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31220 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. LL 3 r� 2 2 O BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL' 311 BUILDING PROJECT 1 NTIF CATION BUILDING ADDRESS: - - - - SANITARY NO. APPLICATION SUBMITTAL DATE D OWNER'S NAME: PHONE: NIC CONTROLp CHITECT/E:NGINEER: LIC NO: ADDKE,S.' L 'N✓fsJJ i o� oESFSHvE Las 4s- St6s a BUILDING PERMIT INFOC :666`Q ❑ Consultant Fees Paid by Applicant(Initial) BLDG 'ELECT PLUMB - MECH LICENSEDCONTRACTOR'SDECLARATION QTY. ELECTRIC PERMIT FEE a I hereby atfinn that l am licensed under provisions of tTapmr 9(commencing JOB DESCRIPTION Cz with Section 701dDivision 3ofthe Business and Professions Code,and my license is RESIDENTIAL: OO in full force and effect. PERMIT ISSUANCE WF ❑SPDWL El KITCHEN REMODEL s�.ZV Litems Class Can APPLIANCES-RESIDENTIAL IOADDITION ❑PLUMBING RE-PIPE to Q 6 Date TS DE er ARCHITECTS DECLARATION ❑MULTI-UNIT []STRUCTURALz p o,z understand!I understamy plans shall be used as public¢cods PANELS - MODIFICATION OZ`S UP TO 200 AMPS ❑INTERIOR p r OCI CHIMNEY REPAIR 24411 LicensedPofessional 201-I"AMPS MPROVEM NTA OWNER-BUILDER DECLARATION OVER 1000AMPS [I BATH ODEOREPAIR ❑DEMOLITION LL 1 hereby affirm that 1'am exempt tram the Corm ccer's License Law for the �S p pts falmsingreason.(Section 003 L5,Business am Profession,Coda Any city ar county SIGNS ELECTRICAL �OTHaa� Yu-11 C which miiats a permit e.comwn.Wer,nations,demolish,or.,it any structure prinrm its issumce,oleo nyuirce the upplicum for such permiuo fleasigned stamment SPECIAL CIRCUIT/MISC. ,S.0 a� mat icemN pSection 0Ne pro visions.(the Contractorsess nd Professions (Chapur9 _ '/ (commencingtheisede i,thereinarn it of basis (.,.h thec,eaintionda e.A.vi Cartel or TEMP.METER OR POLE INSL 11 6 n C Natio is,ramp(therefrom and the cis for the alleged exemption.Any vitiation of ❑NEW BLDG/ADDITION EMOLITIOI yx fL Section 0031.5 by any applicant forapemtit subjects the applicant mvcivil penalty or POWER DEVICES Elzy ANT OD SERVICE y rat more than Eve hundred dollars(5500). MPROVEME C]1,as owner ofthe property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC �. willda the work and Leonard.is not intradediruffined mrsale(See.7044.Business OTHER and Professions Cale:The Contractor's License Law does not apply m m owner of OUTLETS-SWITCHEFFI ropeny who builds or improves theater,and who does such work himself or though his own employees,provided that such improvements meant intended ur uffered far NEW RESIDENTIAL IrtlieSQ FT. sale.If.however,the building or improvement is mid within one yearofcampletian,the SQ.FT.FLOOR AREA S/SQ.FT. owner-builder will have the burden of proving that he did not build or improve for put- 1.as owner of the ut-1.asownerofthe(Sm.70am 44, Business contracting with licensed am ones to TOTAL: crew La the es not apply to an Business aN property no bo CNet The Contractors Li- V/ , who contracts fix suchplymts itha ofpmpeny who licensed orimprovesto thereon,and QTY. PLUMBIN P IT PEE ' who commcu for such projects wimacommcmrts)licensed pursuant mthe Commemrs License law. I PERMIT ISSUANCE ❑I am exempt under Sec. ,B&P C for this reamn Owner Data ALTER-DRAIN&VENT-WAT (E UATI WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.I)EVICE I hereby affirm under penalty of