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31470 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. O BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL BUILDING PROJECT IDFI4TIF'ICATION BUILDING ADDRESS: e��14 ^��/ SANITARY NO. APPLICATION SUBMI'ITAI,DATE ClY (166 O . 'SNA - PHONE: C RACI' S E: ( LICN � N/C CONTROL g ARCHITECT ' NEER: LICNO. R ❑ ! CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees ls td by Applicant(Initial) - BLDGELECT PLU MECH ❑ ❑ 5K ❑ LICENSED CONnsedunORS rprov: LARATION QTY ELECTRIC PERMIT FEE I hereby vffirtn Net 1 ons licensed under provisions of Chapter 9(cummetming JOB DESCRIPTION �Z with Section 70ap of Division 3 of the Business and Professions Cole.and my license is RESIDENTIAL, 00 infulI force and cf t PERMITISSUANCE 7 Licenw--y�Lic.p ❑SFDWL ❑KITCHEPLUMBINREMODEL Dom Cnnwmor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE ARCHITECTS DECLARATION�' [:1 MULTI-UNIT CI STRUCTURAL I understand le PANEIS ZOI/1 yp ns spall bomad records MODIFICATION O Zr::11 UPT02MAMPS ❑INTERIOR C1 CHIMNEY REPAIR 0-ii. licensed Professional 201-INMAMPS IMPROVEMENT Oat I am eUIIAERDECLARATR)N OVER I(100AMPS ❑PATH REMODEIIR AIR ❑DEMOLITION 1 hereby uffmn that 1 am exempt from the Contractor's License Lew for the a6 U following reason.(Section]onstru Business and van,she roll Code:Any city or colony SIGNS ELECTRICAL []OTHER �j which requires n permit re cores the altar,improve,demolish,or repair any swmurt _ 3 pnorwits issuance,also requires the applicant for such Permit mfile nsigned statement SPECIAL CIRCUIT/M ISC. , that he is licensed pursuant to the provisions of the Convector's License Law(Chapter 9 apo (commencing with Semion]INIO)of Dirision3nf ate Busineu mdPnrfessions Codr)or TEMP.METER OR POLE INST. COMMERCIAL. a q ea Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION P� Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES �•pFNpNT ❑FOODSERVICE not more than fivhu.dral Dollars($500). Plot G ❑1,as.wner.1`i1epmpeny,army employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT will do ate work,and the swctom is not intended or offered for sale(S_.011,Business ❑OTHER' 43$ and Professions Code:The Contractor's Liceme Law does not apply to oa owner of OUTLETS-SWITCI IFS-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvomenla ere not intended or offered for NEW RESIDENTIAL ELECIR r sale.If,however the Thai lding or improvement is sold within one year of completion,the SQ.FE FLOOR AREA $/SQ.FT. ownewbuilder will have the burden of proving that he did oat build or improve for pur- poseofsala). - ❑ I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: convent the morel(See,7044,Business and Professions Cale:)The Comtmcmr's.— cause Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE who contracts for such Projects wish a comanctons)licensed pursuant to the Contractors License Law. PERMITISSUANCE' ❑ I am exempt under Sec. ,B&P C for this meson Owner Date ALTER-DRAIN&VENT-WATCH FA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 1 herchy affirm unite,penally of pe Jury one of the tollowing dachromioms: FTI have and will maintain is CenificateofConsent to self-insure for Workers Co.,.- DRAINS-FLOOR ROOF,AREA.COND. STORIES TYPE CONSTRUCTION salla.,u provided for by Section 37011 of the Labor Code.tar the performance of the I'er which-thin permit is issued FIXTURES-PER TRAP have and will maintain Workers Compensation Insurance,as required by Section 7W ofthe Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCCLGROUP APN My Wark<r' C n 1 f 1 ns�JJlI��pp�fggc0Pitt enol P�licyn Carver. Policy N., � GAS-EA.SYSTEM-OVER 4(EA) CERTIFICATE OP EXE. Ff10N FROM WORKER$' COMPENSATION INSURANCE GREASP4NDUSTRL WASTE INTERCEPTOR (This vection need not be completed If1hc permit is for one hundred dollars 1$100) BUILDING DIVISION FEES or less.) GREASETRAP PLANCHECK FP.R I certify that in the performance ofthe work forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. not employ any proms. an in any mner an as to became subject t.the Workers'Compete ENERGY IEE lanim laws of California,Date O Applicant WATER HEAT1iR WNENT/IiLECfR V {� GRADING FEE V1 NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTL'M?RF.ATING SOILS FEE a become subject y the Workers Cnm s or this n provisions of the Lehr Code,you mow � faMwith comply with such Provisions or this permit shall be deemed revoked. WATER SERVICE aQ UO CONSTRUCTION LENDING AGENCY NEW RISIDENTIAL PCMB. SQ.FT. PAID Dae Ramip,is 1 herebyaffirm that there consuraction s,i0lending agency forthe performance of P the work for which this permit is issued(Sec:309"1,Civ.Cd O Lender's Nan1e TOTAL: GUkl Leal Address TOTAL: I cannily that 1 have read this application and state that the above information is - - BUILDING FEE L. 0correct,lagree to comply with all city and county ordinancesond note laws relating to QTY. MECHANICAL PERMIT FEE U7 building colonsuction,and hereby autharizc representatives ofthlscity memterupon the SEISMIC FEF. above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE (We)agree 1a save,indemnify and keep harmless the City of Cupertino against liabilities,judgments.costs and expenses which may in any way amme against said City ALTER OR ADU TO MECH. PLUMBING FEE in consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE SOURCE REGULATIONS, AIR HANDLING UNIT(OVER 10,W CFM) CONSTRUCTIONTAX Milloomaid ApplicaMColnmctor Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant.,future building occupo.tstaremhaMle hazard..,macrivl TREATING UNIT GO IW,000 BTU) 4,defined by the Cupertino Municipal Gude,Chapter 9.12,and the Health unit Safely Cade,Section 25532(e)7 HEATING UNIT(OVER 100.000 BTU) \ ❑Yrs E]No VENTILATION PANS INGLE RHMD) PAID Date Receipt# Will she air Cicant or ntaminants t building occupby nt Hay Area Air malty car Maagemcas et BOILER-COMP(3111'OR 10(1,0(10 BTU)' •mit hazardous air amtamimlms ns AeFincJ by the Hay Area Air Qualify Management TOTAL. Uisu d7 [I Yes (]Na BOILER-COMP(OVBR I00,000 BIG) I have reed the hazard..,materialsAIR CONDITIONER ISSUANCE DATE requirtmenls under Chapter 6.95 of the Coli famin Health&Safety Cede,Sections 2550.1.25533 and 25534.1 understand that little NEW RESIDENTIAL MECH. SQ.FT. building doss not curenay havevtca.,fair it is my respomibilitymmaify the cecowl of -/F./) yr^ �� uirements which mu5l t 'sxuunce oft Cendicme of upon J 2i• J r shnnz ugrnt DA TOTAL: ISSUED BY: OFFICE �'