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30433 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO. 30433 BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. BUILDING PROJECT IDENTIFICATION BU INGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE v a1 - 6 OWN HOryi7y C RACE R'. AME: �� I "1 NIC CONTROLN RCHITECT/ENGI EER: IC NO. R SS: ❑ CONTACT:. PHONE: x BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH CJ 4M �[ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE a I hereby affirm that I um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION OaZ with Smtmn70W)of Divisinn3of the Businexs unJ professionsCWe,and myliaxnu is RESIDENTIAL : 00 infullforceand PERMIT ISSUANCE �u1� ❑SFDWL CKffCHEN REMODEL <U�j License Clss gpPLIANCE.S-RESIDENTIAL ❑ADDITION C PLUMBING RF-PIPE 7 4 Date Commctor m CHITECTS DECLA ATO CMUUH-UNIT ❑STRUCTURAL Z 2V' 1 understand my plans shall he used ae public records PANELS AM - MODIFICATION UP TO 2(10 PS OZ p (-]INTERIOR ❑CHIMNEY REPAIR Licensed Prvfessinnm - 201-II]MIAMPS IMPROVEMENT OWNER-BUILDER DECLARATION OVER 1000AMPS C BATH REMODEUREPAIR ❑DEMOLITION yy kJ< 1 hereby.(firm that 1 am exempt from the COalfnelars License law for the vC OTHER p(3 6 U following mason.(Section 7omm Business andProfessions se,de io demolish. Cade:Any city or woure SIGNS ELECTRICAL �F 4471 0(.' which.arylssu n permit re cams the alae i t for such demolish,ar repair any swment ho :7} poor issuance,also rcyvires the applicant for such permitmlile neigneJ statement SPECIAL CIRCUIT/MISC. L HNot he is licensed personal the provisions of the Contractor's License Law(Chapta9 p0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)orTEMP.METER OR POLE INSL COMMERCIAL: , L that he is exempt therefrom and the basis for the alleged exemption.Any violation of C NEW BLDGIADDRION C DEMOLITION Section 7031.5 by any applicant for a pcnnit isilgeathcepplicaneo.civil penalty,of POWER DEVICES ^� ❑TENANT ❑FOODSERVICE I t mare than five hundred props dollaa(5500). IMPROVEMENT ❑Losowncrofthe he sutu,or myemployceswith wages ed for their sere compensation, SWIMMING POOL ELECTRIC �j will tdo the wor,and the he Contractors not License La dos tonla(Seo.A144,owner DGTHER ttE�E� pod Profession Code:The'Cnmrnow License Law dans not apply to if owner of OUTLETg-SWITCHES-PIX'NREg QZ his o property who builds or improves thereon,and who dura such work hinder(or through his own employeesprovided that such improve .re not intended or altered for NEW RESIDENTIAL[LECfR sale.If,however,due building or improvement is soldold w within one yevrofcompinian,the SQ.FT.Fl.rx1R AREA ESQ.HT. owner-builder will have the burden ofproving that he did not build or improve for pun I� P A D pose of sale,), f- C 1,as owner of the properly,am exclusively contracting with licensed contractors it, T�A construct the pmjmt Sce.7D44,Business and Professions Code:)The Convector's Li. DEC � ���� cense Law does not apply to an owner of prepenpro y who builds or imves Nemon,and QTY. PLUMBING PE4 PERMIT E whocommets fur such Projects with a commetor(n)licensed pursuant to the Commdora List.Law. PERMIT ISSUANCE C de I um exempt under Sec. ,B&P C fur Nis reason IlY OF WeEHI INO Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby affirm under penalty of perjury one of the following declarations: I have and will maintain aCenificeterf Consent to self-insure for Workers Comped- DRAINS-FLOOR.ROOR AREA,COND. STORIES TYPE CONSTRUCTION ,anion,as Provided the for by Section 37M of the Lar Code,for c performance of the Kk for which this permit h issued FIXTURES-PER TRAP havo and will maintain Worker',Compensminn Insurance,as required by Section of the Labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN My Wor );9�pprs I. I so cernerim Polity arm mµ . Cartier. LLC❑ ll r� Policy No.:J!; •44,M b GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' - COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR .BUILDING DIVISION FEES (This section need not be completed ifthe pcmrit is borrow hundred dollars(810)0GREASETRAP or less) � PLANCHF.CK FEE I certify that in the performance ofthe work for which this permit is issued,l shall SEWER+SANITARY-STORM EA.200 FT. nm employ any person in any manner so as to become subject e.the Workers Coati ENERGY PER _ Z sation Laws of California.Dom WATER HEATER WNENT ELECfR OO Applicant GRADING FEE rjl NOTICE TO APPLICANT:IL after making this Cenificale of Exemption,you should WATER$Y$TEMII'RFATING 1'! become subject m the Worker's Compensation provisions of the Labor Code,you most SOILS FEE forthwith comply with such Provisions or this pemrit shall he deemed revoked. WATER SERVICE G O U O CONSTRUCTION LENDING AGENCY NF.W RESIDENTIAL PLMB. SQ.FT. PAID Date ON aci tp I hereby affirm that there is a construction lending agency for the performance of p the work for which this permit is issued(Sec.3097.Civ.C.) 0 F-; Lender's NameIAL: 4041 Leaders Addres TOTAL: 1 certify that 1 have read this application and ante that the above information is BUILDING LI) correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE U building conourse ,sad hereby.uthonu representatives ofthis city to enter upon the SETS T above-mentioned property,for inspection purposes. PERMIT ISSUANCE (We)agree to save.indemnify and keep hannlessthe City of Cupertino against ELE IC FEP.' liabilities,judgments,costs and expenses which may in any way ammo against said City ALTER OR ADD TO MECH. in consequence of the granting of this permit PLUMBING IT AP .ICANT UNDE STANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CFM) tU :CU AT PNS. •n ^� A1 MECHANICAL. E I/X^ I^, v •b AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCGONT Signatumof Applican' omractor Data EXHAUST HOODDNVDUCO HOUSING MITIGATION FEE ZARDOUS MATERIALS DISCLOSURE Will the applicant or None building occupant store or handle haaardmo material HEATING UNI T(TO 1 Most BTU) . . as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safety Cork,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) ❑Ycs CNo VENTILATION FAN(SINGLE REBID) PAID Date Receipt# Will the applicant or future building©cupam use equipment or devices which emBOILERCOMP(3HPOR IW,fN10 BTU) it hoomi air conmminunts as defined - ed by the Bay Area Air Qudily Management 'TOTAL: ! Distad? BOILER-COMP(OVER 100.00OBTU) Dyes CNo I have read the bmardois materials requirements under Chapmr695 ofma Cali- AIR CONDITIONER ISSUANCE DATE forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH, building does not c mently have a mount,that it i,my responsibility to notify the imcuPent of the requircmans which most be met prior to is....ice of a Certificate of Occupancy. Owner ser euNonand a gent - Date TOTAL: ISSUEDBY, OFFICE