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31320 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO- 31320 320 -MECHANICAL BUILDING DIVISION APPLICATION/PERMIT PLUMBING BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA /07/f- 44r��rr)A )6/ a/P �No C4 ` ro /y, 10 [6 q6 OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: t \,// 7T 12 •� D")a`'�� N/C CONTROL# ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑ E V214v ille /vO.P�oiFs -,3 CONTACT. PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLQG/ ELECT PLUMB MECH ;CJ]_ ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I herebv affirm that I am licensed under pros inions of Chapter 9(commencing JOB DESCRIPTION with Section 7(HN))of Division 3 of the Business and Professions Code.and my license is RESIDENTIAL: C'in full force and effect. PERMIT ISSUANCE 2 :t] ; ❑SFDWL ❑KITCHEN REMODEL U License Class Lic.# Q UUJ DateContractor APPLIANCES-RESIDENTIAL ❑ADDITION ElPLUMBING RE-PIPE ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL Z Q✓)Z I understand my plans shall be used as public records MODIFICATION Z G UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR F"❑I, Licensed Professional 201-1000 AMPS IMPROVEMENT ti:L OWNER-BUILDER DECLARATION C ¢' I herebv affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION X O 4 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER y[L 4 rj which requires a permit to construct,alter,improve,demolish,or repair any structure y prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. E >, that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 UJ C..G Q COMMERCIAL: (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. A.4 a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION 0 Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES tt —rn ❑TENANT ❑FOOD SERVICE F Z y not more than five hundred dollars($500). IMPROVEMENT s< ❑1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC F Qo will do the work,and the structure is not intended or offered for sale(Sec.7044.Business ❑OTHER W m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES 4 3^ 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 FP sale.If,however,the building or improvement is sold within one year of completion,the OOR AREA $/SQ.FI. owner-builder will have the burden of proving that he did not build or improve for pur- pose of sale.). F1 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: �^�fA construct the project(Sec.7044,Business and Professions Code:)The Contractors Li- `� cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT who contracts for such projects with a contractor(s)licensed pursuant to the Contractors 1J1' L IJ r'C ri I I NU License Law. PERMIT ISSUANCE ❑I am eze Sec ,B&P C for this reason ALTER-DRAIN&VENT-WATER(EA) VALUATION Owner Date WORKER'S CM OPENS N DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penalty ofpeq6fy one of the following declarations: •1 have a� ill maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIO ded for by Section 3700 of the Labor Code,for the performance of the rthis permit is issued. FIXTURES-PER TRAP will maintain Worker's Compensation Insurance,as required by Section bor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN Compensation Insurance carrier and Policy number are: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRIiASE/INDUSTRL WASTE INTERCEPTOR •* "k„"'-iultDrrrt3 Ivis14? F7E�S"' i section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP PLANCHE E tify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT. any person in any manner so as to become subject to the Workers'Compen- ENER •s of California.Date WATER HEATER WIVENT/ELECTR GRAD E TO APPLICANT:If,after making this Certificate of Exemption,you should NATER SYSTEM/TREATING ubject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE comply with such provisions or this permit shall be deemed revoked. WATER SERVICE CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID i hereby affirm that there is a construction lending agency for the performance of ate Receipt# k for which this permit is issued(Sec.3097,Civ,C.) TOTAL: 's Name 's Address TOTAL: I certify that I have read this application and state that the above information is BUILDING FE (77 t.I agree to comply with all city and county ordinances and state laws relating to Q•I•}( MECHANICAL PERMIT FEE ng construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE :-mentioned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupenino against ELECTRIC FEE lilies,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE msequence of the granting of this permit. ?LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE URCE REGULATIONS. AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX gnature 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) s defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety :ode,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) ❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipt# Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,OW BTU) nit hazardous air contaminants as defined by the Bay Area Air Quality Management TOT ALL istrict? ❑Yes ❑No BOILER-COMP(OVER 100,1H)0 BTU) AIR CONDITIONER 1 have read the hazardous materials requirements under Chapter 6.95 of the Cali- ISSUA E DATE forma 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. Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE r {� � '1 • �wwwv�s ay.��r 'fir► J ,� � I�� J � i � �/__r r �� 1��--� !�� L't