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30641 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O BUILDING DIVISION APPI.ICATION/PERMIT PLUMBING-MECHANICAL /y 1rz l /I_ b(hs BUILDING PRoIECP TH�ETN'FIF'ICATION BUILO SI Mx. VL's7A ),, M.✓ /�jl/ SANITARY NO. APPLICATION SU/yd�M�I'1•1 'AL DA'tl OWN[R'SNAMf:: PHONE: C RACf ME: V/• �a'L'ICN"O✓: / to NIC CONTROLN AR i' 'C'/ENGI .ER: LIC NO: ADDRESS: n ©� �f ❑ CON'(p6j':M_rj� PHONE: BUILDING PERMIT INFO )7�/{!''�4�Pl D _,S ❑_Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Xm LICENSED CO NA C!,DECLARATION, QTY. ELECTRIC PERMIT FEEE I hereby union not l am licensed under provisions of Chapter 9(comencing JOB DESCRIPTION I-OW0Z with Section 70xxftof Dmision3ofthe Businessman Rofessions GMe,and mylicemn is RESIDENTIAL: W 0 in full force end effort. PERMIT ISSUANCE lb 5j License Class Lich ❑SFDWL ❑ EN REMODELF.Zia Ome Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMPLUMBING RF.PIPE FF ARCHITECT'S DECLARATION PANELS ❑MULTI-UNR ❑STRUCTURAL Z O r�Z 1 understand,ny plans shall be or road as public records MODIFICATION OZ C UPT02WAMPS ❑INTERIOR El CHIMNEY REPAIR {•col'- Licensed Pronssimal 201-1000AMPS IMPROVEMENT �14 OWNER.BUILDER DECLARATION OVERIIgOAMPs ❑BATH REMODEIJRF.PAIR TION y PWG G I hereby min.that Ism exempt for.the Contmmors License".for Ne x O d U following reason.(Section 71131.5,Business add Profession Code:Any city or county SIGNS ELECTRICAL FHR 3 WF which requires a permit m entrance ober,improve,demolish,or repair any structure F.1y 100 prima.its issuame.also requires theapplicant for such person 1.file a signed statemsut SPECIAL CIRC UIT/MISC. Nulaculicamsedpursaa.,to the provisions of the Commnar's License Law(Chapter 9 fcontmencingwiI.Section 40001 of Division 3 onto Business and Professions Code)or TEMP.METER OR POLE INST. 46 m C that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDGME) ITION [I DEMOLITION WIy Section 7031.5 by any applicrad for a permit subjecm the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE I.Z not mora than Eve hundred dollers(S500)' IMPROVEMENT< []I,osm peridthepmpeny,or my employaa with wagesmtMir snie compensation. SWIMMING POOL ELECTRIC 0 will do the work,and the stmcwre actual immindedornRered fersele(Sec.7014,Business ❑OTHER end Professions Cala The Communities License Law does not apply turn owner of OUTLETS-SWITCHES-FIXTURES a' property who builds or improves thereon,and who does such weak himself or through his own employees,provided that such improvements core not intended or offered for NEW RESIDENTIAL ELELT SQ FT. sale,If,however(be building or improvement is sold within one yearn!completion,the SQ.FT-„jHA q,ARfR $ISQ.FT. ownerbuilder will have the burden of proving that he did not build or improve for put, p++ AA VV pose of sale.). El I,as owner of the properly,am eaelosively contracting with licensed contractors to TOTAL: container he project(Sec.71144,Business and Professions Cade)The Coniracmr'x Li- 211996 cense law doss not apply to an owner of pmperty who builds or improves thereon,and QTY, PI.0 NG PER FEE OCT4jlb s v who contracts for such projects with a contmmor(sl licensed pmmenuo the Contractors .J License law. PERMIT ISSUANCE /� (sr ,1 lz1JYCItI IIVV ❑ I am exempt under Sec. ,0&PCfnr this«msnn VI' 1 yr Owner ' D,ae ALTER-DRAIN&VENT-WATER{EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE Thereby ef0mtunder penalty ofperjury one of the followingdeitermitim: - ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen. DRAINS-FLOOR,ROLE,AREA,COND. sation,as provided for by Section 3EI)( of the Labor Code,for the performance of the STORIES TYPF.CONSTRUCTION work for which Nis permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Workers Compensation Insurance,as required by Scctien 37110 office Labor Code,for the performance ofthe work far which Nis permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OC G P APN My Workers Compensation Insurance carrier and Policy number are: ' 'Cartier, Policy No.: GAS-EA.SYSTEM-OVER 4(Est) CERTIFICATE OF EXEMPTION MOM WORKERS' COMPENSATION INSURANCE GREASE/INDIISTRL WASTE INTERCEPTOR (ThissaIion need no[he rompleted iftba permit is far ane hvndreddollars l$1(X1) ILDING DIVISION iES or lesx.7 GREASE TRAP PLA 'C f E I cenify Nat in the p-rfortrmnce ofthe work far which this permit is issued,l shell SEWER-SANITARY-STORM EA,200 PC not employ any person in any mconner so as to became subject to the Workers'Compen- EN RGY Z union Laws of Califomia.Date O O Applicant WATER HEATER WNIiNT2LECfR NO E NOTICE TO APPLICANT:IL after making this Corti ficale of Exemption,you should WATER SYSTEh1/1RHATING a ' become subject to the Workers Compensation provisions of the Labor CMe,you must OI W forthwahcomply with such pmvisionsor this permit shall becieemedrevoked. WATER SERVICE a0 .7. Z CONSTRUCTION LENDING ngAGENCY y 2 NEW RESIDENTIAL PLMB. SQ,PT. PAID U k for by nationwhich thauhere issued( ec.30 lending agency(rube parGsrmunce of Date ReceiptN [L L� the work Na whish chis permit is issued(Sec 309],Civ.CJ U lenders Name TOTAL: Leaders Address TOTAL: P. correct,'1 agree that 1 have rcxd this y and un and dime ordinances the shove information mining is BUILDIN FEE �R Nlagreeto<n.and herebylciluric munesemmiancesand scam lawe«Imingro QTY. MECHANICAL PERMIT PEE U Z building nmswnion,end hereby authorize represcmatives nl this cirymcmer upon the SEISMIC&E above-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to rove,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE liabilities.judgments,exsmind expenses whlchnwy in any way cormungninst,ard City ALTERORAODTOMECH. in consequence of the counting minis permit. PLUMBIN APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 110,000 CFM) SOU 'REGULATION . ZMECHANICAL FEE (,I/"/ y AIR HANDLING UNIT(OVER 10.(MCFM) CONSTRUCTION TAX gnatare of ApplicaroConnew Date 17XHAUST HOOD(W/DUC) HOUSING MITIGATION FEE I IAZARD( MATERIALS DISCLO URC Will the applicant or fit building oeeupant store or handle hazardous material 1{EAi'ING UNIT OPO 100.010 BTU) as defined by the Criterion Municipal Code,Chapter 9.12,and the Health and Safety Cade,Section 25532m)P HEATING UNIT OVER linan0 BTU) ❑Yes FIN. VENTILATION FAN(SINGLE RFSID) PAID Dare Racipt X Will the air contntorfmure building by the od useBay aAility or Management BOILER-COMP(3HP OR 100,000 BTU) emit hazardous air contaminants as defined by the Buy Arce Air Quality Menegemen( MIA[,. District? ❑Yes r-INo BOILER-COMP(OVL'N IW,1100 B'N) 1 have read the huzardnus m:ncriuN«yuircments uaJer Chapter fi.95 nl the Cv1i- AIR CONDITIONER ISSUANCE DATE foods Health&Safety Castle,Sections 25505,]5533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently haves tenant,that it is my responsibility to notify the occupant of the myuirementa which must be area prior to Nwarce of a Cedifcam of Occupancy. , Owner or authorized agent Data TOTAL: ISSUED BY: OFFICE