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S0316 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 0 316 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA] D 3 e, OWNER'S NAME: HONE: CONTRACTOR'S NAME: LIC NO: ,r" / NIC ?I – it CONTROL# IL 4 �/� d ARCHITECr/E'GINEER: LI N D ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ! EC E]LICENSED CONTRACTOR'S DECLARATION TY ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing J JOB DESCRIPTION A a Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL: WOO PERMIT ISSUANCE F f in full force and a ect.- �` O4 W J '� ❑SFDWL E KITCHEN REMODEL d U U License Class Lic.# EZ Z WDate Contractor— .f f ��,rte APPLIANCES–RESIDENTIAL El ADDITION El PLUMBING RE-PIPE CC. O to M ARCHITECT'S DECLARATION PANELS El ❑STRUCTURAL •O to Z 1 understand my plans shall be used as public records MODIFICATION Z4— UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR 1 W Licensed Professional 201-1000 AMPS IMPROVEMENT ❑SWIMMING POOLS " ? OWNER-BUILDER DECLARATION OVER]000 AMPS El BATH REMODEL/REPAIR El DEMOLITION W a I hereby affirm that I am exempt from the Contractor's License Law for the 10 U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER J 1 w OW which requires a permit to construct,alter,improve,demolish,or repair any structure (! , h a 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 COMMERCIAL: (commencing(commencing with Section 7000)of Division 3 of the 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 ❑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 Znot more than five hundred dollars($500). IMPROVEMENT x Q ❑I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC a.H.o will do the work,and the structure is not intended or offered for sale(Sec.7044,Business OT W 3=00 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 building or improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT. owner-builder will have the burden of proving that he did not build or improve for pur- pose of sale.). P A ! D ❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE AUG 19 who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's ��'��LLLLNFC-D License Law. PERMIT ISSUANCE ❑I am exempt under Sec. ,B&P C for this reason _ ALTER–DRAIN&VENT–WATER(EA) CITY UP bWL4DI"W1J Owner Date WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS–FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCTIOI 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-I INC.4 OUTLETS OCC.GROUP APN My Worke oni sation jiasurance carrier and Policy num a Carrier: �CL�uf=y1 (,- Policy No.:, � .h��T� GAS–EA.SYSTEM-OVER 4(EA) CERTIFICATE6F EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES (This section need not be completed if the permit is for one hundred dollars($100) or less.) GREASE TRAP PLANCHECK FEE I 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 O Z sation Laws of California.Date WATER HEATER WNENT/ELECTR GRADING FEE Z O Applicant .. V!) NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/I BEATING become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE WH forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE a" Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID U Z 1 hereby affirm that there is a construction lending agency for the performance of Date Receipt# V� the work for which this permit is issued(Sec.3097,Civ.C.) GIr H Lenders Name TOTAL: C) W Lenders Address TOTAL: a I certify that I have read this application and state that the above information is BUILDING E U] 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 i--i above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTR E 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 permit. PL I FE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) CHA A FEE SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,000 CFM) CON'NqUCJON TAX Signature of Applicant/Contractor Date EXHAUST HOOD(W/DUCT) HOUSINGTIGATION 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 It I Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU) Yes No VENTILATION FAN(SINGLE RESID) PAID Date Recei # Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER–COMP(3HP OR 100,000 BTU) TIAL: District? BOILER–COMP(OVER 100,000 BTU) ❑Yes ❑No 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.Fr. 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. O er of authonzed agent Date TOTAL: ISSUED BY: OFFICE