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30911 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 IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATIONSUBMITTALDAT OW AME: CA)r5 NE: CON 'OR' LA T x YNAME: IC NO: 0 N/C COST TROL# AN ICDENGI EER: 1JC NO: ADD ' •t ❑ CONTACT: PHONE: BUILDING PERMIT INFO ❑ COnsultant Fees Paid by Applicant(Initial) BLDG ELE PLUMB MECH ❑ ❑ ❑ LICENSED CONTE TO ECLARAI'I N QTY ELECTRIC PERMIT FEE I hereby affirm that I am licensed under provi.iom of Chapter 9(commencin ��z' p g R ID T ) B DESCRIPTION WO with Section](deal Divinion3nfthe Business and Professions Code,and my license in FSB in l all forccund eller �/•� PERMIT ISSUANCE C F /' / (/ ❑SFDWL El KITCHEN REMODEL Q UZ License Clan—`t—`^—Lic.N ti<1 Duo CrnVaaor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE Fpy A HITECPS DHCLARA : PANELS ❑MULTI-UNIT El STRUCTURAL Z O In Z 1 understand my plans shall be used as public reastds O Z- MODIFICATION UPT02MAMPS I�y E•W Located ProfessionalElINTERIOR El CHIMNEY REPAIR �-I OWNER-BUILDER DECLARATION 201-I010AMPS IMPROVEMENT y a Q 1 hereby affirm that am exempt from the Comracntrs License taw for the OVER 1000 AMPS El BATH REMOUR-lij�A 1 'ION x O L U following ancon.(Seen..7031.5.Business and Professions Code:Any city or wmny SIGNS ELECTRICAL El OTHER ��V E�O FN¢ which rrymor,a permit m cmnsoom,.alae,improve,demolish,or repair any s0ucmre mJ pnono to issuance.also requites me applicant for such permit to file a signed statement ' SPECIAL CIRCUIT/MISC. �-��-- f�EY that he is licensed pursuant to the provisionsofma Cnwcmr's License Law(Chapter 9 W_00 (commencing with5caiso—o of DM,,don 3 ofthe Business and Professions Court or TEMP.METER OR POLE INST H a e that he is exempt Iherefrnm and the basis for the alkgcJ exemption.Any violation of ❑DEMOLITION Section 90.31.5 by any applicant for a permit subjects me applicant m a civil penalty of POWER DEVICES ❑NEW BLDG/ADDITION not more than five hundred dollars S50% ❑TENANT FOOD SERVICE f=CLos mwneroflhc pmpcnY.nnny umpiny«s with wages as lhciLsnle congsensmion. SWIMMING POOL ELECTRIC IMPROV17MFNT yF will do me work.and the someone is not intended oroffercd for eiriSce.]W4,Business ❑OTHER 2 3 and Professions Code:The Contracmrs License Law does not apply to an owner of OUTLIRS-SWITCI LES'-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,prtvided that such improvements ort not intended or offered for NEW RESIDENTIAL ELEC R S sola If,however the building or imp..cousin is sold wiminone ycount compleaioq l he SQ.FT FLOOR AREA $/SQ.FI'. uwncr-builder will have the burden ofproving that he did not build or improve for pur- Fox mf sale.). ❑ I,as owner of the pmpeny,um exclusively contracting with licensed contractors to answer me project(Sec.7614,Business and Professions Code:)The Contactors Li. cense Law does not apply to an owner of property who builds or improve%thereon,and QTY. PLUMBING PERMIT FEE who convects for such pmjeccs with a conwaoq%)licensed Pursuant to the Contractor's License Use ❑ PERMIT ISSUANCE ¢i A I Ism enempt under Sec. ,B&NC for this rc»nn M ALTER-DRAIN&VENT-WATER EA) Owner Dam /JVygnpr N WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE IQr 7 Z�U • [have and will under Penalty calcofrjuryone ofthefollre following Jcdarminns: ❑ Ihave and will maiby Setion)Cale ofthe Lada)nt Cade,for for Worker'sme of