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S 1022 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELEC9'RICAL PE541 r NO. 1022^rat BUILDING DIVISION APPLICATION/PERMIT PLUMBING- r IDENFIFIC V` L L tlU11.DINO PR(IJECr IDENrIF'ICATION - BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'FIAL DATE a /o �E�ti c y- b RIS A �O HONE:�� CON'TRACTOR'S NA`M, � v � �O LICNO:-�� I(_ .�Jt J NIC CONTROL p •'ARCHITFaCf/ NEER: LIC NO: N .�e El— V ❑ CONTACT PHONE: BUILDING PI7RMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH I ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby infirm that I am licensed under provisions of Chapter 9/commencing JOB D SCRIPTION OZ Ngeutlon lBW)nf Oivixinn3n[the Buslnesxand Prnl'essians Cmde,ands li_unseis RESIDENTIAL u1OZ wn PERMIT ISSUANCE FUF in full formandc ,5�333� ❑SFDWL ❑KITCHEN REMODEL U License Clas.v Lic.pa.- gPPhIANCF.S-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE F-Zk Dem Conanine tel ' e� oe<0. El MULTI-UNIT ❑STRUCTURAL F P y ARCHITECTS DECLARATION BAN US ZOyJZ MODIFICATIONI undersand my plans shut[he used as public mcmdx :]]pp UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR Licensed Pmfessinnul 201-1000AMPS, - IMPROVEMENT 0SWIMMING POOPS OWNER-BUILDER DECLARATION OVr:NICXAMPS L3 BATH REM DREP DF OLIT C I hereby affirm that I am exempt from the Contractor's License Law for the X O L U following reason.(Sadon 1031.5,Business and Professions Cade:Any city ar county SIGNS ELECTRICAL []OTHER �— W 0.0 y which requires a permit to construct,slim,improve,demolish,or repair any spectral prioro,its issuance,.lsoretudres theapplienitfnrsuch permit In file a signed satement SPECIAL CIRCUIT/MISC. ;!(o,, that he islicesedpursuanno the provisionsofthe Cmilownr's License Law IChapter9 CC (commencingwitb Section 1000)of Division 3 tithe Business and Profecsinns CwleI or TEMP MFI'ER OR POLE INST. LAI 6 q M se that he is exempt tMrefmm and the basis for the alleged exemption.Any violation of E LUG/ADDITION ❑DEMOLITION ire 16 Section 7031.5 by any applicant for a permit subjects the applicant it)a civil penalty of POWER DEVICES ❑FOODSERVICE Fzr not morethan five hundred deltars Wood. G ❑1,as owner of the prapcty,nrmyemployces wiNwagex as theirsole cnmpensotion, SWIMMING POOL ELECTRIC MPRO MENT will da the work,and the.structun:is not intended clattered for sate(Sec.10a4,Business ER W $ and Professions Code:The Commdofs License law data not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided Nat such impmvcmems are not intended or offered for NEW RESIDEN'I'I AL ELECT SQ ff. sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA VSQ.EL owner Wilder will have the burden of proving Not he did not build or improve for put. pose of sale.). TOTAL"' P" p/ts h us owner mllhe property,um exclusively,mnau,tin6 with limnsed convuann m I construct pmjmt(Sec.7044,Business and Professions Code:)The Contractor's Li- '7 D cense law does not apply In an owner ufpropeny who builds or improvex thereon,ad QTY, PLUMBING PERMIT FEE ®� who contracts for such projects with a cormorants)licensed pursuant the Contractor's _ T add'/3 License Low. PERMIT ISSUANCE lam emmpt under Sec. ,B&P C for th"milon red ALTER-DRAIN&VENT-WATER IFA) Wr `'urV�A-yUA�� Owner Date 11 WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby aRml under penalty of perjury one of the following declarations: ❑ I have and will maintain a Certificate of Conserv to self-insure for Workees Compete DRAINS-FLOOR.ROOF,AREA,CONE). STORIES TYPE CONSI'RUCfION cation,as provided for by Section 37M of the Labor Code,for the performance of the work for which this permit is is.med. FIXTURES-PER TRAP ❑1 have and will clamant Weemes Compensation Insurance,as required by Sectinn 310X1 nflhe l.aybuyr�yCeidde,for tEheI mperhournSmgen ofdie work for whichthisperm /vied. GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP APN Cm orkel;Cygtyen�eaon ltk+tO;y Policy No.: ��5 - sue GAS-E- .SYSTEM OVER 4(EA) T�C/E/RFTICCFICATTE'OF EXEMPTION FROM WORKERS' GREASOINDUSTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES (This sec tion need not he completed if the permit is forme,hundred dollars 1$1(X0 OR BASE TRAP or less) PLANCIIECK PEE I certify that in the performance ofthe work for which��N�is permit is issued,I shall SI7WER-SANITARY-STORM EA,2W 14. or employ any person In any matte sxb tett to the Workcrs'Compen, ENERGY FEE xatinn Lawn ran D. ✓� X- 7 WATER HEATER WNENT/ELECfR z0 APPlicanl GRADING FEE N NOTICE TO I ANI':IL after making din enifcam of Exemption,yno should WATER gYSTEM?NIiATING became subject on the Worker's Conlpensv,in .p.... i....f the Labral Code,you must SOILS FEE {ala ti forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE 0 Q PAID CONSTRUCTION LENDING AGENCY NEW RFSIDIEI TIAL PLMIL SQ.PT. Duro Ree L)Q I hereby affirm that them is a construction lending agency for the Performance of W(✓ the work fill which this permit is issued(Sea.3091,Civ.C.) O U Lender's Name TOTAL: Lenders Address TOTAL I certify that I have read this application end sora Nat the move information is BUILDING FEE loth cored l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SIRSMIC FEE Wildingcnnmructim.lnd Worhy outhmirm represmatives ofdiic city In emerupon the ti ahtve-mentioned progeny for inspection purposes PERMIT ISSUANCE ELECTRIC FEE 47 (We)agree to save,indemnify and keep harmless the City of Cupertino against liabilities,judgments.costs and expenses which may in any way accrue almost said City ALTER OR ADD TO MECH. PLUMBING FEE is consect...c of the grunting of this permit. APPLICANT U' ERST )S AND WILL COMPLY WG'If ALL NON-POI N'r AIR HANDLING UNIT(To 10,(XXI CFM) MECHANICAL FEE S RET L /O-�Q AIR HANDLING UNIT(OVER Placid CFM) CONS'I'RUCTION TAX Applicunt/Contmear Date O( EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEF. HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING ONITCFO 100.0(X1 BTU) as defined by the C lama Municipal CMG.Chapter 9.12,and the Hanlon and Safety Code.Section 255J2fa)? HEATING UNIT(OVER Hp,OIXd BTU) ❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Data Reeeits# Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP Oil 100.001 BTU) emit him air conteminants as defined by the Bay Area Air Quality Management TOTAL. �-�-• District? BOILER-COME(OVER I00,000 BTID ❑Yes ON. I have read the bet Nous mamdaLs tcquirements under Chapter 6.95Mthe Cali- AIR CONDITIONER ISSUANCE DATE Forms Healdi&Safety Code.Sections 25505,25533 and 255M.I understand thin if the NEW RESIDENTIAL.MECH. SQ.FT. building does not currently have a tenant,that it is my responsibility to nmify the(a cupam of the m46iretoenm which const Le n¢t prim to issuance of a Certificate of Occupancy. Owner or outhouses]agent Dam UAL: ISSUED BY: OFFICE