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29377 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 29377 BUILDING PROJECT IDFINTIFIcAn'ION BUILDING ADDRESS: .- SANITARY NO. APPLICATION SUBMITTAL DATE ' O 8 S1`ave Craeelc fS/G �W SNill A G: '� E PHONE: CONT ItIC OR'S`CO�� C NAME: 1,1C NO' / NIC CONTROL# ARCHITGCIENGINEER: LIC NO: ADDRESS'. ❑ 6sa Lai c c S?'- Sa4AC&r CONTACE ' PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MF,CH LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby affirm mm at 1 am licensed ander provisions of chapter 9(camendag JOB DESCRIPTION OW OW,Z with Sectim,70(s)ofDivisinn3ofthe Businessand Professions Cnde,and my license, RESIDENTIAL_ Hn full force and effect PERMIT ISSUANCE <UU� License Class Licp ❑SI'UWL ❑KITCHEN REMODEL g APPLIANCES-RESIDENTIAL n6� Dina-Contractor 0 PLUMBING RE-PIPE- ARCHITECTS DECLARATION .PANELS El MULTI-UNIT ❑STRULTURAL ZOE24 I understand my plans shall be used as public records _ MODIFICATION OZ D UP'10200AMPS ED INTERIOR ❑CHIMNEY REPAIR r4tM Licensed Professional - 201-IOOOAMPS IMPROVEMENT pd OWNER BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODIEIJREPAIR.❑DEMOLITION pG� 1 hereby affirm onnt 1 am exempt from the Contractor Co e;An y c Law for the k 3 6 U following renes a.(Section]onsam Business and Professions h,or Any city os countysummit, SIGNS ELIiCI'RICAL ❑OTHER LL7 4, which requires a permit m consttnm,blter,improve.demolish,or repair any aoucmrc prior to its issuance,also requires the applicant for such pemkto file a signed statement SP17CIAL CIRCUIT/MISC. } that he is licensed parmantto the provisions ofthe Contractors License Law(Chapter 9 W 'GC (commencing with Svelimi700H.fDivision 3.1 he Buxlnessnmd Proleselons Code)or TEMP.METER OR POLE INST. o K that he is exempt therefrom and me basis for the alleged exemption.Any violation of 1EW BLDG/ADDITION ❑DEMOLITION ^rn Section 7031.5 by any applicantfor a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE Qnot more than five hundred dollars($500).�ZIMPROVEMENT I]I,as ownerohhe pmpcny.or my employees with wages astbeir solerompensation. SWIMMING POOH.ELECTRIC Sa will do the work,rand thextrucmre is not Intended nrnflenad for so lo(San.9044,Baxter, .DOTHE la ro and Professions Cede:The Conuacmrs License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES d 3.. property who builds or improves thereon,and who does such work himself or through his own employees,provided thin such improvements are not Natalia]or offered for NEW RESIDENTIAL ELECTR SQ IT. Ey sale.If, m however.the building or improvement is sold within one year ofcompletion,the SQ.PTFIL OR ART LSQ.IT. mer-builder will have the burden of proving Nat he did not hold or improve for par- ❑st ate t the p of the See.7propam,,am exclusively contracting with licensedcontractorsi- TOTAL: L construct the project(Sec.]DLLs Iltsslnesx and Pndesvinns Cndep The Contractors LI- nseLaw does not applyloanowner ofptopertywho builds orimproves daeon,and (yTY, PLUMBING PERMIT FIEHC Who contract,hoorah projects with a en.rectons)licensed pursuant to the Contractor's License Law. PERMIT ISSUANCE ❑Ism exempt under Sec. ,B&PCma Nismaoan ALTER-DRAIN&VENT-WATER(EA) VALUATION Owner Data WORKER'S COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE U7 N b Ili I hereby affirm under penalty of perjury one of the following declarations ❑ Hhin,amd will mjectimirCenificmeofCcamem to self-inapt for Worker's Camper. DRAINS-FLOOR,ROOF,AREA,COND. su it ,as provided fur by Section 3700 of the Labor Gude,for the prrforecame of the STt]R145n, //yyBB CONSTRUCTION work for which this#croon is issued. FIXTURES-PER'rRAP "MINK 5 i"y36 ❑1 have and will maintain Workers Compensvtion Immmm'e,as requited by Section 3700 of the Labor LaborCode. yfor the performance ofine work ff which his p/crtnit is issued, GAS-EA.SYSTEM-I;INC.4 OUTLETS OCMY GkOGP Comer l/LI(I� am/'rOQn ePnli�'Y Nn.Y7LyX.