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29068 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - CITY OF CUPERTINO . BUILDING-ELECTRICAL PERMITNO. 29068 �(� O V H BUILDINGDIVIS10N APPLICATION/PERMIT PLUMBING-MECHANICAL LJ BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: /, ) �� r_ SANITARY NO. APPLICATION SUBMITTAL DATE OWNER'S NAME: yJto E: CONT fry �'LIC // N/C CONTROL# RCHITECT/ENGINEER: LIC NO: CONTACT: non PHONE: //W{•-r L/�'yVf / BUILDING PERMIT INFO �� 1' /�� fJa ��5 i[�/� ❑ Consultant Fees Paid by Applicant(Initial) BLDG 1 C PLUMB ILECIJ LICENSED CONTRA TO�R'3 DECLARATION QTY ELECTRIC PERMIT FEE ❑ ❑ 1 hereby uffrm But I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION DoZ with Section of Division 3 of the Business and Professions Code,and my license is PERMIT ISSUANCE C/� RESIDENTIAL Poo Le V V n full force and cffe /q License Class Lic.p r#-' � O$FTJWL [:J KITCHEN REMODEL Oem�Cnnvactor APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE L ARCHGECPSDECLARATION ❑MULTI-UNIT ❑STRUCTURAL F to PANELS 1 understand my plays shall be usM u public records MODIFICATION OZ-0 UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR Pwk Licensed Professional 201-1DXIAMPS IMPROVEMENT NP Oat I am exempt b DECLARATION Curl OVER I0us)AMPS ❑BATH REMODEUREPAIR C1 DEMOLITION I hereby uflirm that 1 vat exempt from the Cnmmumr's License Lew for the 31Y U following reason.(Section 9031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAI. ❑OTHER Cwhich requires a permit to construct,ulcer,improve,demolish,or repair any structure h prior to its iesuwce.also requyes th<apDlicent for such permitmfileasigned statement SPECIAL CIRCUTTMISC. /raw r tvvtyyrry that he is licensed p.......the provisiodsuf the Cmumecors License Lan,(Chapter 9 CSO (commencingwim Section]000)of Divomn3 ofrhe Bmldessand Professions Cade)or TEMP.METER OR POLE INST. COMMERCIAL:. d c T that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION + ,^„y Section 1031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DV ICES OTENANT ❑FOOD SERVICE Z y not more than five hundred Joilers($S(N). IMPROVEMENT C6 Lasowne1me1'c pmpcny,army employees with wages as their sole compensation, SWIMMIN P •LECTRIC ^I will do the work,and the structure is not intended oroffercd for sale(Sm.]044,Business [3 OTHER 3 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS- FIXTURES Property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are nut intended or offered RT4 NEW RESIDENTIAL E Q rL sale.If.however the building or impmvenent is sold within one yersofcompletionthe SQ.FL p1. RAREA 5/SQ.FT. ow nor-builder will have the burden of proving that he did not build or improve for par- f.� �� pose of soler TOTAL: qg0� 1,m owner of the Smpery, B sines and contracting with licensed contractors to by r construct the Project(Sec.]044,Business and Professions Code:)The Comradors Li- cense Law does not apply to an owner of property who builds or improves thereon andQTY, PL , ING PER FEE UY•LP1 I R who contracts fon projects with a contortions)licensed mormaatto Ne Coomnm's 'I'T1s/ Uf V License Law. -4;_PERMIT ISSUANCE ❑ lam exempt unit,, « er Sec. ,H&P C for this vssm Owner - Date ALTER-GRAIN&VENT-WATER VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE /-Iry)- /ye-) • I hereby affirm under Penalty of Pe jury one of the following declarations: L'o, L,%_/ ❑I have and will maintain a Certificate of Conum to self-insure for Workers Camper- DRAINS-FLOOR,ROOK AREA,COND, STORIES TYPECONSTRUCTLON satimu as provided for by Section 37M m the Labor Code,for the performance of the w rkfmr liehthispmrmisissued. FIXTURES-PER TRAP F have and will mainmid Workers Cnmpensotion Insurance,as required by Section 300 of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INCA OUTLETS OCOGROUP APN My Work s era n d Policypyly�/p, Cartier: o Policy NoGAS-EA.SYSTEM-OVER 4(EA) CERTIFICATEO EXEMPTION FROM WORKERS' COMPENSATION INSURANCE permitGREASE NDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This section need not becompleted ifthe permit is forums,hundred dollars(Slid). GREASETRAP or less.) PLANCHECK FEE I codify that in the perfotmvnce of the work for which this permit N issued,Ishii I not employ any person in an manner so its to become subject the Workers' SEWER-SANITARY-STORM EA.200 FT. y pen- ENERGY FEE 07.. sound Lows of Cal ifomis.Dam WATER HHATF.R WNENT/ELECTR 0 Applicant - GRADING FEE N NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEM/TREATING become subject to the Workers Compensation provisions of the Labor Code,you mint SOILS FEE {ail forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE Q .CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT PAID Doe Receipt# ILI 0 I hereby affirm then m i is s ed(Sm..30 lending agency for the performance of LL U the work for which this pemtit is issued 15a.309],Civ.CJ 0 L) finders Name TOTAL: IllLenders Address - TOTAL 96 Or I certify that 1 have read this application and state rhot Ne above information is BUILDING FEE (A correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE U4 building construction,and hereby authorize representatives of this city in enter upon the SEISMIC HE above-mentioned property,far inspection Purposes, PERMIT ISSUANCE O (We)agree to save,indemnify and keep humtless the City of CoWnimo against ELECTRIC FEE liabilities,judgments,costs and expanses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO 10.000 CFM) + /1 SOURCE REGULATIONS. MECHANICAL FEE !�V AIR HANDLING UNIT(OVER III,"CFM) CONSTRUCTIONTAX Signature of ApplicanuConwcmr - Date EXHAUST HOOD fW/DUCf) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURP. Will the applicant or future building occupant store or handlehuardom materiel HEATING UNIT TO 100,010 BTU) u defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section155d$a)] HEATING UNIT(OVER IOgt)(10 BTU) [3 Yes No VENTILATION FAN(SINGLE RESID) FAIR Date Receipt0 W111 the applicant m future building oechuse equipment or devices which ROLLER-COMP DHP OR 1 Wdsod BTU) milit hazardous air aonWminanls ns Defined by thee Bay Area Air Quality Management TOTAL: 1/ 20 District' / BOILER-COMP(OVER IW,00I BTU) ❑Yes '10< _ I have read the hxrardws materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER IS UANCE DATE fomia Health&Safety C e.Sections 25305,25533 and 25514.I urMerswnd that if the NEW RESIDENTIAL ME CH. SQ.FT. building tine not cu yhnvea¢nun6 than it is my respnnsihilityto notify Ne cupvnt /) of the require a met primo issuance ofa Certificate {_/ Owne oath agent - Dat TOTAL: ISSUED BY: OFFICE