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99110120APPI IP.ANTTm Flu_ IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY eqvI 101 2. 0 'CIT4 OF CUPERTINO BUILDING - ELECTRICAL CAL BUILDING DIVISION APPLICATION/PERMIT PLUMBPROJNG -ECT BUILDING PROJECT IDENTIFICATION TIDENMECHANIFIC IM BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE OWNER'S NAME: P N: NAME: LIC NO: 1\R NIC C NTROL# CL --in-AkLCOM,RACfOWS ❑ RCHITECTIE GINEE LIC NO: ADDRESS: CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant (Initial) BLDG ELECTPLU MECH -� ❑ � WJ E5- QTY. ELECTRIC PERMIT FEE .I ENSED CONTRACTOR'S DECLARATION 1 hereby affirm mat I am bcenaw under previsions of shaper v (commencing JOB DESCRIPTION PERMIT ISSUANCE wire Smtion ID0) of Division 3 of Ne Business and Rofessions Code, end my license is in full fo e . tfIf I_ RESIDENTIAL: ❑ADWL O KITCHEN APPLIANCES -RESIDENTIAL License Limu Date GonlDECL ARCallheue DECLARATION 1 understand my plata shall be used as public records []ADDITION ❑PLUMBING RE -PIPE [I MULTI -UNIT [I STRUCTURAL MODIFICATION El INTERIOR ❑CHIMNEY REPAIR IMPROVEMENT (] SWIMMING POOLS PANELS UP TY)20 AMPS Licensed Professional 2DI-1100AMPS OWNER -BUILDER DECLARATION affirm I hereby arm that I am exempt from the Contractor's License Lew for the following mason. (Section 7031.5. Business and Professions Cwe: Any city or county which tequires a permit nh cmruroct, eller, improve, demolish or repair any stmcturc ❑ BATH REMJQVREPAIR (vx].��DEMOLITION OTHER ` 'L n OVER UIOAMPS SIGNS ELECTRICAL SPECIAL CIRCUITIMISC. QLD promo its issuance, also tectonics the applicant far such permit to file a signed statement that he is licensed pursuant to me previsions of the Comesctofs License Law (CTapler 9 (commencing with Severe 7")of Division 3 of the Business and Professions Corsi) or TEMP. METER OR POLE WST COMMERCIAL: mat he is exempt therefrom and the basis for the alleged exemption. Any violation of ❑ NEW BLDG/ADDITION ❑ DEMOLITION Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of MWER DEVICES []TENANT ❑ FOOD SERVICE not mom than five hundred dollars Who). E] 1. as owner ofthe popery, or my employees with wages as their sole compensation, will do the work, and the stmcturc is nut intendedorolicmt for sale fSm. 7044, Business IMPROVEMENT 00D OTHER SWIMMING POOL ELECTRIC and Professions Cwe: The Contractors License Low dues not apply to an owner of OUTLETS - SWITCHES - FIXTURES NEW RESIDENTIAL El ECIR SQ FT. property who builds or improves thereon, and who does such work himself or through his own employees, provided that such improvements the not morainalor offered for sale. If,however, the building or improvement is sold within one year of completion,the SQ. FT. FLOOR AREA $/SQ. EL owner -builder will have the burden of pmvi all that he did not build in improve for par. ' pose of sale.). I, as oweer of the property, a exclusively confessions with licensed coum cmrs to TOTAL: cense Lo thees not (Seo.]f004,Business and ftyProfessions buiCwe:)'The Cs thereon. nd cense Low does not apply m an owner of propony who builds or improves thereon, and QTY, PLUMBING PERMIT .FEE whocontescu for such p jecB wimamnwmorts)licensed pursuom to the Cnnwdors PERMIT ISSUANCE Limn. Law. ❑ Ism exempt under Sec. B & P C forthis reason Own U ALTER -DRAIN & VENT- WATER (EA) VALUATION WORKER'S COMPENSATION DECLARATION PACK FLOW PROTECT. DEVICE, I hereby ill under penalty of perjury one of the following