30345 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No 30 3.4 5
BUILDING DIVISION APPLICATIONIPERNUT PLUMBING—MECHANICAL
`I I UILDING PRO.BlCT IORNT'IPICNOON
BUILDINGADDRESS , SANITARY NO APPI.ICAI'ION SUBMITTAL OAT(
OWNER:SNAIM1IF/�: /�. .PHONE ONE RAMOR'S NAME: LIC ). ^�_[
it 7. .Gti /� G!/ p{1dNY !EL- 18664996 NIC CONTROLa
is 1MCHITECT/ENG ER: LIC NO: DRESS El
}if �/o¢7C, 5Tk9U&4 Qavr.
CONTACT. PHONE, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BIL�DG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE 't~
1 hereby ntrrm thin I am bcen+ed under prmeieonv of ChIiner 9(cnmmencing I I JOB DESCRIPTION
'y�y100 with Section70thi of Doisbm 3ofthe Boone,,and Profem...CL and my lmemen TFJ�
F,O full fnrceond effect PERMIT ISSUANCI'. jO RESIDENTIAL'
<UZU License Class Cie.k ❑SFDWL ❑KITCHEN REMODEL
NG0. Data Contractor APPLIANCES-RESIDENTIAL ❑ADDITION O PLUMBING RH.PIPIT
ARCHI'I ECTS DECLARATION ❑MULT1-UNIT ❑STRUCTURAL.
PANELS
Z O n Z i unJenlnnJ my pl,w shell he used ex publ¢records MODIFICATION
OZ^0 UP TO 20)AMPS ❑INTF-RIOR - ❑CHIMNEY REPAIR
�4F`; Unreason!Proteaaiunal 201-1000AMPS' - IMPROVEMENT
�E...4I a OWNER-BUILDER f DI he RATION
yC�6 � �I hereby ufrmt that 1 exempt from the CnntranOr'v[Jo emc Law for the OVIiR I WI)AMPS ❑BATH REMODEIIREPAIR CI DEMOLITION
)C3LU Winoutgreason.(Section 7031.5.Business and Pmfineons Code:Any city or county SIGNS ELECTRICAL ❑O'fHIiR
LL1 y O which term...a Noccu m comwa,.Iraq t{nproro,demoltvh,or repair any structure 4
y prior1.it,tntao,e,aHoregmrestheapplsent for such penman ble.signed statement SPECIAL CIRCUIT'/MISC. `(ell
> that he n licensed pursuant m the provisions ofthe Contractor.License Law(Chaper9
� (u,mrncmmagwab Section TX)0icf Drvuwn3 ofthe Business and Prom,%ions C,door 1'EMR MF:'IER OR POLE INST CNHWER COMMERCIAL,
❑
0.L2 K tbut he is exempt therefrom and the basis for the alleged exemption Any vm],tom of D DEMOLITION,
E Section]031.5 by any applicant for a l earn subjects the applicant to acivil penalty of POWF-R DEVICES
FZY not more than five hundred dollar,($Slltl)." ❑TENANT ❑FOOD SERVICE
,SpQ ❑Liumacrafthe pmpeny.or myc.pl.,.,with wages asthcirsolecompensation, SWIMMING POOL ELECTRIC � I IMPROVEMENT
gyp, will dm the work,and the vtorture to not intended or n0ered for sale(See]DN,Bivmclx f OTHER
'I
W aad Profcvvmm Code The Comoscmry License Line does not apply m to owner of I OUTLETS-SWITCHES-PIXTUIiES - 7/V -
propeny who build%or improves Hereon,and who does such work himself or thmug6
his own employees.pmvded that such tmprovemenl+urc no mended or nHefcd fat NEW RESIDENTIAL E1.17cat SQ Ff
sale If,however.the budding or improvements sold wtthm one year ofevmpleoon,the SQ.FL BOOR AREA $/SQ FT
covaer-minder will have the burden o1 proving that he did amt bull or tmpmve for P.,
❑ L m owner mf the pmpeny,.m exclusively ommuseng with becnsed cmaractors to TOTAI�Q 'y�
nrammor the project(Sec.7044,Rosiness nnJ Pndexvons Code I I he Cuntmoor'+I,- e
wrise Law does not apply to an cameras property who builds onvcstswomm and QTY. PLUMBING PERb11T FEE
mpro
whit Inr amb Pealed,with a ttmmacun(v)Iodised pursuant o the Contrdvml+
License I.L. PERMIT ISSUANCEi •�'S.� '•
I am exempt under See ,B&PCfwaEsrcnon SFP 2 7 MR
Owner Dan- ALT I7R-DRAIN&VENT'-WAIPR MA T VALUUAA DON
WORKER'S COM1-17NSATION DECLARATION BACK FLOW PRO'TECI'.❑FVICE I , viii/ - iCV( 'J' •G11Mu
• I herehy affirm under penalty of penury one of the lollowmg declarations' X
❑ lhave and will mmu'ina Cemficute of Consent ho self-insure fur N'orkely Cnmpen- I DRAINS-FLOOR,ROOF AREA.CONU I STORIES TYPE CONSTRUCTION
nwimn,as provided for by Seetinn 3]00 of the Lahur Cal{ka the perlonnurec of the
work for which this pennn is timed I FIXTURES-PERTRAP, '
I have and will mmntnn N'nrkers Cnmpensannn Inmmnee,es regwred by Section - --I -
3700 aline LaborCoJe,for the performance at the work lot whohihts permit is i»oed. IGAS-EA SYSTEM-1 INC.4 OU'TLE1S OCC GROUT' APN
My Wodels n n Insiion rand l'ohcy number�fv.
