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36225017APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY BUILDING DIVISION APPLICATIONMERMIT CONTRACTORS 0 OFFICE t^� _ y (// ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECT' rLUMB yECIf `co o,) CV, ❑ ❑, i❑ WOO FW QUV F Z W vs¢a E' h Z ZOrq,r OZ—p LICENSED CONTRACTORS DECLARATION 1 heeby afem, rim IS. Iiaemed nide, provisions of Chapter v (commencing with SvVmd]fKplaf Division 3oftne Business vndl'mfesai�Cude �ndmylicense is in full force and effect. (/ Llccnse Class Liam Dam Comrucmr A HITELT'S DIiC1.ARA'TION 1 mWcrvmad no I ll be mnnl its hlic records YPtlOfi s1° pn QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION RESIDENTIAL ❑SFDWL ❑ KITCHEN REMODEL []ADDITION ❑PLUMBING RE -PIPE ❑MULTI -UNIT ❑STRUCTURAL. MODIFICATION ❑INTERIOR ❑CHIMNEY REPAIR [WROVFMENT []SWIMMING POOLS ATH REMODEURE•PAIR [I DEMOLITION ER PERMIT ISSUANCE APPLIANCES — RESIDENTIAL PANELS UP 10200 AMPS F.~W Y Y f lY ¢ K 3 a U W W y 0¢� Lieemed Professimmd OWNER BUILDER DECLARATION 1 hereby affirthat I am exempt from the Contractors License Lew (m the m following mason. (Section 703 L5. Business and Professions Cade: Any city or countySIGNS which requires a permit to construct, after, improve, demolish, or repair any strammrc prior to its issuance, also mquires the applicant for such Permit to rile a signed smmment 201=100IAMPS OVER IIXm)AMPS ELECTRICAL S PF,CIAI. CIRCUIT/M ISC, �ap0 a d e C xp,H =p p., IW m L dour he is licensed pursuatnitthe provisions ofNeContractor's LicenseLow (Chapter 9 (connmudcing with Sec(in 17000) of Division 3 of Business and pool essin l,Cmla)or that he is exempt therdronn and the basis for the alleged exemption. Any vfnla0on of Section ]031.5 by any applicant for apcnnit wM1jcmethc applicant it) acivil penalty of n mum rind five hundred dollars (5500). FlI.mowneroflhepropeny,urmyempluyeeswithwagesastheirwlecompensmion, uue is not intended tampered fmmle(Sec. 7044. Business will do Nework.and rhesbm and Profesions Cade: The Conmamor'x License law dons net apply to an owner of property who builds or improves thereon, and who does such work himself or through his own employees, provided For such... amcalled, are ant intended or offered for sale, 11,huwevec thchuildingnrimpmwenmdlvsold within one ycarofcomPlction, la, ownenhuilder will have dire burden of,,twin, that he did not build or improve for put - 'I'HM 1'. METER OR POI.F I NST. COMMERCIAL, [I NEW BLDGIADDITION ❑DEMOLITION El TENANT ❑ FOOD SERVICE IMPROVEMENT OTHER TOWER DEVICES SWIMMING POOL ELECTRIC OUTLETS—SWITCHES—FIXTURES NI?W RESIDENTIAL fit. I'M R SQ FT SO. PP. FLOOR AREA $I$IJ.IW. TOTAL: pore n[ sale.). 0 1, as owner of rhe popery, am excla%ndy lorroming with licensed contractors, to D QTY, PLUMBING PERMIT FEE construct rhe Project (Sec. AIW. Business and e:) Professions CodThe Convenor's Li- censeLawdmxnot apply toanowner ofpmpertywho huildxorimproresthereon. and who cummexs for such p soce¢ with a cummemgxl licensed pursuant tothe Contractor's NOV 12 �ggg D PERMIT ISSUANCE License Law, . ❑ lam exempt render See. .It&llCfm this maxim Dale A Ul 11 R — D6&KA VENT—WX[ER(EA) [By VALUATION tic r WORKER'S COMPENSAIIIIN UECLARA'1ION BACK Fl -l", 1 hereby affirm under penalty of perjury one of rhe