dMmatiu mo a lhave and will for Se Cion 37 a ofConvern toLatin sodinsurefor Worker's Camper- smirk, as provided forma Section 3]00 of me Ivbkr Code, forme perfoman nce of the DRAINS-FLOOR,ftOOF, HEA, GOND ST(IRIES TYPECONSTRUCTION work which this pemtit is issued. FIXTURES -PER TRAP QQ 1 have ew will maintain Worke(s Compensation Insurance, as required by Section have 110 ofthe huhrrCwe, forthc perthe amen and wick fur which this permit is ismed, My We et omplys n d Policy number �I�G Carries Policy No.: t }�.,,Q OCC. GROUP APN GAS -EA. SYSTEM -1 INC.40UTLETS GAS -EA. SYSTEM -OVER 4IEA) CERTIFICATE O EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thissecdon newkm hecompletedlrthepermit is fmonehundreddo1OumlS10) m less) GREA5E NDUSTRL WASTE INTERCEPTOR - DIVafSION FESS ;; GRI3ASE TRAP EC FEU6DING PLANCHECK FEE I certify that in the performance of the work for which this perndt is issues, l shall Workers' not employ any person in any manner so as to become subject to the Compen- SEWER - SANITARY - STORM EA. 200 FT. ENERGY FEE wSruR HEATER WNENVELECI'R GRADING FEE serum Laws of Celifomia. Date Applicant NOTICE TO APPLICANT. If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Code, you most WATER SYSTEMOREATING SOILS FEE forthwith comply with such provisions or this permit shall be deemed revoked WATER SERVICE CONSTRUCTION LENDING AGENCY I hereby affirm that mem is aconstmetion lending agency frrthe pertrrmance of NEW RESIDWFIAL FUND. SQ. FE PAID Date ReeeipU the work for which this permit Is issued (Sec. 3099, Civ. C) Lenders Name - TOTAL: larder's Address TOTAL: - BUILDING PEE 1 certify mat 1 have rend this application and suite met he above information is QTY. MECHANICAL PERMIT FEE correct. I agree to comply with all city and county me finances oun to laws relatikg to building commuctlon, and herby iummite rcprewmatives of this city to enter upon the abov>menooned property for inspection purposes. agree to save, indemnify and keep ham less the City of Cupertino against SGI FLPI PERMIT ISSUANCE liabilnies,judgments, costs and expenses which may in any way same against said CityUMBINGFLEin consequence of the granting of this permit ALTFiR OR ADD TO MECH.APPLICANT j1,n;E1ECAft6(We) AIR HANDLINGUNIT(TO 10,000CIM)REGULATIONS.� UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT NI L E1 HANDLING UNIT (OVER IgaO CFM)CONSTRUCf10N ��AIR TA% Signature oTApphcav mwb, Dade HAZARDOUS MATERIALS DISCLOSURE EXHAUST HOOD (W/DUCT) H UO SNG MITIGATION FEE Will the applicant or future building occupant store or handle haurdous mmenal HEATING UNIT (TO 10,000 BTU) as defined by the Cupertino Municipal Code, Chapter 9.12, in the Health unJ Safety Cwc, Ssfion 25532(a)? L] Y" Will the applicant or future building occupant use equipnmot or devices which mit tremendous air contaminates as de inw by fine Bay Arca Air Quality Management HEATING UNIT (OVER 10.000 BTU) PAID -' Date Receipt M VENTILATION FAN (SINGLE RESID) BOILER -COMP CHPOR 10,00 BTU7 . Q TOTAL: 1� O BOILER- COME (OVER 000.0010 BTU) Disalsi? ❑ Yes AIR CONDITIONER 1 have real me hauNous materials requirements under Chapter 6.95 of me Cali- fomia Health & Safety Code. Sections 25505. 25533 and 25534.1 understewl mm if the build' of cuncn0y have etetum, mat it is my responsibilitymnwfy the amupanf so ISSUANCE DATE / NEW RESIDENTIAL MECH. SQ. FT. aft c to hi h must be met prior to issuance tree teed kv ��r�� Ownerora zcdageutt ISSUED BY: B TOTAL: OFFICE