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30034 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF COPE'RTINO RUILDING-ELECTRICAL. RMIT NO. 30034 BUILDING DIVISION APPIACATION/PRRMIT PLIIMFIING-MECHANICAL. B1111.DING 1'ROdHCT IIIF-NTIFICA'1'ION BUILDINGADDRESS: SANITARY NO. APPLICATION aai�s v� 2 eQ� CATION SUBMITTAL DATE OWNER'S NAME: le— 4T-7V CU��NAME: LIC NO: NIC CONTROLN ARCHITECDENGINF.ER:, LIC NO: ADDRESS: CONTACT. PHONE: - - - BUILDING PERMIT INFO n Consultant FCCS Paid by Applicant(Initial) BLD ELECT PLUMB MECH ` r _- ,-r gr'& ^ (75zfw LICENSED CONTRACTORS DECLARATION ❑ ❑ QTY ELECTRIC PERMIT FEE �a Z I hereby affirm that 1 em licensed under provisions of Chapter 9(commencing� JOB DESCRIPTION with Seor'cea m)ofD JoOhe Puviness and Rvf n Cade, iccnu is 00 infullforcea003) I. . � PERMIT ISSUANCE S RESIDENTIAL: aUV License Cl ss Lic.p ❑SFDWL ❑KITCHEN REMODEL. i.�W Date—. L Comrector APPLIANCES-RPSIDRNTIAL ❑ADDITION [I PLUMBING RE-PIPE F,Cw ARCHITF,CTS1lF,Cl. RATION ❑ AL. MULTI-UNIT ❑STRUCTUR PANELS 1 understand my plans shall be used v+public records MODIFICATIONunderstandunderstandec p UPTO 2(N)AMI'R �'ERIOR [:]CHIMNEY REPAIR P4 ¢] Licensed Professional 201-1000AMPS - IMPROVEMENT s ,l OWNER-BUILDER DECLARATION OVER IfNOAMPS ❑BATH REM EV P IR ElEM ION y10 3 W< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the x6V faflnwimg rcason.(Secm.7031.5.Business and Profesiue,Cale:Any city or county. SIGNS ELECTRICAL Yl 4. which requires a permit an construct,alter,improve,demolish,or repair any strvemm ,��Zyo prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. 999 W that he is licensed pursuanuo the ptovisioms of the Commctar's License Taw(Chapter 9 aGO� (commencing with Section 7000)of Division 3 of the Business and Professions Coe)a, TEMP.METER OR POLE INST. 4 COMMERCIAL Q, n y that he is exemm therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Y• Section 7031.5 by any applicant for a permit subjects the applicant a civil penaltynf POWER DEVICESel ❑TENANT FWD SERVICE �, d mom than five hundred dollars(55(X1). 6 I,us owner of the norm IMPROVEMENT ❑ prupe y ycmployces wish wages es their sole nnnpensininn, SWIMMING I'11OL1?LECTRIC Cl will dr the work,and the structure is not Intended or offered far sale(Sec.?tW4,Business []OTHERh and Professions Code:The Contractor's License Law does not apply to an owner of UUTLIi CE and p pmpemy who builds or improves thereon,and who does such work himself or through his awn employees.provided that such impravements um not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. S� sale.If.however,the building or improvement is sold within one yearofirmpletlam,the SQ.PT.FI.00RAREAj 5/SQ.FT. owner-builder will have the burden of proving that he did urn build or improve for par- poamsale). 'S V I,as owner of the pml'oY.am exclusively contracting wird littnsedcmntmnorsm TOTAL' co®uvct the project(Sec.0044,Business and Professions Coles)The Comrvctnr's Li- c a law does not upply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE who contracts for such pmjeas with a contmctons)licensed pursuam to the Contractors Liam.l.vw. PERMIT ISSUANCE ❑I any exempt under Sec. ,B A,P C fm thinrram Owner Dme ALTER-DRAIN&VENT-WATER(EA) y�{k'/ — VALUATION WORKER'S COMPHNSATION DECLARATION BACK FLOW PROTECT.DEVICE ^//[I/fO �� I herebyamrrn under penaltyof perjurynneoftbe following dcclorations: 4 CCC��LLL// ❑Ihave wJwill maintain oCcnificme of Consent