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S 1213 (2)acgOC w� U C vFi6a O ,7 "- G �OyC w3c O aOC gaF�a • oZ 0 a� d Q UO O4. E fit UZ 40 APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES -USE BALL POINY PEN ONLY CITY OF CUPERTINO BUILDING - ELECTRICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL BUILDING PROJECT IDENTIFICATION " PES l I NO. J 1213 BUILDINOADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE O ER' E'. PHONE: I fG TrAl: uz CONTRACTOR'S NAME. LIC NOj25 0I8541� VAN 734 N/C ❑ CONTROL# ' ARCH ]'ECT/ENOL 'ER: LIC NO: - p[ ES$: /AMwI- CON9'ACT�:( PHONE: - To/� Jv -S v tiu ❑Consultant Fees Paid by Applicant (Initial) BUILDING PERMIT INFO VWD^ ELECT PLUMB SUCH laq7 LICENSED CONTRACTOR'S15ECLARATION 1 hereby affirm that 1 am licensed under previsions of chapter 9 (commencing QTY ELECTRIC PERMIT FEE LOB DESCRIPTION PERMIT ISSUANCE - in 9whh lSectionapld affect. Division3 of 0e Business and Profaxslans Code, and myllconse is License Clamd _I Lic.# Ll3 & Date Contractor RESIDENTIAL' ❑SFDWL Ll KITCHEN REMODEL El ADDITION ❑PLUMBING L PIPE El MULTI -UNIT ❑STRUCTURA MODIFICATION APPLIANCES -RESIDENTIAL ABOUT EC I'S DECLARATION I understand my plans shall he m ed ue public records PANELS UPTO200AMPS -- El INTERIOR Ll CHIMNEY REPAIR IMPROVEMENT E]SWIMMING POOLS [I BATH REMODEWREPpr�AIR ❑ TI N ❑ OTHER bS Licensed Professional OWNER -BUILDER DECLARATION 1 hereby affirm that 1 am exempt from the Contractor's License Law for the following rwson. (Section ]031.5, Bminm9 and Pmfossions Cade: Any city or coumY 201-1010AMPS OVER IINx1AMP5 SIGNS ELECTRICAL which requires a permit to consumer, alter, improve, demolish, or repair any strucwre SPECIAL CIRCUITIMISC.that prier to its issuance, also requires the applicant for such permit to file a signed statement he is Iamused pursuant to the provisions of the Contractor's License Law (Chapter 9 (commends, with Section 900Eof Division Sof the Business and Prnfessinns Corl TEMP. METER OR POLE INST. COMMERCIAL: that he is exemptdomfrom and the basis for the alleged exemption. Any violation of ❑ NEW BLDGIADDITION ❑ DEMOLITION - POWER DEVICES Section 90315 by anynpplicam forapermit subjects lheapplicamm a civil penalty of not more than five hundred dolism(S500). D I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 9044, Business ❑TENANT ❑FOODSERVICE IMPROVEMENT ❑ OTHER SWIMMING POOL EL and Professions Cade: The Contractors Licame Law docs not apply m m owner of OUTLETS -SWITCH IXTURES ,.pony who builds or improves,hereom and who does such work homelier through his own employees, provided that such improvements are not intended or offered for sale. If,however, the building or improvement is sold within one year of completion, the 'NEW R8 ENTIAL F,LE - SQ FT. SQ. FT. FLOOR AREAS/SQ. PT. fir -builder will have the burden of proving that he did not build or improve for par - pose of sale.). L] 1. as owner of the property. am exclusively contracting licensed contrac�orsm AL: rumors, the puffer, (Sec. ]1144, Bminess and Net ..ism C,vep The Contramnrs Li- me Law does no, apply to an owner of property who builds or lmpmves Iherenn, and QTY. G P MIT FEE who ennwctx far such pmjeets with a cnnurucmr(s) licensed purvuunt m the Cnntmdors PERMIT ISSUANCE License Law. 1 am exempt under Ser. , B& P C for this reason A Owner Date ALTER- DRAIN& ENT- ATER(8A) VALUATION \®/ �y -I/ •� /� - WORKER'S COMPENSATION DECLARATION RACK FLAW P ECT. VICE Ihereby aflirmunder Penalty ofperjuryone of the following declarations: ❑ I have and will maintain a Crc enifiruof Consent .self-Insum for Workers Compcn- sound, as provided for by Section 3700 of the Labor Code, for the performance of the k for which this permit is issued, DRAINS-FLO ,ARA, v S !