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30326 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. ^ O ^ ^^ BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J{ `{J'LJ Vh BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE d t S--)-r4 WNE SNE: CO CIOR'S AME LIC NO: ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ECT PLUM MC LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing G • J g'I�rreN O OL Z with Section 7000)of Division 3 of the Business and Professions Code,and my licence is N A i)O O PERMIT ISSUANCE W— in full force and effect. ElSFDWL ElKITCHEN REMODEL U U License Class Uc.# W Date Contractor APPLIANCES-RESIDENTIAL El PLUMBING RE-PIPE n O h ARCHITECTS DECLARATION PANELS MULTI-UNIT []STRUCTURAL Vf z 1 understand my plans shall be used as public records MODIFICATION Z_G UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR Licensed Professional 201-1000AMPS IMPROVEMENT OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODE EPAIR ❑DEMOL ON I hereby affirm that I am exempt from the Contractor's License Law for the O pW,U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER OE"" which requires a permit to construct,alter,improve,demolish,or repair any structure14 19 prior to its issuance,also requires the applicant for such pen-nit to file a signed statement SPECIAL CIRCUIT/MISC. 4 that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 C C (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: y a a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW j3LDG/ADDITION ❑DEMOLITION �C.n(L Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TE(�ANT [I FOOD SERVICE Z y, not more than five hundred dollars($500). IMPROVEMENT a ❑1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC .Fi will do the work,and the structure is not intended or offered for sale(Sec.7044,Business be ❑OTTiER and Professions Code:The Contractors 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. If,however,eche building or improvement is sold within one year of completion,the S ,FfCf UREA ` $/SQ.FT. owner-buildtt ewill have the burden of proving that he did not build or improve for put-pow sale.). [3L as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractors Li- 31996 cense Law does not apply to an owner of property who builds or improves thereon,andQTY PLUMBING PERMIT FEE who contracts forgsucbjectsu with a conactor(s)licensed pursuant to the Contractors Li Lw' PERMIT ISSUANCE ITYUr (iUhLtj!I NO pt B&P C for this on - r Date ALTER-DRAIN&VENT-WATER(EA) /wJ C^ VALUATION WORKER'S COMPENS ECLARATION BACK FLOW PROTECT.DEVICE a8 I hereby affirm under penalty of perj one of the following declarations: V 111iii Ill... • ❑I have and will maintain a Certificate of Consent to self-insure for Workers 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 which this permit is issued. FIXTURES-PER TRAP ❑I have and will maintain Workers 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 Worker's Compensation Insurance carrier and Policy number are: Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSTRL.WASTE INTERCEPTOR BUYIDING DIVISION FEES (This section need not be completed if the permit is for one hundred dollars(S 100) GREASE TRAP or less.)(This FE 'o I certify that in the performance of the work for which this permit is issued,I shall • not employ any person in any manner so as to become subject to the WorkeCompen- SEWER-SANITARY-STORM EA.200 FT. rs ENERGY FEE 2© ZZ sation Laws of California.Date WATER HEATER WNENT/ELECTR 0 Applicant GRADING FEE .y NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING I"t become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE wA forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID .0 Z I hereby affirm that there is a construction lending agency for the performance of Date ei V O the work for which this permit is issued(Sec.3097,Civ.CJ O ULenders Name w It) TOTAL: W BUILDW Lenders Address tM %71 W I certify that I have read this application and state that the above information is _ rr VI correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE V Z-. building construction,and hereby authorize representatives of this city to enter upon the SEISMIC �°ay "~ above-mentioned rt for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino ISSUANCE no against ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING/E in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHA L FEE SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRU N TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITI ATION 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 Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) Yes M No VENTILATION FAN(SINGLE RESID) PAID Date Receipt# Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100000 BTU) 'r-emit hazardous air contaminants as defined by the Say Area Ar . Quality Management TOTAL: District? Q Yes ❑No BOILER-COMP(OVER 100,000 BTU) I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have a tenant,that it is my responsibility to notify the occupant of the requirements which must be met prior to issuance of a Certificate of Occupancy. /J Owner or authorized agent Date L �/ ISSUED BY: OFFICE