the DRAINS-FLOOR,ROUEAREA.CON workf r provided for a Section 3]00 of the tabor Cede,for the performance of the STO uf• TYLLYdE,/CONSTRUCTIOP work have and his pewit is i Worker's FIXTUkES-PER TRAP rL11�INo ❑1 have and will maintain Worker's Compensation Insurance m required by Section 3]00ofthelavar Gee f thepzeformancn ofahe work for which this permit is issued, GAS-EA.SYSTEM-I INCJOUTLFTS OCC GROUT' APN My Wo Comp Insurance carrier and Policy ApNv ��[lo CAS- Carrier. Policy Nm:lx T Eq.SYSTEM-OVER4(EA) CENTIFlCATE OF EXEMPTION FROM WORKERS' COMP17NSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR (This action need rot be rompleml ifine permit is From,hundred dollars(8100) BUILDING DIVISION FEES or leis.) GREASETRAP I certify thd in the perfortwnce oOhe work for which this pemlit is issued,I shall PLANCHECK FEE .of employ any person in any momma sat as In become subject-to the Worker'Compcn- SEWER-SANITARY-STORM EA.2001.1'. ENERGY FEE Z cation Laws of California,Date Applicant WATER HEATER WNENT/ELECTR Z y NOTICE TO bj APPLICANT:If,all,,making this Certificate of Exemption,you should GRADING FEE a ? become subjecno the Workers mors,or Iti, f me labor Code,you mon WATER SYSTEM/fRFATING ❑ttthwith can th mcM1 provisions SOILS LLE � Q pyui pnrvivinns or Ibis permit shall be deemed revoked Wq'fF.R SERVICE a 'U Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID V0 IMr by which nn thattherei isued(See ionlending agency lisrthe perturtnanceal Dam RtteiptM U. H the work for which this permit is issued(Stt.309],Civ.CJ Leaders Name 0 W Lender's Addren TOTAL: TOTAL: f-' Q, 1 cenify sbar I have read$is a,hemiun and state that the abase information is BUILDING FEE IA caret.1 agree ht comply with all city and county ordinances and state laws relming to QTY MECHANICAL PERMIT FEE V Z buildingemistastion,and hereby madmirize repma odocxof Wstltym cnmrupon the SEISMIC FEE above-mentioned property for inspection paVp Cupertino urposes. PERMIT ISSUANCE FE (We)a• a bdemnily and harmless the City of against ELECTRIC E liabilities - m .a g .cis nJ eh tae T E c may in any way magainst said City ALR OR ADD MECH. o ymome, me I t ousm I. PLUMBING FEE fill s A LICANT N . T DS WILL COMPLY WITH ALL NON-POINT AIN HANDLING UNIT(TO IO,INq CFM) OURCERF,UI N MECHANICAL FEE AIR HANDLING UNIT(OVER IFRX CFM) CONST1tUC'1'ION TAX SignomerfApp VCmIIacmr spam EXHAUST HOOD(WMULT) HAZARDOUSM , IALSDISCLOSURF. HOUSING MITIGATION FEh Will the applicant orfumre bei ing:wcupunl atom or handle hazardous material HEMINGUNIT(FOIW.UWBTU) a defined by the Cupenin,Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 255321h)? HEATING UNIT(OVER IMM)BTU) ❑Yes 0N VENTILATION FAN(SINGLE RESID) PAID Will the applicant or fmure holding orea,co l use equipment m devices which Date Receipt M emir hazardous air conmminunta as defined brittle Bay Area Air Quality Management BOILER-COMP(3HP OR 100.00D BTI17 District? ❑Yes 7N BOILER-COMP(OVER 101M)BTU) TOTAL. I have mud the hazardous materials"pammmats under Chapter 6.95 of me Cali- AIRCONDITIONER Paris Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the ISSUANCE DATE building rocs mol currentlyhaventenam,mat it ism bilin Pau1` theoeco NEW RESIDENTIAL MECH. SQ.FT yce ofui Y y pant til'aM1e rnryiremmmt%which must he mel poor to issuance of u Certificate of Occupancy. Owner rr amhurized mgcnl Dute TOTAL' ISSUED BY: OFFICE