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99090185 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CIT BUILDING CUPVISION BUILDING-MECHAICA / PERMIT NO. � �J V V T BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. BUI GPAWECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE /0 5a 1 N, $/renP AV9- -2d_`7 NE ' OME� nO-(.✓r �HOyV'E: ?� CONTRACT 'SN ME:Q ( L1'C NO: NIC CONTROL# CHITECT/ENGINEER: 'C v LIC NO: ADDRESS Y) ❑ -CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH ❑ ❑ ❑ LICENSED CONTRACTOR code,S DECLARATION Q•ry, ELECTRIC PERMIT FEE 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing ,IDB DESCRIPTION OCZ with Section 700E of Division 3 ofthe Business it Profso o ylicense is W O O PERMIT ISSUANCE RESIDENTIAL: F+ty r in full force nod effect.`w i_ .3�� m ❑SFDWL El KITCHEN REMODEL �UU Licens lass J� Lic.N APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE NL Date Cnntmctor ARCHITECT'S DECLARA' N El MULTI-UNIT L1 STRUCTURAL PANELS Z ,�idp a I understand my pWns shall he usod es public recoPos MODIFICATION OZ`~p UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR F4�"ly Licensed Rofessional 101-1000AMPS IMPROVEMENT LJSWIMMING POOLS J$ .Ej OWNER-BUILDER DECLARATION OVER IOW AMPS BATH REMODEVREPAIR El DEMOLITION 6 I hereby.(Seto that 1 am exempt from the Contractor'¢License y o for the 6 V following reason(Section 7onstr Business andimprove. Professions Cade:Any city or county SIGNS ELECTRICAL OTHE '3 ti which requires a permit to construct,alter,improve,demolish, file repair any swment ��d her h o its licensed p alsoant to res the ovisio s of for Contractors ractor Lice s Low(Chapter SPECIAL CIRCUIT/MISC N, that he is licensed pursuant the provisions of the Contranor's License Law(Chvpmr 9 00q (commencing with Section 9000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL, a c W 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 permit subjects the applicant to a civil penalty of POWER DEVICES v ❑T ANT ❑FOOD SERVICE FSpnot mom than five hundred dolls,($50% ❑ 1.as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRICROVEMENT E: will do the work.and the stmeture is not intended or offered for sale! ece.WA ,Business OTHER u1"' and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES 4'3 property who builds or improves thereon,and who does such work himself or through his own employees,provided that.ouch improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.IL however,the building or improvement is sold within one year of completion.the SQ.FT.FLOOR AREA $/SQ,pT. owner-builder will have the burden of proving that he did not build or improve for pur- pose of sale.). ❑1,as owner of the pmpefty,ant exclusively comment,with licensed contractors to TOTAL: construct the project(Sec.7044,Business and Professions Codd:)The Conductors Li- cense Law does not apply to an owner of property who milds or improves thereon,and QTY. PLUMBING PERMIT - FEE who commits for such projects with a contractorts)licensed pursuant to the Communes License Law. PERMIT ISSUANCE ❑I am exempt under Sec. ,B&P C for this reason ser Date ALTER-DRAIN&VEST-WATER(e) 1 VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penalty of perjury Ona ofine following dedderaions: ❑I faceted will maintain aCetificate of Consammself-insure for Worker's Compen- DRAINS'-FLOOR,ROOF,AREA COND. STORIES TYPE CONSTRUCTION eatlon,as provided for by Section 37W of the Labor Cade,for the performance of the wo k for which this permit is issued. FIXTURES-PER TRAP I have and will maintain Workers Compensation Insurance,as required by Section of the Labor Code,for the normative of the work far I Inchthistthiss pker/mit is i`ssuyed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUPMy Cumeorm�eaf eovrlie Pot iand yNo.Y nIJ yLs� JL GAS-EA.SYSTEM-OVER 4(EA) -3) lot CERTIFICATE OF EXEMPTION FROM WORKERS' O J COMPENSATION INSURANCE OREASFIINDU$TRL WASTE INTERCEPTOR BUILDING DNISION FEES (This section need nm bewmpleted ifthe pennitis furore hundred dollars($100) GREASE TRAP or less.) PLANCHECK FEE I verify that in the verfmmance oftbe work£orwhich0is permit is issued.l shall SEWER-SANITARY-STORM EA200 FT. not employ any person in any manner so as to become subject to the Workers'Cottager- .pen- ENERGY FEE OZ sation Laws of Califrmis.Date O Applicant WATER HEATER WNENT/ELECTE GRADING FEE r'7 f�A NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMiTREATING F ? become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE 0 forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE - CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID U Thereby affirm lhauhere is uconatrvetion leading agency for the performance of Date Receipt# (Ty F the work for which this permit is issued(Sere,3097,Civ.C.) Q Lenders Name TOTAL: Lender's Address TOTAL: I molly that I have read this application and state that the above information is BUILDING FEE y correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE V Z building conmrvdion,and hereby argamize representative$of this city to erraticism the SEISMIC IEE above-memi mod property for inspection purposes. PERMIT ISSUANCE(We)agree to save,Indemnify and keep harmless the City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accord against said City ALTER OR ADD TO MECH. PLUMBING FEE in consequence of the granting of this permit. APPLICANT U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,"CFM) SO CE REG TIONS. MECHANICAL FEE 7,6C AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Si ore mof t cam/Contmctor am/ EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous mamnd HEATING UNIT(TO 1110,(X1)BTU) as derined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety Cade,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) ❑Yes No VENTILATION FAN(SINGLE REMD) PAID -- Date Receipt# Will the it Ou to orfawn¢building occby the use Amaequipment Quordevicewhich BOILER-COMP(HPOR l0b,"BTII emit hazardous air cumaminants as defined by the Bay Area Air Quality Management TOT Districts L]Yes 1-1 No BOILER-COMP(OVER IW,Wp BTU) I have read the harallous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE forma Health&Safety Code,Sections 25505.25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT building doesnotc fly M1aveamnanr thin it is my ressprnxibillty to no'yWeoc pant Y / of Lh��mehl h mvxl be met prion.ismance of a G if'VOceup�,h must be met prior m ismence of a C if'VOc470, Ow�m uthodzed agent��uthorized agent�� TOTAL: ISSUED BY: OFFICE