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29171 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ' CI TY OP CUPERTINO BUILDING-ELECTRICAL PERMITNO. 29171 NG DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDI BUILDING PROJECT IDENTIFICATION BUILDINGAD ESS: SANITARY NO. APPLICATION SUBMITTAL DATI rl Ly I OWNER'S NA PIDNE: - CONTRACTOR'S NAME: LIC NO: �'/ NIC CONTROL0 �ARCHITECt/ENGINEER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ _ ❑ � ❑ LICENSED CONTRACTOR'S under D inions ATION QTY. ELECTRIC PERMIT FEE 1 hereby affirm that l um licensed under provisions of Chapter 9(commencing JOB DESCRIPTION Qa2 with ilformlight dsfir Division 3ofthe Business and Professions Code.and my license as RESIDENTIAL: in full force and cBbct. PERMIT ISSUANCE �tV� ❑SFDWL [IKITCHEN REMODEL U License Class Liab APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE Dee TSDEContracor �y ARCNITeuse DECLARATION ❑MULTI-UNIT ❑MODIFILRAL IE�--�� PANELS Zpv2� Iundersmnd my plans shall bou.ud as public rtttnNs s MODIFICATION OZI, UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR 1-e4 l�t Licensed Profcsomind 201-IOMAMPS IMPROVEMENT ' a OWNER-exempt L ad me Contractor - OVER IOW AMT'S s .❑BATH REMODEUREPAIR ❑DEMOLITION K I hereby vffrm that 1 oat exempt from the Cssions Code:Any c Law Inaba — 3f whichfollow guiresa emit to construct.alter importand , demolish, ineairay fitcountySIGNS ELECTRICAL LJ OTHER LL which requires a permit re ronsweL aloes improve,demolish,or repair any seucmre � prior to issuance,also requires the vpplicam for such permit file asigncd stemtnem SPECIAL CIRCUIT/MISC. y shat he is licence)pursu uano the provisions of the Contractor's License Law(Chapter 9 00 (commencing with Section 7000)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLE INST. ' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑ 9LDG/ADDITION ❑DEMOLITION .n R• Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES �y ❑TENANT ❑FOOD SERVICE not more than five hundred dollars($5010F IMPROVEMENT C ❑ I,as owner ofthe property,or my employees with wages m their sole compensation. SWIMMING POOL.ELECT RIC will do the work,and the aoumum is not intended mothered Tarsale($m.7044,Business ❑OTHER add Profenimet Code:The Cram nsum,License Law does not apply men owner of OUTLETS-SWITCHES-FXV-RFS propany who builds or improves thenen,and who does such work himself or through his owa employees,provided that such improventems ore not intended of offered for NEW RESIDENTIAL ELECTR SQ ET. sale.ILhowever,the building or improvement issold within one yearofcompletion.1he SQ.FT FLOOR AREA .SISQ.ET . owner-builder will have the burden of proving that he did not build or improve for pu, �� pose of aowne 199 ❑st az owner of the property,70,1 am,Business exness and contracting with licensed nonce es i- _ TOTAL: n 2S censeLathe project(Sec.o an Businessand Professions Code:)The es lracton. Li- Ory o Li- cense Lewdoes maapply toan oath a of property who buiIds mrimpro the Contractor's QTY. PLUMBING PERMIT FEE Ory r p�Clr['EL who contracts for such projects with u cnmmmor(s)license)purauam m the Commcmrs Es 1 IIVV Li se Low. PF,RMITISSUANCR Murder ,B&P C for Nis reason ALTER-DRAIN&VENT-WATER(EA) VALUATION Da WORKER'SCOMPENSAT N ECLARATTON BACK FLOW PROTECT,DEVICE I hereh affirm under penalty 1 pe jar ofine following dedamtiona: ❑Ihave and will mainmina Cenificmcmf Coneemmavlf-in.vurc for Worker',Cani DRAINS-FLOOR,EWE AREA,COND' - STORIES TYPE CONSTRUCTION mine.as provided for by Section 37W of the Labor Codefoce ,for the perrmanmf the work for which this permit is issued. FIXTURES-PER TRAP ❑1 have and will diamo id Worker's Compensation Insurvnmas required by Section 3700ofthe Labothe e performance ofthe work for which this Permit is issued. Z GAS-EA.SYSTEM-IINC.40UILETS OCC.GROUP APN My Workers Compensation Insurance carrier and Policy number are: Carrie, -Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE Of'EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRHASE(INDUS'TRL WASTE INTERCEPTOR (This action need not becompletcd ifde pemiit is fur-onehundrcd dollen($100) BUILDING DIVISION FEES or less.) GREASETRAP PLANCHECK FEE I reunify that in the performanceofthe work for which this permit is issued.)shall SEWER-SANITARY-STORM EA.2W FT. not employ any person in any manner an as to become subject the Worker.'Compere ENERGY FEE OZ sation laws of California.Date WATER HEATER W/VENT/ELECfR O Applicant GRADING FEE LI) NOTICE TO APPLICANT.If,after making this Cenificme of Exemption,you should WATER SYSTEM)'FREAUNG "y^ become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEB w G foMwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE. CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID L)❑ hereby thi that ismedgerdimnlending,vgencyfor the performance of am ceipt# W rr the work for which this Permit is iswed(9ea.3097,CIv.CJ - O(J I-order's NameAdd. TOTAL: U� Lender's Adtifyt I certify Nm 1 have read this application and trate that the above information is BUILDIN,FEE VVJ' correct.)agree to comply with all city and county ordirunces and nate laws relating to QTY. MECHANICAL PERMIT FEE building construction,and hereby authorize representatives ofthis city to enter upon the SEISMI FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE, (We)agree to save,indemnify and keep harmless the City of Cupertino against ELE IC FEE Iiahilities,judgmmstx,costs and expenses which may in any way mcnavagaimt said City ALTER OR ADDTO MECH. in consequence ofihe granting ofthis permit. PIA ING E APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00)CFM) ME {pNIC SOUR CE REGULATIONS. AIR HANDLING UNIT(OVER 10.00s)CFM) CO STRUC ION TAX Signature of Applicint/Contracmr Dom EXHAUST[OO[)(WMUCT) H SING MITIGATION PER MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(JO I00.003 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code.Section 25532Ia)? HEATING UNIT(OVER 100,00)BTU) ❑Yes ❑No VENTILATION FAN(SINGLE RESID) ID Will the applicant or future building occultiou use equipment or devices which Dam Receipt four hazardous air communist oa defined by the Buy Area Air Quality Management BOILER-COMP I3HP OR I00.0100BUH TOTAL: Dnstnct? ❑Yes ❑Nm -BOILER COMP(OVER 100,000 BTU) � 7 1 have read the hazardous materialsAIR CONDITIONER requirenunu under Chapter 6.95 of the Cali- ISSUARCEDATE fomia Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.Er. building docs not currently have a tenant,that it is my responsibility to notify the mm,not of the requirements which most be met prior to issuance of a Certificate of Oct.,.. Owner or vunionized agent Dote TOTAL: ISSUED BY: ,OFFICE