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S0716 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO' 0716 0 6 BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL C BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAl LL OCL Ile OWNER'S NAME: PH�� 5CONTRACTOR'S NAME: LIC NO: N/C CONTROL# CC 147 C6 '��i ARCH IEECT/ENGINEER: LIC NO: ADDRESS: ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH !! d El LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION W O p A x z with Section 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL:H W in full force and effect. PERMIT ISSUANCE U U License Class Lic.# ElSFDWL ❑KITCHEN REMODEL h Q�W Date Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ElPLUMBING RE-PIPE F D ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL •p v)z I understand my plans shall be used as public records MODIFICATION j z4 A UP TO 200 AMPS • _W El INTERIOR ❑CHIMNEY REPAIR Licensed Professional 201-]000 AMPS OWNER-BUILDER DECLARATION IMPROVEMENT E]SWIMMING POOLS +„� a OVER 1000 AMPS M DE EPA M a I hereby affirm that I am exempt from the Contractor's License Law for the ❑BATH REEl DEMOLITION 3 w F following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER 0 1.�.w0 v1 which requires a permit to construct,alter,improve,demolish,or repair any structure n r or Q 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 Contractors License Law(Chapter 9 ..Q 0 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL: X Ao k that he is exempt therefrom and the basis for the alleged exemption.Any violation of E]NEW BLDG/ADDITION ❑DEMOLITION M rn 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). ,".,Q ❑ IMPROVEMENT I,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC Ao will do the work,and the structure is not intended or offered for sale(Sec.7044,Business ❑OTHER W 3 oo 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 Z Q 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 put- of sale.). I,as owner of the property,am exclusively contracting with licensed contractors to TOT i RE _ E-1 �� construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- ■f•1�' cense Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. PERMIT ISSUANCE DEC 0 81997 ❑I am exempt under Sec. ,B&P C for this reason Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER 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,COND. STORIES TYPE CONSTRUCTIOP 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 BUILDING DIVISION FEES (This section need not be completed if the permit is for one hundred dollars($100) GREASE TRAP or less.) 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 becom `bj to the Workers'Compen- ENERGY FEE Z sation Laws ofDate WATER HEATER WNENT/ELECTR OZ-.O Applicant��}+�o�. .� (__J— Pmaa ��� GRADING FEE T: -- NOTICE TO APPLICANIf,after king this erti icate of Exemption,you should NATER SYSTEM/TREATING become subject to the Workers 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 U Q I hereby affirm that there is a construction lending agency for the performance of Date Receipt ;Jr 77 Hthe work for which this permit is issued(Sec.3097,Civ.C.) TAL: Lenders Name U Lender's Address TOTAL: W I certify that I have read this application and state that the above information is BUILDING FEE Ht) correct.I agree to comply with all city and county ordinances and state laws relating to QTy, MECHANICAL PERMIT FEE U Z building construction,and hereby authorize representatives of this city to enter upon the A SEISMIC FEE r-i above-mentioned property for inspection purposes. (We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE 7/liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. C 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 CFM) SOURCE REGULATIONS. MECHANICAL FE AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TA Signature of ApplicanL/Contractor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATIONE 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 X,o VENTILATION FAN(SINGLE RESID) PAID Date Receipt# 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) i7 District? T AL: ❑Yes kNo 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.I 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 ( f of the m;u' m is whit mu t or to issu f a Certificate of cu Owner or authorized agent I Bate TOTA : 4 ISSUED BY: OFFICE � CITY OF CUPERTINO 4PPUCATION FOR BUiLDING PERMIT PHONE CONTR. f7prrr) ---ADDRESS 1295 The Alamed.a BOND BEA,,�Vl- ` ~`�"~~� - ' - -_ ' - - ~E . � UNDER-rt{}oR T(ED0w'w� DiAPHJ7R'4/45 '