnrs m TO'PAU construct the project(Sec.7019,Business and Pmfessions Co...,The Commnmr'.Li MAR1996 cense taw does not apply to an owner ofpropeny who builds or inmproves thereon,and QTY, PLUMBING PERMIT PEE: who contracts fmsuch pmjeets win a cuntmctons)licensed pursuant nu the Contmcmle License Lew. ❑I am eaempi under Sec. ,B&PC forliis reason PERMITISSUANCE CI IT yr wren l HYII M:ITR-DRAIN&VENT-WATER(EA) Owner pate VALUATION WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE .44 I hereby affan under penalty of perjury one ofthe following declarations: ]I have and will maintain a Certificate of Continuo self-insum for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPO CONSTRUCTION nation,ai pnwided for by Section 3]00of the Labor Cole,for the perfurmnce of the work for which this permit is issued. FIX'I GRES-PER TRAP ❑I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance ofne work for which this permit is issued. GAS-EA.SYSTEM-]INC.a OUTLETS Do OCC.GROUP APN MyaCompenmtion Insurance career and Policy number are: Colmar: Policy No.: GAS-EA.SYSTEMOVER a(EA) CERTIFICATI!OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/1NDUSTRL WASTE INTERCEFIY)N (This section need not he completed Wom permit k far one hundred dollars($100) BUILDING DIVISION FEES IasJ OR EASE TRAP I ecnify that inflan performance nof the work for which this permit is issued I hell PLANCt{ECK FEE any not employ any person in any manner m usmbecome subject to Workers Conner- SEWER-SANITARY-STORM EA.2g1FT. - .mss� ENERGY FEEZ cation Lawsnt California.Dote WATER HEA'1'CR W/VENT/ELECTR GRADING FEE Applicant NOTICE TO APPLICANT:If,after making thin Cenificme of Esemptlnn,you should WATER SYSTEM/TREATING abecome subject to the Worker's Compensation provisions of the Labor Cndc,you must SOILS FEE, W barroom comply winsuch provisi.na.nhis pcnnirshall he decimal revoked. WATER SERVICE � Z CONSTRUCTION LENDING AGENCY NEWRESIpEN'1'IALPLMB. SQ.FT, PAID ,UO I herchy affirm that there is a construction lending agency for the perfommnce of Data Receipt# 15s F the work for which this permit is issued(Sec.3097.Civ.C.) p 0 L) Lender'.Name TOTAL: Lender's Address TOTAL: y 1 ecnify that I have read this applicalion and state that the above information is BUILDING FEE ' V2emilel.l agree locomplywinnll city andc:mmy nrdinancesond rmclawxrdafngin QTY. MECHANICAL PERMIT FEE 'G F7 building canswction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE ab.ve.memioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Culmina Oil ELECTRIC FEE liabilities,judgmene,costs and expenses which may in any way eceme...inn said City ALTER OR AUD'fO MECH. in consequence ofthe granting ofthi^ m I. PLUMBING FEE APPLICANT !DE TANDS ND i1LL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,INN1 CFM) SOURCE ONS. MECHANICALFEE AIR HANDLING UNIT(OVER R(M CFM) CONSTRUCTION TAX gra re cant/C.mrcmr Me EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE W' aapplicant.r future building ocwpmm.mre nen handle hazardous nu.eshd HEATING UNIT(TO 100,00)H'1'(J) as define by the Columbus Municipal Cale,Chapter 9.12,and the Health and Safety Code,Seed..25532(a)] HEATING UNI'((OVER 100,(1(10 BTU) ❑Yee F-1 No PAID VENTILATION FAN(SINGLE RGSID) Will nuse e int or devices which Date Receipt# emit hazardous air cotaminnts m defneA by the Bay Arco Air Quality Mmwge°tont BOILER-COMP(3)IP OR 100X1)BTU) TOTAL: 3 0 istndl ❑Yes ON. BOILER-COMP(OVER 100,000 BTU) 1 hall,tend the humorous matenals AIR CONDUION13R requirements a under Chapter 6.95 of the Cali- ISSUANCE DATE forma Healgdoes&Safety Codehave Sections 25505,233)7 and 25537.1 umlersmnd rout if nc NEW RLSIDP.NTIAI.MECH. SQ.PT. building does not is which haves a event,that 0 is tory responsibility t.e notify the pancy. of the requirements which most be nater poor m issuance of a Cenificnte of Occupancy. ' Owner nen amhonxed at Date TOTAL: ISSUED BY:` OFFICE