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31016 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY .11 + CITYO CCUPERTINO BUILDING-ELECTRICAL e PERMIT NO. 31016 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATI �017'lIK 1 . CI L07 3 OWN ER'S NAMPH s ONE: CONTRACT'OR'S NAME: .LIC NO: f Pq l ( _!J-5 a " NIC CONTROL#. TO'-s' , pq.H11ECT/ENGINEER: 1 LI�— .�� ADDRESS: - ❑ �� st. CONTACT: ' P Ne: BUILDING PERMIT INFO 1r V �aN ( 4}��Sf�4`".-S ❑ Consultant Fees Paid by Applicant(Initial) ELECT PL I MECH " h-- LICENSED CONTRACTOR'S DECLARATION `T QTY ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chepw 9(commencing JOB DESCRIPTION ,4faj0'Z with Section]000)ofDivision Satire Busiaesaond professions Codgand my license is RESIDENTIAL Fw in roll force and effect. PERMITISSUANCE ❑ �UZU License Class - Lie SFDWL ❑KITCHEN REMODEL y6i Data—Contractor - APPLIANCES-RESIDENTIAL []ADDITION - ❑PLUMBING R&PIPE F.,pm ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT LI STRUCTURAL O Z ' I understand my plans shall be uud as public records MODIFICATION UP T0200 AMPS Loaned Professional ❑INTERIOR El CHIMNEY REPAIR OWNER-BUILDER DECLARATION 201-1000AMPS N, IMPROVEMENT I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000AMPS17 0 BATH REMODEUREPAIR ElDEMOLITION 3 d F following reason(Section]031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER Cwhich requires a permit to construct,alter,improve,demolish,or repair any structurei !�/+�y prior to its issuance,also requires the applicant torsion permit to file a signed statement SPECIAL CIRCUIT/MISC. "1y GE Nat he is licensed pursuant to the provisions ofthe Contractus License Law(Chapter 9 00 (commencing with Section]000)of Divisima 3ofthe Bu,inessand Profewmns Code)or TEMP.METER OR POLE INST 6 that he is exempt therefrom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION 4X1 Y• Section 7031.5 by any oppiicaut fora permit subjects the applicant to a civil penalty of POWER DEVICES [-]TENANT FOOD SERVICE ba more than five hundred dollars($50)). IMPROVEMENT 0,p ❑1,as owner of the property,or my employees with wages us their sole compensation, SWIMMING POOL ELECTRIC F will do thework.and be sracture is not intended oroffered for sale(See,7044,Business ❑OTHER 4y1 and Professions Code:The Contractor's License taw rices not apply m an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his awn employees,provided that such imprrvememe are not intended or offered for NF.W RESIDENTIAL ELECTR SQ sale.If,howevecthe building or improvement is sold within ane"an"fcompletion,the 0 -SQ.FT.FLOOR AREA $/SQ.FT. owner-builder will have be burden of proving that he did not build or improve for put- ... pose of sale). ❑I,as owner of the progeny,am exclusively contracting with licensed contractors to construct be project(Sec.](sP1,Business and Professions Code)The Connector's Li- pf fbOJ c e taw does not apply to an owner of pmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE s whocontmcts forsucM1Projec¢with a complaints)licensed pursuant to the Communes License Law. PER ISSUANCE ❑ Tem exempt under Sec. ,R&P C for Nis reason Owner Date ALTER-DRAIN&VENT-WA ) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penalty of perjury one of the following declarations: , .I have and will maintain aCertificate ofConsent o self-insure for WarkeYs Catalano. DRAINS-PLOOR,ROOF AREA,CON0. P+V satson,as provided for by Section 3700 of the tabor Code,for the performance of the STORIES TYPE CONSTRUCTION work for which this gamut is issued. FlXTURES-PER TRAP Ej 1 have and will maintain Workers Compensation Insurance,as required by Section 3700 of Ne Labor Coca,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC GROUP APN My Worker's Compensation Insurance carrier and Policy number are: - Cwier. " Policy No.: GAS-EA.SYSTEM-OVER 4(EA) .` rf pN 1 D CERTIFICATE OF EXEMPT'ION FROM WORKERS' 1� COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR (Thissection need not becom lered iflhe BUILUM0 DIVISION FEES p Permit is foronc hundred Jollms($I W) or lase) GREASE TRAP (certify that rsnthein perforanyO sanceo theas work for subject bjech tto(he W rkersued,(shall SEWER-SANITARY-STORM EA.200 FT not employ any person in any manner so as m becbm<subjem to tnc Workers'Camara- RCY E 0 z ,mien Laws of California.Data WATER HEATER WNENT/ELECTR all Ii z0 Applicant - GRADING FF.F. y NOTICE TO APPLICANT:If,afmr making this Cri ifleate of Exemption,you should WATER SYSTEM/IREATING abecome subject m be Worker's Compensation provisions of the Labor Code,you must _ SOILS FEE {1a forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE Q Z 'CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.LF. A U 1for by whaffirmthatthere issrn (Spe.30 lending agency for performance or (L H the work for which this permit is issue)(Sec.3U9],Civ.CJ U Lendri"Name W Lender's Address TOTAL: TAL: 1 certify that I have read this application and late that the above information is It V1 correct.l agree to comply with all city and county ordinances and state laws relating to Q'pY• MECHANICAL PERMIT FEB U7- building construction,and hereby authorize representatives ofthiscitymenteruponthe� above-mentioned property far inspection purposes. LI PERMIT ISSUANCE (We)agree to save,indemnify end keep harmless the City of Cupertino against `liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH.in conugaence of the granting of this permit. ` APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL:DI'ON-POINT AIR HANDLING UNIT(TO Ig000 CFM) SOURCE REGULATIONS. - MECHANICAL FEE IsAIR IfANDLiNG UNIT(OVER 10,001)CFM) ell IqRD CONSTRUCTIONTAX Signamrcof Appliewu Contmcmr Date EXHAUST HOLD OVIDUCT) HAZARDOUS MATERIALS DISCLOSURE ' HOUSING MITIGATION FEE Will the applicant or future building occupant store or handle hazardous material s HEATING UNIT TO,110,000 BTU) as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Code,Section 25532(x)? - HEATING UNIT(OVER I W."BTU)"I ❑Yes E]N. " VENTILATION FAN(SINGLE RESID) " PAID' Will the applicant or future building occupant use equipment or devices which Data Receipt It atilt hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER=COMP QHP OR 100,000 BTU) , District? TOTAL: ❑Yes ❑No BOILER-COMP(OVER 100,000 BTU) - 1 have read the hazardous malarial,requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE fomia Health&'Batey Cade,Sections 25505,25533 and 25534.1 andemtand that if the NEW RESIDENTIAL MECH. SQ.FT - "�r—� �7 building does not currently have xtenant,Net itis my rests'. ,ld mnmify the occupant of the requirememe which must be met prior m issuance of a Cerificto of Occupancy. /'� OwnerorauNnnzedagent Dnte - TOTAL: ISSUED BY: J l-� OFFICE "