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30721 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - I CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30721 BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL BUILDING PROJECT'IDENTIFICATION BUILDING ADDRESS: I SANITARY NO. APPLICATION SUBMITTAL DATE 2068'] CRWIb cr ri"o ' Co- L',,oz l qg OWNB PHONECOy7 CTOR'S NAME: r MCNO: INAC CONTROL It 7/7 ,. ARCHITECT/tiNGINEER: LIC NO: ADDNE ; os' c*t&" ST 2c&'/ CONTACT, PHONE: BUILDING PERMIT INFO lf � ��/ —/�yO ❑ Consultant Fees Paid by Applicant(initial) BLD ELECT PLUMB ., MECH o T El EJ 1:1LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby affirm thatI am licensed under provisions of Chapter �c�aZ th Sectian]IXp)ofDivieionlofthe Business and Rafeasions Cale.and my license is RESIDENTIAL: o wt PERMIT ISSUANCE. W full force onJ effect"-I ❑SFDWL ❑KITCHEN REMODEL Q Lione lou 1i Lica - pppL1ANCE5-RESIDENTIAL ❑ADDITION PLUMBING RE-PIPE fn GZ G one Contractor RCHI'FECTSDECL ON PANELS ❑MULTI-UNIT []STRUCTURAL ZW I understand my plus shell be used as public records MODIFICATION OZ— UPT0 2M AMPS rrt3�.aQa..4TIT Licensed Pmfessimml 20I-I[Ky1AMPS IMPROVEMENT INTERIOR [I CHIMNEY REPAIR pa;Y -4 OWNER-BUILDER DECLARATION yy C W GGGG 1 hereby affirm that I am exempt from the Commmors License Law for the OVER 1000 AMPS El BATH REMODEUREPAIR [I DEMOLITION X 3❑U following reason.(Section 7831.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL [D OTHER 1Isa11 W w.1- which requires a Permit to construct,altee improve,demolish,or repair any structure yy� prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. ythat he is licensed purmaur'a License no the provisions of the Contract Law(Ch�pter9 I+TCOO (commencing with Section]088)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: d e that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION `ry Section 90315 by any applicantfor a tuition sabjemsthe applicant so pplicn civil penalryol' 'POWER DEVICES []TENANT ❑FOOD SERVICE not mom than Bre hundred do[]..(S5W). - F G O1,In IMPROVEMENT owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC COTTER will dmhe work,and the structure is not Intended or offered mrsele(See.7044,Rosiness soil Profession,Cale:The Contmcmrs License Law does not apply a sn net of OUTLETS-SWITCHES-FIXTURES property who builds or improver thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ IT, sale.If.however.the building or improvement is sold within one year of completion,the - SQ.FT.FLUOR AREA S/SQ.FT, owner-builder will have the burden of p.si,,h.I he did not build or improve for pus- - poseafsdleJ. P Al D ❑I,as owner of the progeny,am exclusively mntrecting with licensedcordracvirs in TOTAL: consumer the project(Sat.T144,Business and Professions Cade:)The Contractors Li- DEC censees Law donorand,[.an ioamsif property who builds or improves therenn,and QTY, PLUMBING PERMIT FEE 271996. who mmoms fcrsuch projects with acontredat(a)licensed pursuant m the Contractors License Lew' PERMIT ISSUANCE ❑ Iuat exempt under Sec. ,B&P C for this reason 1`111)( (jr LUI`EhI1NU ALTER-DRAIN&VENT-WATER(EA) VALUATION Owner Dam IIIr��a WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby affam under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Cunsenuo self-insum far Workers Camper- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTION ration,as provided for by Section 37B)of the Lahr Code,for performance of the -. .,it for which this permit is issued. FIXTURES-PER TRAP ❑1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the LdWr Code.for the performance of the work for which this permit is issued, GAS-EA,SYSTEM41NC.4 OUTLETS OCC.GROUP APN My Workers Compensation Insurance carrier and Policy number am: GAS EA Cama: Policy No.: BEA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEPS (Thissection need not ifthe permit is fu rone,hundroddullars($103) GREASETRAP or less) m b � PLANCfiECK FEE ' I certify that in the performance ofthe work for which Pur Permit is issued,l shall SEWER-SANITARY-STORM EA.200 Ff. not employ any Persian in any manner so as m subject become subjeco the Workers'Compem ENERGY FEE ration Laws of California.Date WATER HEATER WNENVELECTR O plc icard GRADING FEE. o-zr y NOTICE TO APPLICANT:IL after making this Certificam of Exemption,you should WRIER SYSTEMiTREATING a become subject to the Workers Compensation provisions of the Labor Core,you must SOILS FEE forthwith comply with such provisions or Ws Permit shall has deemed revoked. WATER SERVICE Ps CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PT. PAID L) 0l hereby affirm that there is a construction lending agency for the performance of Date Receipt9 me wmk for which this permit is issued(Sec.3097,Civ,C.) O17" Lenders Name TOTAL.: t[H Lender's Address TOTAL: r 04 1 certify that 1 have rend this application and state[hat the above information is 'BUILDING FEE iFrLn conem.I agree to comply withal]city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT FEE (�Z building connmctiem;and hereby.uthmim representatives ofonatily victim,upon the SEISMIC FEE � `+ shove-mentioned property far inspection psryosea. PERMIT ISSUANCE (We)rine to since,indemnify end keep harmlesnhe City of Cupertino against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way same against said City ALTER OR ADD TO MECH. in consequence of me granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,008 CFM) SOURCE REGULATIONS. MECHANICAL HE AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTIONTAX Signature of ApplicanVCurnmelor Date EX I MUST GOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will[he spieltemnur future building..Parismmor handle haaallous mm coal HEATING UNIT(T0100,000 BTU) az defined by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safely Code.Salton 35532(.)? HEATING UNIT(OVER I(t),00)BTU) a Yes No .� VENTILATION FAN(SINGLE RESID). PAID Date Receipt Will me applicant or future building occupant use equipment or devices which mi[hazmRais air cnnmtrtimn[s ns defined by the Ray Area Air Quality Management BOILER-COMP(3HPOR IW.tIq)RTII) TOTAL: �Dlalticl^ Yes FUN. BOILER-COMP(OVER IO(L"BTU) ❑ I have mail the hazallous tnemrials requirements under Chapter 6.95 of the AIR CONDITIONERe Cali- ISSUANCE DATE fomis Health&Safety Code,Sections 25505,35533 man 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. Willing does not currently have a mnam,mm it is my m1portability,to notify dm cecuprint of be requirements which most W met prior m Issnnnce of o Certificate of Occupancy. - II Owner or uuthmiud.,car Date TOTAL: ISSUED BY: I' OFFICE