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31421 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 1 3.g p ^q BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �K/JI.4 L BUILDING PROJECTIDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT( OW([J/ER'S NAMCi CV1'RACI'ONNAM/�—JC I N/C CONTROLK2Sz ZOfQ ! ARC ECT/ENGINEER: LIC NO: ADDRESS: ED/// ko S&yn y U CONTACE PHONE: - BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MCCH ❑ ❑ ❑ LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby aflirtn That Tom ffic Iftl under ind Profession, of Chapter 9(commencing JOB DESCRIPTION {D{�1aZ with Sution]OIX))ofUivisionlofNe Business end Professions Code,and my license is RESIDENTIAL, F0O in a PERMIT ISSUANCE til farce and eRect^ 3 //�^L /�/ ❑SFDWL A❑-KITCHEN REMODEL EMLreense Clms Lic.N r— ! W APPLIANCES—RESIDENTIAL ❑ADDITION XLUMBING RE-PIPE 1.6 Date Cnn DECLARATION g,Ow ARCHITECTS he DECLARATION PANELS [I MULTI-UNIT El STRUCTURAL Z O y 7, 1 understand my plain shall be asst as public records MODIFICATION .OZ-Q UPTO201AMPS I ❑INTERIOR ❑CHIMNEY REPAIR Pseud Licensed Professional - 201-U100AMPS IMPROVEMENT gw�; OWNER-BUILDER DECLARATION OVER IIXIOAMPS El BATH REAfODEUREPAIR L)DEMOLITION yyx lY W A I hereby affirm that 1 am exempt from the Comractor5 License Law for the W 3 d U Billowing reason.(Section 7031.5,Business and Professions Cush:Any city or county SIGNS ELECTRICAL ❑GTHER Y7=O which reyvira a permit to consumer,alter,improve,demolish,or repair any swcwrc prior m its issuance,also requires the applicant nonsuch permit to file a signed statement SPECIAL CIRCUIT/MISC. } that he is licensed pursunno the provisions ofthe Contmmors License Law(Chapter 9 �0 (commencing with Section 70W)of Division 3 oflhe Business and Professions Coact or TEMP.METER OR POLE INST. COMMERCIAL: G y that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Y• Section 70.31.5 by any applicant for a Permit ubjects the applicant to a civil penalty of POWER DEV ICES ^v( .TENANT ❑FOOD SERVICE not morewnthan five epropeundred dollars($500)empl, MPROVEMENT 20 ❑bathe work, thepesureaor me is my set wendeswithwagesmlhei(ea compensation, SWIMMING POOL ELECTRIC F andwill dothework,and Cmic: he Cmitisnots License aw it...ad rmle(SI,to mn, vaer of OTHER property ernfehob Calc:The improves th uson License Luo fist era apply s if owner of OUTLETS—SWITCHES—FIXTURES progeny wbo builds or improves thereon,and who fines such work himself or through his own employeese Provided that such improvements are not intended or offered for NEW RESIDENTIAL EL[CfR SQ PI'. owri L baweve60e have lot bur improvement is soldddwithin one ild or improve put- SQ.FT.FLUOR ARCA SAO.FT. Own er-huildcr will have Ne M1UNm of proving rant he did not M1UIIJ or Intpmvo Cnr pro pow as own. ❑st as t the p of the Progeny. B exclusively contracting with licensed mar memss i- TOTAL: A construct the project(Sec.]1141,Business and Professions Code:)The Conuacmrn Li- M cense Law Jnes nm apply to en owner nl progeny who builds or improves thereon,and Q'IY. PLUMBING PERMIT FEE. �pp,p�� whocaamca forsuch projecawithacontracmriM licemadpursuanuodu Convectors YV®'J (� �� License Law. PERMIT ISSUANCE Ntl vD mil C 1 an,exempt wider Sec. ,1)&PC for thin reason (� •Owner Data ALTER—DRAIN&VENT—WATER(EA) (yeAEUATIDNVU WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE r••� l1' 1 hereby affirot under penalty of perjury one of the following declarations: ❑Ihave and will maintain oCenificate of Consent