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31251 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL- PERMIT NO. 51 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 312'2 IV's BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: - - SANITARYNO. TAPPLICATION SUBMITTAL DATE 11440 1032 OWNER"NAML•:n� pFIDNE: 13 CON A f 'S NAME: - NIC CONTROL IT ARCHITECT/ENGINEER: LIC NO: ADDxn S /no FIPVIAIO D r' ❑ � CONTACT'. PHONE: BUILDING PERMITINFO ❑ Consultant I=Paid by Applicant(Initial) BLDG ELECT PLUMB MECH a �c ❑ ❑ LICENSED CONTRACTORSr ,powimotoof CON' QTY. ELECTRIC PERMIT FEE I hereby atfnm Nm 1 um licensed under pmvininna of Chapter 9(commencing ' JOB DESCRIPTION iN Section]Wf))of Division]of me Business and ProfcssinnsCode,and mylicense is RESIDENTIAL: DO w 0 1PERMITISSUANCE [- in full forte euro attar. 3(0 1, 0 SFDWL 0 KITCHEN REMODEL �UU License Clu- Contractor APPLIANCES-RESIDENTIAL UADDITION ]PLUMBING RE-PIPE Q a Dam Caroms / ARCHITECTS DECLARATION UMULTI-UNIT, USTRUCTDRAL Z8 m I understand my plans shall be used as public records PANELS MODIFICATION pyp UPT0200AMPS RIOR 0CHIMNEY REPAIR F Licensed Profcammul 2014000AMPS IMPROVEMENT J3 OWNIiR-BUILDER DECLARATION - OVER IWOAMPS U BATH REMODEUREPAIR 0DEMOLITION yy X Q 1 hereby affirm that 1 am exempt tram the Cacuito's License Law for the k�a W following reason.(Section 7031.5,Business and Professions Code:Any city mcounty SIGNS ELECTRICAL D OT-IER 4477 0 which requires;a Perms to construct,enter,improve,demolish,or repair any structure ff.�. procto its issuance,also requires the applicant for such pemtit to file a signed statement SPECIAL CIRCUIT/Ml AC. yr" that he is licensed purauanuo the provisions of the Contractors License Ln,(Chaplerf) G� (commencing with Section 7")ofDivision J of Ne Business and Professions Code)or TEM P.METER ORM INSL COMMERCIAL: G G that he is exempt therefrom and the basis for the alleged exemption.Any violation of 0NEW BLDG/ADDITION 0 DEMOLITION e� Secdon]031.5 by any applicant for o permit subjects the applicant to a civil penalty of POWER DF,VICES ^m OTENANTPROV El FOOD SERVICE not..it than Eve hundred dollars y empi. IMPROVEMENT f�C ❑Lashmamst Ncinemom,mmyemploycetwlNwages ned far ale(Ssite cnmpensadnn, SWIMMING PO ECI'RI wdl do the work,and the he Com is not intendede Law do far sale(Sec_to an Business ❑OTHER �yyyI and arty whions Code:The Contractors License WIN loan not apply to if owner of OUTLETS-SWITCHES-FIXTIf —3^ his own who builds or improves therms,um who rices such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RPSIDLNTIAL ELECfR wile.If,however.the building or improvement is sold within one year ofcamPletlom,the SQ.FVLXRfRD LSQ.FT. owner-builder will have the burden of proving that he did not build or improve for put- P' H 1 V pose of sa", TOTAL: ❑I,as owner of the property,am exclusively contracting with licensed contractors to OCT - �� construct the pro (See. Business anns e) mctors ject(S )Oil, d Professions CodThe Com ' Li- ccoelawdoesnotapplymanowiterofpiopenywhobuildsorimprovesdamon.and QTY, PLUMBING PERMIT FEE wbucontmets for such projects with a contmmor(s)licensed pursuant fm the Commences (� uL License Low. PERMITISSUANCE CI�y T i Uf UUPEh I INU Cl Iamexemptunder Sec. ,B&PCforthis reason Owner Date ALTER-DRAIN&VENT-WATER(F) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE AIn/'1 I hereby aRrm under penalty of perjury one