perjury one of the following declarations: ❑Iheveend will maintamaCerdfcauti Coment to self-insurefor Workers Compce- DRAINS-R,OOR,ROOEAREA,COND. .lion,m powidW for by Section 37W of the Labor Cods. erforma e,for the performance of the s STORIES TYPE CONSTRUCTION work fur which Ifds permit is issued. FIXTURES-PER TRAP 1 have and will maintain Workers Compensation Insurance,as requited by Section 37W of the labor Code.for the performance ofthe work lot which this permit is issued GAS-EA.SYSTEM-1 INC. 5 OCC.GROW APN My War Co do him toner n l Policy nbeer ' Carrier:Win;° P, only No.: ,32- 9 � GAS-EA.SYSTF.M.OVER4(EA) CERTIFICATE F XEM ONFROMWORKER ' COMPENSATION INSURANCE GR WASTE I E R 1 IN rDIVISION RTES (This tretionneednotM completed lithe permit is(.,are hundred dollars(SIM) GREASETRAP or lis.) PLANCIIECK 2 /' I certify that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W IT. AdKint employ any per on in my manner so as to become subject to the Workers'Comped- ENERGY FEE uon Laws or Califomiv.Drat WATER HGATER WNENT/ELE R Applies.( GRADING FEE rNs NOTICE TO APPLICANT.If,after making this Ccnificate ar Exemption,you nhnuld WATER SYSTEM,"pil I become subject to the Workers Compensation provisions ofthe Labor Cal you must SOUS FEE LaLI fnnhwim comply with such provisionsmmis permit shall be deemed revnkN. WATERSERVICE Q � z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. SQ,FT PAID Date Via p W. 0 work which thi that there issued(See.30 len ding agency for performmce of / the work for which thin permit is issue)(See.3091,Civ.CJ Q U Lenders Name L: WLender's Address TOTAL: 1 teary that I have read this application and sum the.the above information is ING FE lZi mrect.I.'m ,comply with all city and ammyordinunce,ondstme laws relvtingm QTY. MECHANICAL PERMIT F O U building construction,aN hereby authorize op¢sentatives of Nis city to enter upon the SMIC abovdmemhard property far inspection purposes, PERMIT ISSUANCE (We)agree to save,indemnify end keep harmless Ne Cityof CLpenino agvast 7HOUSINGMIT liabilities,judgments,cans and expenses which may in any way occur,against said City ALTER ORADDTO MECH. MBING FEE in consequence of untingofthispediAPPLICA 'RSTANDS AND COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO 10,(00CFM)SOI) -REG' (IONS. CHANICAL FEAIR HANDLING UNIT(OVER 10,(00 CFM) NSTRUCTIO AX ngmano.fApplicanVConuacmr Date EXHAUST HOOD(W/DUCT7 ATIONFEE / ERIALS DISCLOSURE Will the applcmt orfuture building occupant store or handle hazardous material HEATINGUNI'r(TOIW,WDBT Code.Smile.25532(.)2 HEATING UNIT(OVF.R IW IXgI U)❑Yrs ❑No D - VENTILATION FAN(SI .RESID) Dem R 'eipt M Will the applicant or future building occupant me equipment or devices which BOILER-COMP(3HP OR 103,"BTU) •mit hazardous air contamivu res defined by the Bay Area Air Quality Management 'TOTALi _ j Distrio2 - ❑Yes ❑No BOILER-COMP(OVER I WAW BTU) I have mod rhe hamNous materials na,iatnimms under Chapter 6.95 of the Cut- AIR CONDITIONER ISSUANCE DATE moral.Health&Safety CNe.Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.f.. building deer act currently have a Reason.that it is my respmsibility to nosily me occupied of me requirements which must he met prior u,issuance of o Certificate of Occupancy. Owner or,authorized agent - .' Doe TOTAL: ISSUED BY: OFFICE �+gP�C�L �� --��