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31082 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPC'RTINO BUILDING-ELECTRICAL. PERMIT NO. 31082� O H L //� BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL. J BUILDING PROJECT IDENTIFICATION BUILDINGADDRESS: SANITARYIN APPLICATION SUBMITTAL DATE 1043, N • f orl-uk vc Cv t,--fiw U4 9,Sal . OWNs NPr (LI- Z1ZGNLfoY _ CONTRACTOR'S NAME: /G LIC NO: N/C CONTROL Bq,-.(5 (Joe ARCHITIiCT/ENGINEER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑.Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ ❑ LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE ]OB DESCRIPTION 1 hereby arm But 1 am licensed under provisions of Chapter 9lcnmmencing ,O„�Z affirm withllfimm�Od e)ocDivisian 3nithe business and Professions Cale.and my license is FOO in full Cies, effect. PERMIT ISSUANCE ,,�,, � �UUUF Liccnnc Class Lica FDWL '(MITCHEN REMODEL F�fil Dmc CnnvWar APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM BI NO RHPIPE f�,py ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL. >> PANELS VLO q Iundemand my plans shall he uuA us public records - MODIFICATION O,ZI-O UP T0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR FSI❑-Y1 Licensed Professional 201.tMMAMPS IMPROVEMENT S0.bjr OWNER-HUILDER DECLARATION OVERIMOAMPS ❑BATHREMODEVREPAIR ❑DEMOLITION G W ante Q I hereby infirm that I am exempt from the Convacmts License Low for the 3 L eJ following reason.(Section 7071.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER tL�j which¢quirtmi s u perr m construct,alter,improve,deman demolish,or¢pair y structureO prior to its issuance.also requires the applicant for such pemut or a signed statement SPECIAL CIRCUIT/MISO yIhot he is licensed paaoanuo the provisiomrifthe Convectors License Law(Chapmer9 d00 commencing with Section 7000)of Division J ofthe Business and Pmfessions Code)or TEMP.MITF.ROR POLE IN L COMMERCIAL• y e e' that he is exempt Mawfmm and the busis Ru Hct ullegcd sxempnian.Any violation of El NEW BLDG/ADDITION ❑DEMOLITION x�t4 Section 7011.5 by any applicant on a permit subjects the applicant to a civil penalty of POWER DEVICESl {4sl1 rn ❑IMPROV ❑FOOD SERVICE FxM nn un ase shun lose thundred e property. ormycrop' 41, IMPROVEMENT D ❑Lothe owner afinep,opedy,or mycmntended wofferewages rsale( ee.cam.Business SWIMMING POOL ELECTRIC will Jct the work,and the he Conci...t intended or offered s notl apply to an BusinessV ❑OTHER 3 and Professions Cade:The Contractor's License tow does not apply tu owner of OUTLETS-SWITCHES-FIXTURES his..y who builds or improves thereon,and who does such work himself or through his awn employees,e provided]Nat such improvements arc not intended orofferedfar NEW RESIDENTIAL ELGLTR SQ I4. saleerbuddevenllhave Me burden en ofpment isin year improve the SQ.FT.FLUOR AREA 5lSQ.PT. owner budder will have Ne budcn of proving that he did not build or improve fur pur- e of sa ^le). oro �sl.us r of the proprry, exclusively contracting with licensed contractors to TOTAL O PAID I consent thesproject(Sec.7M4,Business and Professions Code:)The Conlmnur's Li- cense Law does not apply turn owner ofproperty who builds o,improve,thereon,end QTY PLUM RING PERMIT FEE •I '1 1'1C11aD whncoulamR for such projects with ucnmrunnr(a)Iicenapd Formant to the Cnmmemr's MAR 11 RLl! License law. PERMIT ISSUANCE❑ I am exempt under Sec. ,B&P C for this reason ALTER-DRAIN&VENT-WATER(F.A) ALUATION Owner Dam RKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affum under pc..try of perjury one of the following declarations: I have and will mamma a Certificate of Consent to self-insure for Workers Camper- DRAINS-FLOOR.ROOF.AREA,CONE) STORIES TYPECONSTRUCfION Ration,as providM for by Section 3700 of theTabor Cade,for the performance of the work for which this permit is issued. FIXTURES-PER TRAP ❑1 have and will maintain Workers Compensation Insurance,as required by Section 7700ofohe Lahor Code,for the perannunceof the work for which this penmim is issue, GAS-EA.S YS TIN.I INC.4 OUTLETS OCC.GROUP N'N My Workers Compensation houmnce carrier and Policy number on: CAN EA Carrier Policy No.: ( ) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR (7Lis cation need tat be enmpined if the pemdl is for ons hundreJ dallms(SI00) BUILDING DIVISION FEES or less.) GREASE TRAP PLANCHECK FEE Lecnify Niminthe performance ofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200 FT. nom employ any person in any manner so as to become subject to Out Workers Cape.. ENERGY ITE ,Z samion Lows of California.Dam 7�O Applicant WATER[]EATER WNENT/ELECITt GRADING EEE G to NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMH RPATING abecome subject to the Workers Coinpcnsmion provisions of the Laor Code,you must SOILS FEE Liz forthwith comply with such provisions or this prod,shall be Deemed,waked. WATER SERVICH Q .�. Z CONSTRUCTION LENDING AGENCY NEW RIiSIDEM'IAI.PLMH. SQ. PAID (� O work afFum mhauhere isand(See. 097.Cing agency far me perfomrvnce of Data Receipt v the work for which this permit is issued(Sec.7097.Civ.CJ 01--� Lenders Nemo TOTAL: V Lenders Artifyt TOTAL: 0. I certify that 1 have read this application and some that Ne above information mining iR BUILDING hEE h wilding agree to comply withal]city and uapsereativeso ais state laws QTY. MECHANICAL PERMIT FEE U z building asmwcdon,and hereby emhorim repreunuoives of Nis cloy no caro,upon the SEISMIC FEE above-menlioned property,for inspection purposes. PERMITISSUANCE (We)agree m save,indemnify and keep harmless the City of Cupeninn nguinn ELECTRIC PCI: liahilities,judgmenms.costs and expenses which may in any way accme agmuQ said City ALTER OR ADD'TO MECH. in consequence of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM) SOU F.REGULATIONS. MECHANICAL FEE 5- t AIR HANDLING.UNIT(OVERHL0011CFM) CONSTRUCTION TAX Signature ofA lipmWConvactor Date EXHAUST HOOD HVMUCp HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will he applicant.,future building occasion store orhmdle hasardnus mmerial HEATING UNIT(TO 100,000 BTU) as Jeftal by the Cupertino Municipal Code,ChaPte,9.12,ad Ne Hcahh and Safety Code,Section 25532(ap HEATING UNIT(OVER 100,000 BTU) ❑Yes 0 N PAID VENTILATION PAN(SINGLE RF_SID) Dmc Receipt N Will the -11 emanmoffuture building by meBuseequipmentor deviceswhich BOILER-COMP OHP OR 100,000 BTU) nthict? us Cir conmminanu as Acfimud by the Bay Area Air Quality Management TOTAL: 3 Drcvst ❑Yes ON. BOILER-COMP(OVER 100,000 BTU) L have mad me hares mm,materiels u veer Cha tar&95.f the Cali. AIR CONDITIONER Haltinreg2remen p ' ISSUANCE T� fomin g does&Safety Code,Sece.to ar 255115,is on,and 255]4.L understood that if dte NEW 0.ESIDENTIAI.MECH. SQ.FT. building ntrate is which have. Nam.issom responsibilitytonotify Ncoccupant of the requimnmms which must h<mel prior m issuanm of a Qrificme of Qcupuncy. Owner oruuthmixeda cto Uaie 3 -' G TOTAL: ISSUED BY: =( OFFICE