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S 0231 (2) I APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.ELECTRICAL PP.RMII'NO. BUILDING UrvI510N APPLICATION/PERMI-P PLUMBING-ntEcudnlcAl. BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE OWNS 'S NAME: PHONE: COM'RACfORS NAME: LIC NO: NIC CONTROL# 'J ARCHITECT/ENGINEER: LIC NO: ADDRESS: �^^ ❑ 1 CONTACT: � PHONE. BUILDING PERMIT INFO ❑ Consultant Fee#Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONT'RACTOR'S DECLARATION QTY (ELECTRIC PERMIT FEE I hereby atHrm that I am licensed under provisions of Chapter 9(commencing 106 DESCRIPTION with Section](KK)of Division 3 of the Business and Prnlessinns Code,and my license is RESIDENTIAL I+1 O PERMIT ISSUANCE in full force and t. ❑SFDWL ❑KITCHEN REMODF:1. U��] Licrn' ass Lic.N ZZW Uvte � Z Cr trued"6 22 APPLIANCPS—RI'SIDIENTIAL ❑ADDI'T'[ON F1 PLUMBING RE-PIPE .,,as � El MULTI-UNIT ❑STRUCTURAL. F.Dyn ARCHITECT'S DECLARATION PANELS ZO 7J. lundctam rsd my pDmshell heuued as public record. MODIFICATION OZ-q UITO200AMPS ❑INTIiRIOK ❑CHIMNEY RI7PA1R Licensed Prolexsinnal 201-1000AMPS IMPROVINEM' 0SWIMMING POOIS PGOWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEURITAIR DEMOLIT19N . pl)errm 69V I hereby affirm m that 1 aexempt titanium Connector',License Law for the X3 iL U following reason.(Seciion](131.5.Business snit Professions Case:Any city al county SIGNS ELECTRICAL (]OTHI,R _ i which requires..Penni.to condruc6 alte,imprnvx.demolish,or repair my sesame F,LL.,Oa prior to its issuance,also ventures the applicant for such permit to file a signed statement SPECIALCIRCUIT/MISC. that he lx licensed pmrsu.ntto the pmvisimuofthe Cmarn LicenwLm,(Chapter 9 1y tY�� (commencing with Section 7")of Division 3 of the Business and Professions Cocitor TEMP.METER OR POLE INS/ COMMERCIAL: a L o that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION X,^„ Section by any appiicam.for a Permit subjects the applicant to a civil Penalty of POWER DEVICES (]TENANT ❑FOOD SERVICE I-„zynot more than five hundred dollar Hilg)). IMPROVEMENT 6 1,as owner of the property,or my employees with wages as their sole compcosation. SWIMMING POOL FI.CTRIC ' f0 will do the work.and the structure is not intended or offered for sale(Sec/](N4,Business ❑OTHER It. and Professions Code:The Contracturs License Law does not apply to an owner of Dl1TLlff$—SW CHfS—ITXTU •S property who builds or improves thereon,and whir does such work himself or 11 u h his own employees,provided thin such improvements are not intended or off for NIiW RES, .NUAL ELELfz SQEL sale.If.hownm the building or improvement is sold within one year ofcompletion,the SQ.FF.11-OOR AREA SISQ.ET. owner builder will have the burden of pinking that he did not build or improve for pur- pxe of sale.). ❑I,as owner of the properly,am exclusively contracting with licensed contractors to AL: mnmmrt the project(Sec.7044.Business and Professions Code:)The Contractors Li. it W V cerise Law does not apply In an owner of property whit builds or improves.hereon.and QTY. PLUMBING PERMi/ PEE who contracts for such projects with a cordracmr(spicensed pursuant to the Contractor's T UN 25 License taw. 1117RMIT ISSUANCE ❑lam exempt under Sec. .B&P C for this recon Owner Date ALTER—DRAIN&VEN —WATERQA) C' ITYgUF 06ftTI0HPV WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. I hereby in.under penalty oeperjury one of,hc veli following Wodecision.,kerCm ❑(haveand wie maintain sCertificate ofConsion to Labor ode,for the Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. S'1'ORIliS TYI'F.CONSTRUCTION work(as provided for by Section 3](Ifl of the Lahr CMe,for the penformence of the work for which this permit is issued POSTURES-PER TRAP ,have and will coeoWorker's Compensation Insurance, inquired by Section 3700 of the Labor Conde. for r the performance of the work for whit.h this Pennit is issued. GAS-EA.SYS'FEM-I INC.4OUTLETS OCC.GROUP APN My Worker's Compereation Insurance carrier and Policy number are: Carrier: Policy No.: GAS-EA.SYS'FF.M-OVER 4(EA) CERTIFICATE OF EXEM PEON FROM WORKERS' GREASEIINDUSTRI.WASTE(V_/CEPTOR COMPENSATION INSURANCE HOLDING DIVISION FEES (This section died not bei completed ifthe permit is for one hundred dollars($100) CREASE']RAI' or less) PIANCI IECK FEE I.yanythat inia Pc��fO 'w�rkf�h 71 ismeW isers'Co ,en-sued.I shut gF.WiiR-SAN I'PARY- 'ORM EA.200 IT notemployany personhe anyandm d.¢65yk Yy/b mthe Workers'Compen- ENERGY FEE z scion Le C Inmiu )ate s WATER HEATH VENT/ELllC R C z .,ifn Las GRADING FEE try ICE TO APPLICANT:If,alter making this Certificate or Exemption,you whould WATER SY :MTREATING ("' ? become subject to the Workds Com irsawinn provisions of Ne labor Cale,you must SOILS FEE forthwith comply with such Puri or this permit shall ha deemrxl revoked. WATE .CRVICF �z CONSTRUCT ION LENDING AGENCY S NEWRESIDENI$At,PLMB. SQ.PF PAID pate Receipt# V Q (hereby affirm that there is a construction lending agency for performance of the work for which Nis permit is issued(Sec.3097.Civ,C.) 1, Ai 0 Lender's Name k. TO'T'AL: LUA Lxmixes Address ^ TOTAL: 1 certify that I have read this application and state that the above information is BUILDING FEE Lary correct l agree mcmmply with all city and county ordinances and mate laws relating to QTY MECHANICAL PERMIT FEE V z building construction,and hereby authorize representatives of this city to enter upon the SEISM IC FEE stove-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmlcas the City of Cupcnino against • ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. in cnewtim id:of me granting of this permit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-PAINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEES hQLRC1i.REGULATIONS. I AIR HANDLING UNIT(OVER I0,W CEM) CONSTRUCTION TAX gnature of Applicant/Contramar Dart EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant nr(mere building occupant pore or handle hazardous material HEATING UNIT CFO 100,000 BTU) as definad by.he Calcium,Municipal Chale,Chapter 9.12,an I the ifedN and Safety _Jr1A Ind Cale,DYes 25532m)? ❑No HEATING UNIT(OVER 100.000 RU)T ���� VENTILATION FAN(SINGLE.RESID) ('AID i Date Receipt# Will the aircount or imatum building ce the by Are. AirQmity or Maceswhich BOILER—COME(3HP OR 100,000 BTU) emit hnaoNous nit conwminanwax AeBnoJ by the Huy Aree Air Qmdity Management ^L TOTAL: District? E]Y. ON. BOILER—COMP(OVER 100,003 BTU) I have most the hinardous materials requirements muter Clhapter 6.05 oftha C.16. 7 AIRCONOITIONER ISSUANCE DATE form.Health&Safety Cods.Sections 25505.2!533 and 25534.1 midersmml that if Nc NEW RESIDENTIAL MECH. SQ.FT. building does na io mntly have a tenant,thea it is my resgmsibil'uy is notify the occupant ofthe remitteem,whi met prior to items of Cer ificia fOxe ncy. 1 1 Z007 Ir Owner nr sutainum'agem Lane TOTAL • ISSUIiU BY: OFFICE