mself-insure(or WnrkKs Compcn- DRAINS—FLOOR,ROOF,ARCA.COND. saris¢,an provided for h Section 37M of the Labor Cade,for the STORIES TYPECONSTRUCTION p y performance the work for which this permit is issued. FIX'fURP.S—PER TRAP 1 have and will maintain Workers Compensation ofthe w Insurance,which req Per by Section M,W.the Labor Cada fanh..ouncmcount, the work for numbr0is permit is issued. GAS—EA.SYSTEM-1 INC.40UTLETF OCC.GROUP APN My Workw's Compensation Insumace curtiu and Policy rumba arc: ' mer. Polley Na.: GAS—EA.SYSTCMd)VER 4IEA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GRPASEBNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES(Thlssection meednotMonmplelcd rthcpermit isfnrnnehundmilm lar,SIyq GREASE TRAP or less.) PLANCHRCK FEE Icenlfythat inlhe performance ofthe work for-which thispnmilis forest,I shall SEWER—SANITARY—STORM CA.200 FT. not employ any person in any manner ser as ro hecome subject 1.the Wnrke(s'Compcn- ENERGY FEE OZ sudor Lawaof California.Data WATER HEAT"ER WNENT/ELECfII C Applicant GRADING FEE y NOTICE TO APPLICANT.If,after making this Cenificale of Exemption,you should WATER SYSTEMPTREATING abecome subject to the Workers Compenwtion provisions of the Labor Code,you must SOILS FEE ' {✓a forthwith comply with such provisions in this permit shall la decomi mvoked, WATER SERVICE Q ,L z CONSIOat them iso conNLENDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID L) O Ihercby affirm Nanherc isanmswctinn lending agency for the performance of Date Receiptb D. Fthe work for which this permit is issued(Sec.3097,Civ,C.) Lender's Name _ TOTAL: WLender's Address L: rJ C I eenify that 1 have read this application and state that the above information is BUILDING FEF. CA correct.l agree to comply with all city and county ordinances and sate laws relating to QTY. MECHANICAL PERMIT FEE V z building eonswnian,and hereby authorize represenativw of this city to error upon the SEISMIC FEE ulawe-mcmioned property for inspection purposes. Oto)space to save,indemnify and keep harmless the City of Curet against PERMIT ISSUANCE ELECTRIC FEE liabilities,judgments,costs and expenses which may in any way acerae against said City AIXER OR ADD TO MECH. 0 n consequence of the granting of Nis permit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WI ALL NON-POINT AIR HANDLING UNIT(TO IR0dCFM) SO Cle ,pTIONS. JMECHANICAL FEE 2^ AIR HANDLING ONE"r(OVER 10,000 CFM) CONSTRUCTION TAX Sign arcof ApplicsoVCmu.amr ! Dom F.XHAUST'BOOD fW/DUCT) HOUSING MITIGATION HE MATERIALS DISCLOSURE Will theappllaom or future building mcupant smrcor handle hnnudomnnnenal HEATING UNIT(TO 1(Qm10 BTU) w defined by the Coquimbo Municipal Cate,Chapter 9.12,and the Health and Safety " Code,Section 25532(x)^ HEATING UNIT(OVER I W,0fx9 B'IV) ❑Yes ❑No . VHN'1'RATION FAN(SINGLE RCS ID) PAID Dam Receipt hi Will the air comm or future building by the Bt use equipment or Mann which BOILER—COMP QHP OR 10L0kM BTU) emit District r us air contaminants as define0 by the Bey Am Air Quality Management TOTAL: Disuiel7 ❑Yes ❑Nn BOILER—COMP(OVER 100.000 BTU) /I --7(' I have read the baznnlnus arman.H regtirernams not,Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE mean Health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MICH. SQ.FT. of the ra, rawtcurrently haveoanent thin it is my res of aCroftetminifytheoccupant of the requirements which man be it prior m ism y r e of a CeniOcem of Occupancy. Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE