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31130 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO ' BUILDIN 1.ELECTRICAL PERMIT No, 31130 11 3 0 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. 3 IIUILUING PNO.IECI'IDIiNR'IF'ICAI'ION BUILD�ADDµESS: � SANITAIIY NO. APPLICATION SUBMI'19'AL DATE VwVs3 a 3 �0. OW as�N Z. olve: coNTRncrol' e: L�3o �� - NIC CON THOLN 0CHITECT/ENG >k: LIC NO: D I( �r n _ ,y,/// ❑ CONTACT. PHONE: /T BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION ,OQTY. ELECTRIC PERMIT FEE 1 herehy affirm tat I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION Z with Section of Division 3 of Business and Professions Code.and my license is RESIDENTIAL: E,wr in full farce and effect. PERMITISSUANCe �UUU License Class Lica ❑SEDWI, ❑KITCHEN REMODEL. rF�a Data Contractor APPLIANCES-RESIDENTIAL ❑ADOPTION ^.UMBING RE-PIPE ARCHITECT'S DECLARATION PANELS F.Py ❑MULTI-UNIT ❑MODIFIURAO 0 ZZ F2 Z d m�,��yytt��bball leaned as public reeoNs MODII'ICATION FES Lr,wr Iesatne UI'TO?W AMPS El INTERIOR ❑CHIMNEY REPAIR _ OWNER-BUILDER DECLARATION 200-1 10AMPS IMPROVEMENT 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑HAD A REMODT:IJRCPAIk ❑DEMGLIT[ON iry5 4 U following reason,(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER su IL Fy¢' which requires a permit to consumer,alter,improve,demolish,or repair any swcwre cool prior to its issuance,also requires the applicant for such permit o File a signed statement SPECIAL CIRCUIT/MISC. that he is licensed p....at to the provisions.(the Comretnors License Tow(Chapter 9 ffLL❑ (commencing with Section 7")of Division 3 ofthe Business and Professions Code)or TEM B METER OR p,OLE INS'(. d q o C that he is exempt)herefmm and the basis for the alleged exemption.Any vi ilaimi of DG/ADDITION [D DEMOLITION Section 703 L5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES >qm not more than five hundred doll ars(5500). ❑.MPROV1iMENT ❑FOODSERVICE SD E]1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC, hIPR will do the work,and the stmcmre is not intended proffered prosaic(gee.]IW,BusinessR mand Professions Code:The Contract v License Low does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or trough his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTS SQ IT sale.If.however the building or improvement is sold within one year of completion,he SQ.FT.Fy,( H R $/SQ,IT.. ownerhailder will have the burden of proving that redid not build or improve for mn. potentiate.). �eppe� nsdL as owner of the prapary,am exclusively matmning with licensed contractors to TOTAL.: iY1(1 � ��aD comm atW the project(S .]( ,Business and Professions Col the Comtmctds Li- MAR 2 arse Law does coal apply to ea owacr of property who build,or improves thereon and QTY PLUMBING PERMIT PEE who contracts for such projects with a contr9tods)licensed pursuant o the Contractor's CITY Urp(�IN License Law. Pr.-RMI'1'ISSUANC k.Urt U ElIam exempt under Sec. ,B&P C fortis reason Owner Dmc ALTER-DRAIN&VENT-WATER GIA) VALUATION WORKER'S COMPENSATION DF.CI.ARAI'ION BACK FLOW PROTECT.DEVICE 1 hereby affirm under penalty of pe jury one of the following declambons: ❑I have and will maimaio a Cerificale of Consent o self-insure for Workera Cowper- DRAINS-MOOR,ROOK AREA,COND. STORIES TYPE CONSTRUCTIONnation,as provided for by Section 3]00 of the Labor Code.for to performance of the work for which this permit is issued. FIXTURES-PER TRAP EI I have and will maintain Worker's Compensation Insurance,as requitM by Section 37W of the Labor Code,for to performance of the work for which this permit is yiis�s(u,W/. GAS-EA.SYSTBMI-I INC.4 OUT LOS OCC.GROUP APN My/Cameerk scum natio sworcc carie 1.1cy NoYl/ '//S[ /-/ GAS CA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' GNEASP/INUUSTNL WASTP.INTI3NCEPTOR COMPENSATION INSURANCE (This section dead not be completed RIB,permit is for one hundred do][.($1 W) BUILDING DIVISION FEIS or less.) GREASETRAP PLANCHISCK PER 1certify tervetopey ,,acce.the bac for which this permitis issued,I shall nod employ any penton many manner so as to become million mthe Workers CompeerSEWBR-SANITARY-STORM EA,200 fq. ENERGY IEB O Z sodium Laws of Calif..!..Data WATER IWATER W/VEMPHLECTR Z O Applicant GRADING FEE ti ,it, NOTICE TO APPLICANT.IL after making this Cenificam of Exemption,you should WATER SYSTHM/fRRATING a ^' became subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE M fy (y (. esh im comply with such pnowi ,or this pard,shot]to damW revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FC PAID L) 0 1 herebyaffdrm that them iso construction lorair ,may forte perf.murceof Dam Rittsiv cel a W. the work for which this permit is issued(Sec.3W7,Cie CJ O F" Lender's Name Un TOTAL; WLender's Address T G I certify than I have read this application and statethat the above information is BUILDING FEE. Vt contain.l agree to comply with all tidy and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE Uz building construction,and hereby mountain representatives oflhis city to enter upon the SEISMIC IEE above-mentioned property for inspection purposes. PERMIT ISSUANCE (We)Nara ml to save,indemnify and keep harmless the City of Cupertino against ELECTRIC liabilities,judgmems,cas,end expenses which may in any way accmeagainst said City ALTER OR ADD TO MBCH. in consequence of the granting of this permit. PI.UMBIN F:. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT TO 10,000 CFM) SOURCE REGULATIONS. MECHANICALFEE -Ze12 (oft CFM) HANDLING UNIT(OVER 10. CONSTRUCTION T Zgratre wApplicanVComnacmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGA ION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO I00,000 BTU) as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health end Safety Code,Section 25532(a)? HEATING UNIT(OVER I 00,0A BTU) ❑Yes VENTILATION PAN(SINGLE RESID) PAID a Will me applicant or antra building occupant use equipment or devices which Dara Be lid oft hazardous air contaminants as deemed by aM1e Bay Arta Air Quality Management BOILER-COME(3HPOR 100,00)BTU) Disatrict? Elves 8ry/ BOILER-COME(OVER 100.000100.000 BTU) 1 have read d,hazalloos materialsR CONDITIONER re,u 53ean under Carrara,Chapterrstaofthe Cali- ISSUANCE DATE forma Health&Safety Cuda,Saunas 25505,is my and 25534.I uMetsmnd tot if to NEW RESIDENTIAL MECH. SQ.IT. building does nm currently have anent that o is ua responsibility to notify the ancy. /)tithe require, h must the,ma prior m issuance of a Certificate of Occupancy. ✓ / -- uaare—y/el euthonad agent �� Dere TOTAL: ISSUED BY: OFFICE