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30453 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES:-USE:BALL POINT PEN ONLY - CITY OFCUPERTINO . BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATIONTERMIT 30453 PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION - V BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE R'S NAME: PEON / CONT,ACTOR'S NghIE: a LIp NO: ZZQ N/C CONTROL k ARCHITECT/ENGINEER: - '• LIC NO: ADDRESS:'' W�TL4�•- 6 ❑, CONTACT:. PHONE: BUILDING PERMIT INFO - -' ❑ Consultant Ptta Paid by Applicant(Initial) - BLDG ELECT PLUMB MECH E El LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE .1 hereby affirm that 1 am licensed under provisions of Chapter 9(cemmencing JOB DESCRIPTION 'OOO with Sedion'/oap of sion3ofine B¢sinexs and Professions CsWe,and mylicenseis- PERMIT ISSUANCE RESIDENTIAL' in full force and effect. aVUU�" License Class Lic.N OSFDWL [I KITCHEN REMODEL 11 Date Contract.," APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE y'iZM ARCHITECT'S DECLARATION .. [I MULTI-UNIT ]STRUCTURAL [F.� 1 understand m 1 z O-7y- y plans shall be used as puFlic records PANELS- MODIFICATION oz-, - UP T0200 AMPS `F.h, Lmensed Professmnal INTERIOR El CHIMNEY REPAIR ey OWNER-BUILDER DECLARATION 201-1000AMPS MPROVEMENT " yyy I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IPAO AMPS ❑BATH REMOfJEL/REPAIR �DEMOLITION 'a4,34 Fr following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER ��,/)t a't.+/sy e�l� 4411 W O which requires a Permit to conswci,alter,improve,demolish,or repair any stmcam, - J ti prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.,_ , �{0pyFG�r, Q that he is licensed pursuant to Ne provisions ofthe Commet.ex License Law(Chapter 9 sN 00 (commenting with Section]000)of Division 3ofthe Businessand Professlons Code)err TEMP.METER OR'POLE INST. COMMERCIAL, d y o y tbar he is exempt therefrom and the basis for.the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION iYC] 0. Section 1031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES . f.ZZZ,y not more than five hundred dollars($5W) ❑TENANT ❑FOODSERVICE .. q6 D 1,as owner of the pmpsny,ar my employees wuh wages as th' .ole cnmpensm nq SWIMMING POOL ELECTRIC IMPROVEMENT 02G' O will do the work,and the stmm cre is not Intended oroffered forsele(Sec]0,14 Business OTHER' and professions Code The Contractors License Law does n t apply man own of OUTLETS-SWITCHES-FIXTURES 1' ❑ property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements ere not intended or offered for NEW RESIDENTIAL ELECTR S sale.If.however the building or improvement is sold within one year ofeompletion.the SQ.FT.FLOOR AREA $ISQ.FT owner-builder will have the burden of proving that he did not build or improve for par, - pose of,ala.).r - T• ' ❑I,aownerofthe property,amexclusively commcons with licensed onmmnnrsm ' ,. - - C , ob1, a the project(Sec.popery, a excl ss and Professions Code)no Contractor's Li- Y cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT A who contracts for such projects with ecomracsor(s)liwnsed pursuant to the Contractors License Law, PERMIT ISSUANCE ' ❑I am exempt under Sec. ,A&P C for this reason ALTER-DRAIN&VENT-WATER(EA), Owner - Dam > VALUATION WORKERAT 'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE' I hereby affirm under penalty of perjury one of the following declarations: F' ❑I have and will maintain a Cenificam ofComent to self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. - 't salting as provided far by Section 37W of the Labor Coda,for the performance of the STORIES TYPE CONSTRUCTION work far which this permit is issued FIXTURES-PER TRAP Fl I have and will maintain Worker's Compensation Insurance,as required by Section 37W ofine Labor Crude.for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP• APN My Work' ComPg aatio,I 1p�gp a saryier and Policy n her are Carrier-f�:�1. zs. LB Policy No.: I- GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROMWORKERS' COMPENSATION INSURANCE 1 . 9 G_REASFIINDU_STRL WASTE INTERCEPTOR BE DNISION PEES (This section need not be wmplesed if the Permit is for ne hundred dollars(SIM) or less) GREASE TRAP PLANCHECKFEE '. I cad fyth �n the perfo mce ofatth1 cw�eekor,wmch th spsom'.riesuC1 Isball SEWER-SANITARY-STORM EA.200 FE not employ an an.lic l ne�/'1.. li subject to the Workers Camper- ENERGY FEE .Z cation Laws J rnie.Da /_L• 7 WATER HEATER WNENT/ELECTR - z O APPlicant GRADING FEE - fff///�� NOTICETO APPL CA f, her making this Certificate of Exemption,you should WATER SYSTEM/rREAUNG SOILS PEE b a [^ become suM1jwt m the Wo a Compensation provision of the Labor Cade,you must - Li) forthwith comply with sue s or this permit shall bo deemed revoked. WATER SERVICE ' aQ � Z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.FT: PAID L)O Ihereby affirm that is a construction lending agency for theperformenceof Dam Receipt U• Lis F' the work for which this pemut Is issued(Seo.3091,Qv.C.) O LJ Lenders Name - TOTAL, Lender's Addreea - - TOTAL: a I certify that l have read this application and.state that the above information ie BUILDING FEE 5-6 wr fA correct.i agree to comply with all city and county ordinances and Stam laws relating to QTY. MECHANICAL PERMIT FEE V building construction,and herchy minimize representatives rilhis city to enter upon the SEISMIC HE abeve-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree m save,indemnify and keep harmless the City of Cupcnino against ELECTRIC FEE ' liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR AUD TO MECH: - - in ommocluenw of the graming of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING,UNIT(TO 10.00)CFMj SOURCE REGULATION S. - MECHANICAL'FEE ' AIR HANDLING UNIT(OVER 10.0fill CFM) CONSTRUCTION TAX Signamm of AppllcamlConlmomr pat. EXHAUST HOOD(W/DOC1) HOUSING MITIGATION ME MATERIALS DISCLOSURE - Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO I OR(HIB BTU) as defined by me Calamine Municipal Code,Chapter 9.12,and the Health and Safety - Code,Section 25532m)? HEATING UNIT(OVER 100,000 BTU) ❑Yes b6Vo t VENTILATION FAN RES ID) PAID Will the applicant nr future Receipt Mre building occupant use equipment or devices which BOILERCOMP(3HPOR 100.000 BTU) emit hazarmi tremendous air common as defined by the Bay Are - a Air Quality Management - District? E]Y. /kNo POILER-COMP(OVER 1110,000 BTU) TOTAL: I have read the he� materials requirements under Chapter 6.95 of the Cali- • AIR CONDITIONER ISSUANCE DATE fomia He Safety Cod emions 25505,2553)and 25534.1 understand mai if me NEW RESIDENTIAL MECH. SQ.Fr. - 4 - - - buildin oe otburall tenamflaint itismy resparribilitymnotifyme occupant _ _ beth u' entsw ' rat no issuance ofa Cenificam ofccupu y. , - Ownerorartho'ed gen Da TOTAL' ' ISSUEDBY:.� 0FFICE