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B0285 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUII,DING-ELECTRICAL PERMIT NO��y� ^ p� r BUILDING DIVISION APPLICATION/PERMIT FLUMBING-MECHANICAL .� x °'� BUII.DIPIG PR�JECT IDENTIFiCATIOiV 50001 �" BUILDING ADDRESS: �/�, SANITARY NO. APPLICA7'ION SUBMITTAL DAT `7� �3 �,� C..G��I� C��-+�v ��—c—ys� OVVNER'S NAME: PHONE: CONIRACTOR'S NAME: LIC NO: ` � 7�-. v ) , � N/C CONTROL# N� 6 t ARCHITECT/ENGINEER: LIC NO: ADDRESS: �.U,� ❑ —� �- } ,y CoNTnCT: °"T' il . �� PHONE:�g.7',�T`l�. �SI�� BUILDINGPERMITINFO �� .., ,t�� fi„i � �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH �Aa;�Y� � ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARAT'iON Q�y ELECTRIC PERMiT �F. I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION Q a Z with Sec[ion 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL: �1 O p PERMIT ISSUANCE a w� in full force and effect.��^ �.'�rj��, ❑SFDWL ❑KITCHEN REMODEL �U V License Class X Lic.#�L� p,ppLIANCES-RFSIDENTIAL ❑ADDI110N ❑PLUMBING RE-PIPE �a�W Da[e Contrac[or F�� ARCHITECTS DECLARATION pA�s ❑MULTI-UNIT ❑STRUCTURAL Q�Z I understand my plans shall be used as public records MODIFICATION z,.�.,"" UP TO 200 AMPS �„F"W Licensed Professional ❑INTERIOR �HIMNEY REPAIR 201-1000 AMPS IMPROVEMENT �SWIMMING POOLS y��a OWNER-BOILDER llECLARATION OVER]000 AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION ''a a d I hereby affirm that I am exempt from the Convactor's License Law for the O w U ❑OTHER �'I D Id�� ]�P.�.1� 'w6, following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL /1 '"7—'— O� which requires a permit to conswe[,alter,improve,demolish,or repair any structure {-ny�_�j u„A�r�-j,e,,,f —L(,n �a prior to its issuance,also requires Ihe applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC. ��, that he is licensed pursuant[o the provisions of the Convactor s License Law(Chapter 9 A� (commencing wi[h Section 7000)of Division 3 of the Business and Professions Code)or 7'EMP.METER OR POLE INS . COMMERCIAL: G,o pl, 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 appLcant for a pertnit subjcets the applicant ro a civil penalry of POWER DEVICES ❑TENANT ❑FOOD SERVICE F z�., not more than five hundred dollazs($500). "'�d I,as owner of the ro IMPROVEMENT ❑ p perty,or my employees with wages as[heir sole compensa[ion, SWIMMING POOL EC'fRIC ��x Q will do the work,and the swcNre is no[intended or oHered for sale(Sec.7044,Business ❑OTHER "o�o and Professions Code:The Convactor's License Law dces not apply to an owner of OUT'LETS-S TCHES-FIXTURES p"3� property who builds or improves[hereon,and who dces such work himself or tivough his own employees,provided that such improvements are not intended or oHered for NEW RE ENTIAI.ELEC7'R FI'. sale.If,however,the building or improvement is sold wi[hin one year of completion,the SQ.FT.FL,OOR AREA $/SQ.FT. ownervbuilder will have[he burden of proving tha[he did no[build or improve for pur- pose of sale.). ❑I,as owner of the property,am exclusively contracting with licensed contractors[o TOTAL: conswet the projcet(Sec.7044,Business and Professions Code:)The Contrac[ois Li- � cense Law dces no[apply to an owner of property who builds or improves thereon,and . PLUMBWG PERMIT who contracts for such projects with a convactor(s)licensed pursuant to the ConVactor's License Law. PHRMIT ISSUANCE ❑I am exempt under Sec. ,B&P C for Ihis mason ALTER-DRAIN&VENT-WATER(EA) VALUAT'ION Owner Date WORKER'S COMPENSATTON DECLARATION BACK FLOW PROTECT.DEVICE � s J �i S• ��C I hereby affirm