^ �tl(Yj/ L` TYPECONSTRUCr10N FIXTURES-PERTIlh ynar��t have and will moinain Worker's Cnrritom lion lmmmmce, as required by Section �" 9100 ofthe Labor Code, forthe pertmmance ofthe work for which this permit is issued. My Workki s �o� lion Ins carrier and Policy number Carver, C F(1•kl Policy No.: %lrQIse- .3 GAS -EA. SYSTEM -I INCA JI&TS GROUP APN RAE CJ GAS - EA. SYSTEM -OVER CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE ,arm, (This,came mordant be eompletedlfthe ft is future lumdred dollars or less.) GREASE/INDUSTR, WASTE INTERCEPTOR CN BGf V11 LvS - - PLANCHECK GREASE'1'RAP Loy any that irthe performance of the workfor ms,which this the Woaissue..pa,shall nw employ any person in any mono eq�� o become subjeer to the Workers' Compen- SEWER - SANITARY -STORM EA. 21s)FT. ENERGY FEE NNJ snlimn Laws of CaHfomia. Dae // Applicata WATER HEATER WNENVELECTR GRADING FEE NOTICE TO APPLICANT: If, after refusing this Certificate of Exemption, you should become subject in the Worker's Compensation of the Labor Code you must WATER SYSTEM/TREATING SOILS (hien orman hal e forthwith comply with xuCM1 pmvisinns or this permit shall be demned revoked. WATER SF.RVICF. CONS'TRUC'TION LENDING AGENCY I hereby ofBmUhat there is a construction lending agency for the Pedernales, of PAID NEW RESIDENTIAL PLMB. SQ, FT. D' a Receipt, - the work for which this permi�Lesued (Sea. 3097, Civ. C.) Leader'sName SIT- TOTAL: TOTAL: Lender's Address NU - 1 certify that I hove read thio oppliwtion roti sera that the above infnrmntirn is BUILDING fEE correct. Iagree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize nomasenativesofthis city In enterupon the QTY. MECHANICAL. PERMIT FEE' - SEISMIC E PERMIT ISSUANCE ELECTRIC PE abrve-mentioned property for inspection purposes. (We) aee m save, indemnify and keep harmless the City of Cupcaino against gr Ilabilities,judgmena,costs and "Emove.s which may in any way accrue again.c, said City se in ngnence of the granting of this permit. ALTERORADDTOMECH. FEE AIR HANDLING UNIT (TO 10,000 CPM) MECHANICAL ME APPLICANT UNDERSTANDS JINJP WILL COMPLY WITH ALL NON -POINT SOURCE EGU TIONS. - AIR HANDLING UNIT (OVER IQW(I CFM) CONSTRUCTION TAX �,�/D-•GO Signa. of Appluent/Coumpeor Dam HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE - HEATING UNIT (TO 100,001 BTU) - ill the applicant or future building ntcuporl store or handle hazardous material sa Je toed by the Capetian Municipal Code, Chapter 9.12, and the Health and Safety HEATING UNIT (OVER 100.000 B'TO) Code, Section 25532(n)9 ❑Yes I ^•No PAID VENTILATION FAN (SINGLE RESID) Data Romm,# BOILER- COMP UHP OR 100,x10 BTU) Will the appliwmmfurore bonding by the BayManageces ment emir hazardous sir contaminants as defined by the Buy Arra Alr Qmli,y Management tyAea ipment or Air District ❑Yes PIN. TOTAL, BOILER-COMP (OVER 100,0(X) BTU) , AIR CONDITIONER I have haoffidOm matetions ials under Chapter 6.95 thethat Cali- - - ISSUANCE�E NEW RESIDENTIAL MECH. SQ. FT. & S fet M505,11533 a name Sections 25505, 2553] ad 25534.1 i nnotahmd that if the Tania g allS &Safety only have building tlees n , currently M1avr a tenant, that h Is my responsibility m notify the occupant of the uirco ms which nus metTrior to iasmmceofu Cetifame oftXcupnn. 4 ISSUED BY: TOTAL] O ser rnuthorizc g t Dam OFFICE