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S 1014 (2) ANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ICI ^FCUPERTINO BUILDING.ELECTRICAL PE$MIT NO. � O�� Ikftl)ING DWISION APPLICATION/PERMIT PING PRODB NG-MPIDENTIFIC l�`� BUILDING PR(1JECT IDENTIFICATION BUILDING ADDRESS: SANITARY,NO. APPLICATION SUBMITTALDATE 4.1 ER'S N�� , C 6 O ONE: CONTI�f R'S NAME: IC NO'. Yh JZI N/C COMI'ROLN TECT/LNGI E C LIC NO. gDDRESS: ; I ❑ CONTACC PHONE: U`3 BUILDING PERMITINFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI CH LICENSED CONTRACTOR'S DECLARATION cry. ELECTRIC PERMIT I ❑ pI� I hercM1y nffmrm LICENSED 1 am liccnmd under pmvisions of Chapter 9(commencing LOB DESCRIPTION F g4Z with BCCI, 7f100)ofUivIslas 3of,he Businessland Professions Code.andmylicenseis AL: 00 in full force and effect, I'ERMI'I'ISSUANCI3 aUfFf]] License Class LiaN ❑PLUMBIN RE-PIPE ZRl Date Connector APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBIURAL, PIPE Fly A HI ECT'S DECLARATION PANELS T ❑MODIFfURAOOZ4— L) I ad,5nxt dd my plan. all eta eda punlic sec • MODIFICATION OZ� Oa-t UP T02fNIAMP$ ❑CHIMNIiY REPAIR I.5gG ] Licensedd Profesiones 20140WAMPS ENT 0SWIMMING POOLS LLJOWNER-BUILDER DEC ATION OVE IIXIO AMPS OATH REMODEUREPAIR 0DEMOLITION W 1 hereby farm that 1 ton exempt from the Connector's License Law for the h4'OTHER O y U following re-wm.(Section 7031 5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL C y which requires a permit to construct,alter,improve,dg ndish,or repair any structure prior to its issuance,also requires the applicant for such penalto rile a signed statement SPECIAL CIRCUITIMISC. } that he is licensed pu...I Ionic pmvi mourthe Contractors License Low(Coupnn9 G� (commencing with Seaimn]gXO nl Division]ori the Businc.esam Pmfetsirro Cod0tar TEMP.METER OR POLL INST. COMMERCIAL, that he is exempt 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 n a civil malty of POWER DEVICES 0•TENANT ❑FOOD SERVICE t more than five hundred dollars(5500). IMPROVEMENT FS8 01,as owner of the property,or my employtts wiNwegesns Nair sole compencuti0m, SWIMMING POOL ELECTRIC ❑OTHER will do the work,and the stclure is not intended oroffered for sole(See.7044,Business a and Prefessinns Calc:The Contractors License law does not apply m-a owner of OUTLETS-SWITCHES-FIX3'ORES pmpeny who builds or improves thereon,and who dace such work himself or through his can employees,provided that such impmvements are not intended or named for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however,the building orimpmvement is sold within one year of completion,the SQ.FT.FLOOR AREA E/SQ.FT. owne,buildef will have the burden of proving that he did not build or improve fan pun- p.a poseofsale'). T f D ❑I,as owner of the property,i m exclusively contracting with licensed contactors m co®nuct the Inject FS..71144.Business and Professions Code)The Contractor's pertLi- sense,Low does nor apply to an owner of property who builds or improves on ves there ,and QTY. PI.UMBING PERMIT -E nD who contracts far such pmjents with,.emoanot(s)berated pursuant to she Contractor's _ License law. PERMIT ISSU /s'Ts, ❑I am exempt underSee. ,B&PCfm Nismasnn Vn ALTER-DRA & - �R(EA) N Owner Date /IL WORKER'S COMPENSATION DCCLARATION BACKFLOW E CG ©M` 1 hereby amrm under penalty of Perjury one of the following declarations: C/ I have and will maintain a Ceeifcac of Consenuottlf-insumm Worker's G' 'in- DRAINS-FLOOR.ROOF,AREA,COND. - STORIES TYPE CONSTRUCTION s ltimn,a provided for by Section 3700 of the Lubor Code.for 1hm perrofmun c of the work for which this permit ix issued. FIXTURES-PER TRAP ❑1 have and will maintain Workers Compensation Issuance,as required by Section 3]U0 flhe 1,uhnr Cnh for the perfomlancc of the work 6r whi hlh's pentrdHsissucd. