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29000 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO 2 9 0 0 0 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTMCATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT OWNER'S AME: PHONE: CO ACT S NAA1E: LIC NO: `jo a 7 v G ,y N/C CONTROL# ARCHITECT/ENGINEER: LIC NO: ��ikh� '6- �� C�i�� ❑ CONTACT: PHONE: U BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH �-��mss-' L�- ' ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION A a z with Section 7000)of Divisio of the Business and Profession Cod& nd my license is W O O PERMIT ISSUANCE RESIDENTIAL: F W in full force and� �0 7 ❑SFDWL ❑KITCHEN REMODEL U U License Class v' Lic.# rF Q WLR. Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE I ARCHITECT'S DECLARATION PANELS ElMULTI-UNIT ❑STRUCT'URAL p h Z I understand my plans shall be used as public records MO IFICATION Z A UP TO 200 AMPS El INTERIOR HIMNEY REPAIR F W Licensed Professional 201-1000 AMPS IMPROVEMENT OWNER-BUILDER DECLARATION CG a I hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION OW wilk U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER O which requires a pemut to construct,alter,improve,demolish,or repair any structure >Pi v, prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. } that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 y A0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: p M a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION W Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE not more than five hundred dollars($500). F1 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT rFr c will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER a3 000 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT. sale.If,however,the bSildin or imp ement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT. owner-builder will have the rd roving that he did not build g improve for Pur- (4 A Lr' , pose of sale.). 8 ❑I,a owner of to c usivel nit ti ce sed contractors to TOTAL: Li- co th pr ect ,Bus s an essraiis Co e. a Contractor's Li- DEC 0 5 199 cense of pl`7' n owner o ro rty o builds or improves thereon,and QTY, PLUMBING PERMIT FEE who c s for such{pr�ec wile a nt a licensed pursuant to the Contractor's License . PERMIT ISSUANCE ❑I am x pt under Sec. ,B&P C for this reason Gf Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / \�— I hereby affirm under penalty of perjury one of the following declarations: . �J ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for this permit is issued. FIXTURES-PER TRAP ve and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN My Work C�o nsatSo�t�sttt#nce carrier and olicy,#tyn of 7 3 947 GAS-EA.SYSTEM-OVER 4(EA) Carrier( /V' PolicyNo.:�(,t/" r!' "/d.� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE(INDUSTRL WASTE INTERCEPTOR BUB-DING DIVISION FEES (This section need not be completed if the permit is for one hundred dollars($100) or less.) GREASE TRAP PLANCHECK FEE 1 certify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE sation Laws of California.Date WATER HEATER WNENT/ELECTR Z O Applicant GRADING FEE ►�fj NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING (~; become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE wQ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID V O I hereby affirm that there is a construction lending agency for the performance of Date Receipt# GL H the work for which this permit is issued(Sec.3097,Civ.C.) O V Lenders Name TOTAL: w Lender's Address TOTAL: D I certify that I have read this application and state that the above information is BUILDING FEE 1 HV] correct.I agree to comply with all city and county ordinances and state laws relating to QT]! MECHANICAL PERMIT FEE V ,7.-, building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE ~ above-mentioned property for inspection purposes. 9,510 (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. in consequence of the granting of this perrnit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal e,Chapter 9,12,and the Health and Safety Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) [3 Yes o S VENTILATION FAN(SINGLE RESID) PAID / Date Receipt# Will the applicant or future buildin cupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU) emit hazardous air contaminants as de by the Bay Area Air Quality Management TOTAL: District? ❑Yes o BOILER-COMP(OVER 100,000 BTU) I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE forma Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. building g9mi7currently have a tenant,that it is my responsibility to notify the occupant T of the m et prior to iss ante of a Ce a^jcupa�C ,. / / Owner or authorized igen Date TOTAL: ISSUED BY:ti �J ,/ nFFI�F