under penalry of perjury one of the following declazations: � er- ❑I have and will maintain a Certificate of Consent to self-insure for Worker s Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTIO� sauon,as provided for by Section 3700 of the Labor Code,for the pedormance of the work for which this pamit is issued. FIXTURES-PER TRAP �_ ` �I have and will maintain Worker's Compensation Insurance,as required by Sec[ion �' '-"� 3700 of[he Labor Code,for the perfortnance of the work for which this pe[mit is issued. GAS-fiA.SYS7'EM-1 INC 4 OUT1.E OCC. ROUP APN My Worker's Compensation Insura ce carrier and Policy n ) Carrier: S3}1u�[ ��yt� Policy No.: � ��h�� !9-g GAS-EA.SYS7'EM-OVER 4(EA CERTTFICATE OF EXEMP'f[ON FROM WORKERS'�`�y� COMPENSATION INSURANCE � �I�r�� GREASE/INDUSTRL WASTE TERCEP7'OR g�, N NLSION FEES (This section need not be comple[ed if[he pertni[is for one hun do�lars($1 ) GREASE TRAP or less.) P NCH I certify that in the performance of the work for which this permit is issued,I shall SEWER-SADIITARY ST'ORM EA.200 Ff. not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE O z sation Laws of Califomia.Date WATF,R HEATER NENT/ELECTR GRADING FEE z� Appl�cant � �j NOTICE TO APPLICANT:If,after makmg this Certifica[e of Exemption,you should Wp�R SYS ATING y H�"� become subjut to Ihe Worker's Compensahon provisions of the Labor Code,you must w� forthwith comply wi[h such provisions or this pertnit shall be deemed revoked. Wp'I'ER S VICE p"A CONSTRUCTION LENDING AGENCY NEW IDENTIAL PLMB. SQ.FT. PAID �,7.. Date Receipt# I hereby affirm that there is a conswetion lending agency for the performance of U O the work for which this pertnit is issued(Sec.3097,Civ.C.) w Lender's Name TOTAL: �a Lenders Address TOTAL: BUILDING FEE I certify that 1 have read this applica[ion and state that[he above information is r HV� correc[.I agree to comply with all ciry and county ortlinances and s[ate laws relating to , jyj$Cj�j{j�JjCj�j p�jvjj'j" FEE V Z building construc[ion,and hereby authorize representatives of[his city to enter upon the SEISMIC FEE � above-ment�oned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep hazmless the Ciry of Cupertino against ELEC7'RIC FEE liabili[ies,judgmen[s,ws[s and expenses which may in any way aceme against said City pLTER OR ADD 7'O MECH. in consequence of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFMI SOURCE REGULATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER 10,000 C CONSTRUCTION TAX Signamre of ApplicandContractor Date EXHAUST HOOD(W/DUCI') HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or fu[ure building occupant store or handle hazardous ma[ena] HEA77NG UNIT(TO]00,000 BTU as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? HEATING UNIT(OVER]00, BTUI /,�y Yes o /�—(�' `►��.y � � VENTILAT'ION FAN(SI LE RESID) pAID Date Receipt# �j Will Ihe applicant or fu[ure buildmg occupant use equipment or devices which �� " emit hazardous air contaminants as defined by[t�e Bay Area Air Quali[y Management BOILER-COMP(3 OR 100,000 BTU) TOTAL: Disuict? BOILER-CO (OVER 100,000 BTU) ❑Yes �tNo AIR CON TIONER I have read the hazardous materials requirements under Chapter 6.95 of the Cali- ISSUANCE DATE � fomia Heal[h&Safery Code,Sections 25505,25533 and 25534.I understand that if the � ESIDENTIAL MECH. SQ.Ff. � building dces not wrrently have a tenant,that it is my msponsibil�ry to notify the occupant of the requ'vements whic ust be met prior to issuance of a Certificate of Occupancy. �� , Owner or authorized gent�. Date T�TAL� lSSUED BY: ��"�e' ��'�� OFFICE