to self-insuiefnr Worker's Cmmpen- DRAINS-FLOOR,ROOIy AREA,COND, sation,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION work for which this permit is issued, FIXTURES-PER TRAP 0 1 have and will maintain Worker's Compensation Imummer.as required by Section 37M of the Labor Cade,for the Performance of the work fdrwhich this permit is issued. GAS-EA.SYSTEM-I INC.4OUTLETS OCC.GROUP. APN My Whrke cec rend Policy y � ��+/ Carver, �a 9LfeJt c Policy No.: Zr'//7 GAS-FA.SYSTIM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASUINDUSTRI.WASTE INTERCEPTOR ('This section need not he completed ifthe permit is furore hundred dollars 61 fli BUILDING DIVISION FEES or less.) GREASE TRAP PLANCHECK FEE I comfy that in the perfora anecol the work for which this permit is issued,I.shall not ermloy any penton in any manner wi as to hecamesuhjen to the Workers'Cmmpeo- SEWER-SANITARY-S'IQRM EA,400 PT. ENERGY FEE z sodium l,mwsnf California.Date 0 Applicant WATER HEATER W/VI?NT/ELECITt GRADING FEE vl NOTICEID APPLICANT,If,after,making this Cenificate of Exemption,you should WATER SYSTRMaTREA'I'ING a5 become subjectto the Worker's Compensation provisions of the Labor Code,you must SOILS FEE aQ forthwith comply with such provisions or Permit shall law deemed revoked. WATER SERVICE 7z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLH3. SQ.FL PAID U 0 l hereby vffnn that there is a construction lending agency for the perfonnancenf Date ReceiptM Ii P the work Far which this permit is issued(Sec.31X)],Civ,CJ 0 U Lendmv Name TOTAL: Lenders Acres, TOTAL: aI artily that 1 have read this application and state that the above information is BUILDING FEE 0 s f 1 oor .lagrec to comply wilhallcqual county ordinances and state linvaod tingto QTY. MECHANICAL PERMIT FEE 7A U 77 building concoa ction,and hereby aotlernic mpmrinives of this city to enarutm pthe SEISMIC PEE , above-mentioned propeny for inspection purposes. PERMIT ISSUANCI? (We)agree m rave.indemnify and keep harmless the City of Cupertino against ELECTRIC FF.F. 07k.Z. -.O liebilities,judgmcnis,costs and expenses which may in any way accrue against said City ALTERORADDTOMF.CH. inconsequence of the granting of this petrol. PLUMBING FEE APPLICANT U��444 DERSTANDS AND WII 0. LY WITH ALL NON-POINT AIR HANDLING UNIT CTO IQIXXI CFM) SOU S. MECHANICAL FEE/ 11 1 (G� l� AIR HANDLING UNIT(OVER 10,11,00 CFM)ss� CONSTRUCTION TAX Squiltycmf ApPlirnVCmmra use EXHAUST BUILD 0W/DUCT) HOUSING MITIGATION PEE HAZA US MATL+RIALS DISCLOSURG Will the vpplicem utero building occupant score or handle hvzmdnus material HEATING UNIT(TO 110,010 BTU) as defnod by the Cupe no Municipal Cndv,Chvpmr 9.12,end the Health and Surety Code,Section 8532(a)? HEATING UNIT(OVER 100.000 BTU) ❑Yes ❑xm VENTILATION PAN(SINGLE REBID) PAID Will Ne applicant or future building occupant use equipment or devices which Data Receipt N •emit bazmdnus air comaminama s defined by the Bay Area Air Quality Management BOILER-COMP OOP OR IOO,OOB BTU) TOTAL: DiRrict? BOILER-COMP(OVER I00.W0 BTU) ❑Yea ❑No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ' ISSUANCE DATE fontia Healthd,does h Safety Code,Sections 25505,25533 I, and 25574.1 understand hand the NEW RF.SIDIiNT1A1,MECH. SQ.PT. bo the redresnotaurhichntly have he hurt Lthud it ismsmof.Certifto icate ofythearay. t of the mluiremenm which must he met prior issuance of a Cmifcme of(kcupuncy. Owner or authorized agent Duce TOTAL:: ISSUED BY: V� OFFICE