�yy� GAS-EA.SYSTEM-OVER 4(EA) V9r t• VUI'I fl `a APN CERTIFICATE OF EX17MMON FROM WORKERS' COMPENSATION INSURANCE GREASEIINDUSTRI-WAS'T'E INIERCEI'rOR BUILDING DIVISION PEES (This section need not he completed if the penult is foronc hundred dollars($](X))or less.) GRIiASP.'rRAP PLANCHF,CK FET? Toy anythatinthe jeffimnaanymannro da,as becomein,for subjecch t to perthe it is Worker, ed C, per.shall SEWER-SANITARY-STORM EA.2(X1Irl'. not employ any person in any manner yr es to become suhjecun the Worken'Cnmpem � - ENERGY FEF, ,Z satiun laws of Cvlifomis.Data 7O7 O Applicant WATER HEATER W/VENT/ELCCTR GRADING FEE tom- y NOTICE TO APPLICANT:If,after tanking his Certificate of Exemption,you should WATER SYSTEMTREATING a leamme subjat m the Worker's Cian,ammi m provisions of the labor Code,YOU must SOILS FEE forthwith comply with such provisions nr this permit shall he deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.IT. PAID V I for whiidni thUnhercissued( eetHKO.ding agency far the performance of Data 0 the Lework for which Nis permi,is issued(Sec.31N].Civ.CJ ' � I"' Leaders Name TAL: >' {U Lenders Address TO'T'AL: 1 certify that I have read this application and state Nat the above information is BUILDING FEE F-t N correct.I agree to cmnply with all city and county ordinances and tame laws aluung m QTY MECHANICAL PERMIT FLEE U 7- buiddia,asamouctum,end herebyauhnriu represenmtivesofhiscity memerury.he SEISMIC FEE ahave-marooned potpcny for inspection purposes PERMIT ISSUANCE (We)agree m save,indemnify and keep harmless Ne City of Capetian against ELECTRIC FEE liabilities,judgmems,cove and expenses which may in any way accrue against said City ALTER OR ADD n'O MECH. in consequence of the"iof his punnet PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CFM) SOURCER " ONS. MECHANICALPEE AIR HANDLING UNI'I(OVER 10.0011 CFM) CONSTRUCT ION TAX 5i,efffuncof Applicant/Cnntrnm �y ['me EXHAUST HOOD(W/DUCq HOUSING MITIGATION FTE HAZA S. A'fER1A1S DISCLOSURE Will the applicant on future building occupant vote or handle hamNous material HEATING UNIT(TO I W.000 BTU) us definud by the Calvert an Municipal Code,Chapter 9.12,and the'I Iealth and Safety Cade,Section 255320)? HEATING UNIT(OVER 100,000 BTU) ❑Yes s ❑No VENTI LAI ION PANS I NGLE RESID) PAID Dam Receipt# Will the applicant m ;i building by dan ni Byse Area Airidntordevicagemas et HOILER-COMP QHP OR 100,000 B'IIH emit hazardous air contaminants;is deMcd by thn❑ny Arca Air Qtiallty Management M District? BOILER VER 100,000 BTU) . ❑Yes ON. I have real me hmerdous mm m.[, AIR CONDITIONER r5,25533 sunder Chapter if the ISSUANCE DATE fomia HealthHama&Safety Cale,Sections.that,2553]and 25534.I understand that if the NEW RGSIUENT'IAL MIiCH. SQ,FT. of he re Joel not currently M1as,a tenant,that it is my responsibility to notify the cease, - uftheregrimmentswhichmostbemetpriortnissuanceofa CeniGeme of Occupmcy. ' Owner or auNorired age. Date TOTAL: ISSUE.DBY: VV0 OFFICE