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29159 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING'MECHANICAL BUILDING PROJECT IDENTIFICATION 29159 BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAI t i 9 sr�a Dip— CuPr�/jo -a-� OWNER'S NAh1E; VHONE: CFI NTRAQ'OR$NAg1E LIC NO: 4 o AM��&(Z .ZS7 232 I� CCd�1Si�• 4 g3o NIC CONTROL It ARCHITECT/ENGINEER: LIC NO. ADDRESS ❑ �2I 67 N4. CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 'I hereby affirm shot 1.m licensed under provisions of Chapter 9(commencing JOB DESCRIPTION DMZ with Section]Clyd)of Doislon 3 ofthe Business and Professions Cole,and my license is in full force and off (- 7 PERMIT ISSUANCE RESIDENTIAL �UU License Clan —' Liana II��JD �a-� ❑SPOWL ❑KITCHEN REMODEL yQW Done Canvuctor pplF �67Alsg APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE ARCHITECTS DECLARATION'" /��( ❑MULTI UNIT ❑STRUCTURAL. Z O n Z 1 undcramnd my plans shall be used as public records PANELS _T\ MODIFICATION O Z UPT02fgIAMPS FBF-w Licensed Professional ❑IM1TERIOR El CHIMNEY REPAIR 201-1000AMPS IMPROVEMENT �ct:0: OWNER-exempt m in Ce Contractors OVER 1000 AMPS KRAili•REMODEIJREPAIR DEMOLITION yy Q I hereby affirm shot I am exempt from the Convannr's License Law for the 5<3 a U following reason.(Section 7031.5,Business and Profexaions Code:Any city or county SIGNS ELECTRICAL ❑OTHER Yu11 LL.y which rtquirts a permit m conswe6 aBa improve,demnlisR nr rvpar any slrvcmrc prinno its issuance.also requires the applicant for such permit o rile a signed statement SPECIAL CIRCUIT/MISC. Qthat he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 a % HC (commencing with Section]BlgB of Division 3 of the Business and Pmfessiens Code)or TEMP.METER OR POLE INST COMMERCIAL that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section 7031.5 by any applicant for a potion mbjects theapplicam to a civil penalty of POWER DEVICES so ❑TEN NT FZ} not more than five hundred dollars(S500). ❑FOODSERVICE r2¢ I,as owner of the OVEMFNT 2 ❑ the somy,uf try cremated ate l stall( ea compensation, SWIMMING POOL ELECTRIC M-2 will Jn the work.and lM1e structure is not intended ondfered lbr vk(Ses.]OW,Business 3 m and Professions Cndc:The Contractor's License Law dues not apply to an owner of OUTLET'S-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work hi tmelf or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Ff. sale.If,however.the building or improvement is sold within one year ofcomplelion,the SQ.FT.FLOOR AREA $/SQ.PT. serer,lumicer will have the burden of proving that he did not build or improve for pur- prse rf.ala). C]I,as ow..rrof the proper},ant exclusively cumoteling with licensed comments nm TOTAL: J\ construct the project(Scar,]OW,Business and Professions Code:)no Convamnts Li- renew Law does not apply it)an owner of posterity who bacilds or improves thereon,and QTY. PLUMBING PERMIT FEE who wntracts for such projects with a coneranorts)licensed pursuant m Ne Contractors Lacomw Law. ❑ Iamexcon,im Jcr Sec. ,B&PCfur this reason PERMIT ISSUANCE, ALTER IN&VENT-WATER(EA) Owner Dam J� VALUATION WORKER'S COMPENSATION DECLARATION BAC O 1 v �Af �Iqa 1 hereby of firm under penalty of perjury one of the following dmlamtic m: VV ❑Ihaveand will mxinminaCenifica¢of Consent to sell'-insure fur Worker's Compcn- DR A. onion,as provided for by Section 37N)of the Labor Cute for the perfontwnce of the STORIES TYPE GQN$TRGGTIQI o work for which Nis permit ix issued. FIXTURES-VER Tiff ❑1 have and will maintain Workers Compensation Insurance,as requirel by Section 3700.1'be WborCade.for the performaneeofthe work fur which this permit is issued, GAS-PA.SYSTEM-I INCA S OCC.GROUp qp,N My Worker' Compenamion�m eg and Policy formation: Caries—.l,L{J�i_L•Y/f !la !Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCEGREASFJINDUSI'RL WASTE INTERCEPTOR It (This section need not becompleted ifthe permit is forene hundred doll./S luld BUILDING DIVISION FEES nr jr—) GREASE TRAP PLANCHECK FEE 1 certify Per in the any man nee dlhe work for which It to peel is issued,I plat's net aremploy Lows.any persnnin any manner sit avmbecome subject the Wnrkcrs'Compen- SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE Z vthon lows of Califrnnia.Dam WATER HEATER W/VENT/BLECTR z ^O Applicant GRADING FEE NOTICE TO APPLICAN'p:IL after making this Certificate of Exemption,you should WATER SYSTEMITREATING I" heannc subject¢m the Worker's Compensation provisions of the La lwr Cade,you most ti forthwith comply with such provisions or this permit shall Na deemed revokest. WATER SERVICE SOILS FEF. CONSTRUCTION LENDING AGENCY z NEW RESIDENTIAL PLMB. SQ,FL PAID VQ I for which thi that thereisacd(Ser.on len ding agency fonheperfnrmvnee of Dvm Recuptp W N the Lenders for which thispermit it issued(Ss.309].Civ,CJ ULenders NamAddress Uj Isndcrs AJJrexv TOTAL: F0. 1 certify that I have read this application and.state that the above information is TOTAL: BUILDING IEE V) cotrcm.l agree to comply with all city and county ordinances and some laws relating it, QTY. MECHANICAL PERMIT FEE C„)Z building conamction.and hereby andante representatives ofthis city am enter upmnlhe SEISMIC FEE above-nmntioned property for inspection pupmxes. PERMI f ISSUANCE (Wo)agree to save,Indemnify anti keep harmless the City of Cupertino against - ELECTRIC FEE liabilities,judgments,costs and expenses which on,,in any way nectar against said City gLTGR OR ADD TO MECII. I.consequence of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0110 CFM) SOURCE'REGULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10.0011 CFM) CONSTRUCfION'1'AX Stgncomeof AOplicanVCmdraror Date EXHAUST HOOD(W/DUCT) HA-IARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION IMF. Will thevpplicant ortumre buildingoccupant Immo"handl.haemdous material HEATING UNIT(TO I00.000 BTU) .s dcOned by the Cupertino Municipal Cade.Chapter 9.12.and the Health and Safety Code,Section 25532(.)9 HEATING UNIT(OVER I(p,IXp BTU) ❑Yes ❑No VENTILATION FAN(SINGLE RMID) PAID will the applicant of future building occupant use equipment or devices which Date Receipt p C iIIIIIIIIIIIIIIIIIIenal hasco mus air conmminana a,defined by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,0011 BTU) ✓ Dir..", TOTAL: ❑Yea f_1 No BOILER-COMP(OVER 100,000 BTU) I have rand the haezNuus materials reyuirementa under Chapter 6.95 of the Cali- AIRCONDITIONER humin Health&Safety Cede.Sessions 25505.25533 and 25534.1 understand that if the ISSUANCE DATE buildingdees asurtmently basearenml,that it is mymsWnsibilitymnotifyiheoccupanl NEW RESIDENTIAL MECH. SQ.FT. of do,mquiremcros which most be met prior to comov a of a Ccnificote efoccupanry. Owner or awhnnecd agent Date TOTAL: ISSUED BY: OFFICE