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC GROUP AI'N rkrril pr11.�1' Ins- a tamer and Policyr a GAS-EA.SYSTEM-OVER Card W V • Policy No.: CERTIFICATE 'EXEMPTION FROM WORKIiRS' GRIiASEl1NDUS'fRI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES fmissection need not he completed tithe permit is foram hundreddallars(SI0111 GREASETRAP or lees I PLANCHECK FEF lemaythmintheperfnmunceaflMwod(.,which dispennitis issued,l shun SEWER-SANI'T'ARY-STORM F.A.21X)Ff. mol employ any person in any manner so as to become mbject lathe Wnrkmrv'Compcm ENERGY FEE Z section Lewsof Califxons.[)ate - WATER HEATER WNENT/ELECTR Z Applicant I GRADING FEE y NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMO REATING SOILS FEE (~ " become subject to the Workers Compensation provisions of the labor Code,you must (Ys forthwith comply with such provisions or this permit shall W deemed revoked, WATER SERVICE 0, Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID `U Z T hereby affirm that them iso constrocrinn lending agency for the performmnce of I I Receipt IF the work for which his permit is issued(Sce.3197.Cie CJ 0 Lendefs Name 'TOTAL: U Lenders Address TOTAL: a1 certify The,l have read this application and state that he above information is BUIL G F V1 coned.l agree to comply with all city and county ordinances and state laws relming to QTY, MECHANICAL PERMIT FEE SEISMI '.E U 2 building commustion.and hereby auNnrim representatives of this city to enter upon the above-mentioned property for inspection purrynes. PERMIT ISSUANCE [LLCI'RIC FE. (We)agree to save,indemnify and keep harmless the City of Cupcnino against Iiabilities,judgmems,a msand expenses which may in any way home-gains'said City ALTER OR ADD TO MECIF PLUMBING E in consequence of the gaming of this pend. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CFO 10,04lI1CPM) MECHANIC LFEE I I CEREGULATI S, AtsnyoliAIR HANDLING UNIT(OVER 10,001)CFM) CONSTRUCTIO X Signature of Applic""Comadnr Date EXHAUST'HOOD(W/DUCO HOUSING MITIGATIO FEE NA_RDOUSMA : IALSDLSCLOSURE Willtheappliemlorfunumbuilding cupamilom or handle hmardous material HEATING UNIT TO 100.00 BTU) m defined by the Cupertino MuniciP it Cale,Chapter 9.12,and the Health and Safety Code.Section 25532(m)7 - HEATING UNIT(OVER 100,010 BTU) ❑Yes ON. VENTILATION FAN(SINGLE REBID) PAID Dae Rmmi If Will the applicant or future building occupant use equipment or devices which HOLLER-COMP(31{POR If0,IN10 BTU) emit h rmarous air mntaminanu as defined by the Bay Area Air Quality Management TOTAL: District? BOILER-COME(OVER I01),(00 BTU) _ ❑Yes F1 No I have read the huardmus materials requirement,under Chapter&95 of the Cali- AIR CONDITIONER - ISSUANCE DATE fomi-Health&Safety Code.Sections 25505.25533 and 25534.I orkarmnd that if'he NEW RESIDENTIAL MECH. SQ.FE building does not currently have.mort,but it is my responsibility to notify the occupant of the rr'{mirementx which must M met prior to issuance of.'Cenifcam of Occupancy. Owner or authmiud agent Dam TOTAL' ISSUED BY: OFFICE