of the following declmmiom: (.00 •❑ I have and will maintain a Cenifcme of Consent to self-insure for Workers Compen- DRAINS-MOOR.ROOF,AREA,GOND. STORIES TYPECONSTRUCTION nation,as provided for by Section 3700 of the Labor Code,for the performance of the Walk for which This pemtit is issued. FIXTURES-PER TRAP XI have and will maintain Workers Compensation Insumncc,as required by Section of Nc Labor Code,for the performance of Ne work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN My Wo%''s'Co_mRe�� do rand Policy no Carrier, j , _ Rc_-a n}au pattp�ame Policy No.: 'sGAS-EA.SYSTEM-OVER 4(EA) �'YIT�CEFRTITIFICffATE 01;EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRF.ASMNDUSTRL WASTE INTERCEPTOR B LI ISION FI?PS (This section need air be completed if me permit is for one hundred dollars($100) GREASETRAP or lens.) PLANCHEC I cenifythat inthe performance ofthe work for which this permit is issued,lshall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner m a I he, s bjen to are Worker"Compen. ENERG Oz cation laws of Cdi[Ymia.Da s�Ot 'J 1 WATER HEATER WIVENT)ELECfR GRA Applicant d.Ii y NOTICE TO APPLICANT.If,after making Nis Certificate of Exemption.ymi should WATER SYSTEM/TREATING (~' become subject to the Workers Compoom mer provisions of the lobar Code,you nun SO&&E mi W forthwith comply with such provisions or Nis pert shall be deemed revoked. WATER SERVICE. Q Ts CONSTRUCTION LENDING AGENCY NEW RESIDEM'IAL PLMB. SQ.FT. PAID V 0 Ihembynttirm The,them iso rnnsuumion lending agency fmthe performance of ate Receipt# the work for which this pczmit is issued(Sec 3097,Civ.C.) - 0I--' Loodmea Nome TOTAL: W 'L ndces Address TOTAL: I certify mut I have read this application and state that the above information is - BUILD[/6 FEE V) correct.l agree to comply with all city and county ordinances and stem laws relating'. QTY. MECHANICAL PERMIT FEE Ll z buildingconsuection,and hereby authorize representatives mfihis city toemciupon the SEISM FEE above-mentioned property for inspection purposes. PERMITISSUANCE (We)agree to save,indemnify and keep harmless the Ciry of Cupertino against ELE 'RIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the granting of this permit. PLUMB[ FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICA FEE SOURCE REGULATIONS. AIR HANDLING UNIT(OVER BEOW CFM) CONSTRDCTIO TAX _ Signature of ApplicanuCouracon - Duro EXHAUST HOOD(WMUC) HOUSING MITIGA ON FEE HAZARDOUS MATERIALS DISCLOSURE Will lhert,licant is fair.huilding smcupommomor handle hazardous material HEATING UNIT GO INE"BTU) as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety - Coda Section 25532(a)? HEATING UNIT(OVER I Oq(gfl BTU) D Yes C]No VENTILATION FAN(SINGLE RESID) PAID Dam eceipt# Will the applicant or more building occupant use equipment or devices which BOILER-COMP QHP OR 100.000 BTU) emit Thrombus air conmmiwnts as defined by the Buy Area Air Quality Management T District? ❑Yea UNn BOILER-COMP(OVER 100,000 BTID - I have mud the havudons materials requirements under Chapter 6.95 of the Cub- AIRCONDITIONER ISSUANCE DATE forma Health&Safety Code,Sections 25505,25533 and 25534.1 undimarrai that if rite' NEW RESIDENTIAL MECH. SQ.FT. building docs wt currently have.¢pant,Net it is or,roxpomibilit mnntify the occumal of the rquiremema which mum be met prior to issuance of a Certificate of Occupancy. Owner or authorized agent Dam TOTAL: ISSUEDBY: OFFICE v