following declarations: Fl I base and will maintain a Certificate of Concur to self -insure for Workers Comped- s DRAINS ROD 'AR .C© TYPE CONSTRUCTION sarion, as provided for by Section 37M mine labra CMe, for the Parbointt of the work fur whichthis serol is issued. FIXTUR —PER TRAP 1 have and will maintain Worker, Compennotion harmonic, as required by Section 3700.frhe Labo Ca c, tort erfonot of@n work far which chis pcnnit in dies nm GAS— - C. UT' TS AYN OPLANCHECK�E' My Works �nlio nee 1 Policy ((f Policy No.: �J�� and �'AM-"OFE) Carrier: GAS—EA.SYS'1'EM OVERIRAN GREASPANDUSTRL WAS'RI INTERCEPTOR 1MFI'IONFROMWORKERS' COMPENSATION INSURANCE NG UI VISION FBES "B"xce.mnn completNifNepermitisforonehundmdollas(SIM) GREASETRAP or less.) SIMER—SANITARY—STORM EA.200F'T, ENERGY FEE I certify ,inth, dance ofthe work for which this permit era Is,11 nm employ an prim ymannursoaxmbcn) gryhkiYmhis^ m WATER HEATER W/V1:Nq'IEI.EC`rR GRADING FEE z Q Z VI Cd 5:M 7 z U 0 I~ 4UTi 6t N U Z eulinn Lowe of du. Dom (� ` APPliwm NOI'ICF, ,LGN , a e, g this Cenifcalc of Excell you should udie subject to he Worker's Compensation provisions of the Labor Cask, you must forthwith comply w ith such provisions or this Permit shall be deemed mvoked. CONSTRUCTION LENDING AGENCY l hereby dlriono that there is a construction lending agency for the Performance of the work for which this permit s dressed (Sec. 3097, Ci, C.) Lender's Name WATER SYSTEM/TRFAUNG WATER SERVICE SOILS FEE PAID NEW RESIDENTIAL PLMB. SO. PL Dam Receipt m TOTAL TOTAL'. I<IWcr's Address 1 certify 0mt I have rued this application and Aare that he above irlonmation ix correct. I agree to comply with all city and county ordinances and state laws relining to building construction. and hereby aohome representatives ofthis city to enter upon the BUILDING FEE QTY. MECHANICAL PERMIT FEE SEISMIC FEE PERMD' ISSUANCE ELECTRIC EEE ahrvcmentioned pmpcny for inspection purryrms. (We) agree m savrhamdess the City of Cupertino against PLUMBING FEE liablitics,judgmcnts, c may in am way acme agaimt'aid City ALTER OR ADD TO MSCI I, .nnagnenccnl'r graIiRSCOMPLY WITH ALT. NON -POINT AIR HANDLING UNI' PROfg)CUSE MIiCIIANICALFF.E PIO_ AIR HANDLING UNI' LIVER 10.000 CFM) CONSTRUCTION TAX ' Signature of nnlactor Um c EXHAUST HOOD IW/DUCT) HOUSING MITIGATION ME IIA% \RDOUS MATERIALS DISCLOSURE: Will the applicant or fumrc building occupant store or handle hazardous material as defined by the Curl lno Municipal Code, Chapter 9.12, and the Ileanh and Safety Cadq Station 25532daC IIEATING UNIT (TO 100,IXp BTU) HEATING UNIT (OVER 100,010 BTU) V13N'i H,XGON FAN(SINCLE RESID) �Ycf ❑NoPAID Dale Receipt# Will the applicant n, future building occupant use equipment or devices which im�s as defined by the Bay Area Air Quality Management min hrobill air cdnramm BOILER —COMP (3HP OR 100.000 BTU) TOTAL: Di,ticr! BOILER —COMP (OVER HLBODO BTUI ❑ Yes AIR CONDITIONER 1 has call the ntam,iAs mquiremams under Chapter 6.95 of the Coli- ISSUANCE DATE NEW RESIDENTIAI, MICA. SQ. PT. t'omia Heart & S,c Na, Section, 25505` 25,533 and 25534. 1 undetsmnd that if rhe haildingdo, 1 Idly haveatuwm,dhat it is my regi,on,hi fly ylarooly Net ' p I the rcqui Mend n e of aCyn)Iieur12x. y. / / ISSUED BY: TOTAL: own t err amMsrixed aged, Date OFFICE