CyW �f17F.to�JU//Yc cl'obcy No 'j-�'Y OIC jy9 GAS-EA.SYSTEM-OVER XfEA)
CERTIFlCATEOF EXEMPTION FROM WORKERS' GREASFJINDUS'TRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BA DI IN FCBS
(This ucuon ne,d not be completed tithe permni+lor one hundred Jidlars($11)(1) GREASETRAP. ......eee 'r -
orless) I PLANCyIpKyryv _ � i••• �b
Toy any that in pert cancer ufthe as wodlor whahthtspernwiv.....'...... SEWER-SANITARY-S'IDRM EA 200 FT. 8/{-tE _ i �^
not employ any person m any cancer az e,taome subject to the N'orkeri Compery _ CNIiR I ( )
Z Vh mn Lax+of Ca n1omm Date -
-ZO Applicant IWAIER HEATER W/VF.NTFLFCTR
PP —
t cant GRADING PEIi
y became NOTICE TO APPLICANT:If.after making this Qisions a(h Exemption,you should NgTER SYSTEM?REATING -
'[ ?
became wompm the Washes Cmnxor In,, provisions ofthe Labor Code,you neat t SOILS FEE
4Q 4nNwnh comply with mchpmnnnn.or thrcpermit shall be deemedrevitked HATERSERVICIi
7 'Z CONS'I RUCTION LENDING AGENCY , NEW RESIDEN I IAE PLMB SQ.FT - , IPAIU X
U O (hereby union'hat is a construction lending agency for the performance of Dee Rc{eq
L) the wok for which lhix Pemnl to¢eueJ(See 3097,Ctv:C.1 , >�L �)klDY 1J.
Leader,Num-LU Ismdelvnedre" TOf`RC�O.qJ �. .1�A
V! e I c agree that 1 have with this y and county and state shut me show inhtnnation_ Bl11LDING Rill p-
U �V1 cmrrect lagreeottmmplywithyamh end nrdmenc es and cstate lax'erupongm (QTY. AIECIIANICAL PERMIT FEE
huildingenmwchnn.imdhruby ewhnnn•repreeanimecv ufthucny tuenterupnn the'
�• / SEISMIC FEE 7 2Q
ah've-mcnuoned property for inspection purposes PERMIT ISSUANCE 3.,3 ,JQ •O/1�,/rj
0,10 agree m x.se,mdcmmty and keep harmless the City of Cr,rur.-gdosh ELECTRIC FEE Ord V J
'liehtbucv,).dgmems,ants andexpenscv whmh maymany way accrue ngninst smJ City ALTER OR ADD'ro MUCH. PLUMBING Fl3EI
consequence of the nothing of this permit v
APPLICANT UNDERSTANDS AND WILL COMPLY WITII ALT,NON-POINT AIR HANDLING UNIT(10 HL1X)l1 CFM) - �'PLUMBNGFE FEB
SOURCE REGULATIONS.
' ,�.��' / - �-7 �y� AIR HANDLING UNIT(OVER III,IXXI CFM1IJ CONSTRUCTION TAX
/ Signatutcof Applium/Contra or Date EXIIAUSTHOOD(W/UUCT7 (HOUSING MITIGATION FEE
IIAZAR OUti M11ATIiRiALS DISCLOSURI3
Will Ne.pp.....or fuoreboldonacupant,tommlarim! hazvdmasmatend HEATING UNIT(TO 100.000 BTU) -
us dermal by the Cupcninm MrmeP,l Code.Chant,9.12,end @c Health and Safety
Code,Section 255321.)" - FIRM INC,UNITtOVER 100,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RBSID) IPAIU Dom Receipt
Will the applicant or furore budding receptor me No ptrecto or devices which I
con huaardom av cnmammnms m dcrneJ hy,the Bay Arca An Quit ity Management (BOILER-COMP(3HPOR 100,000 BTU) y
IOTA
Utsvmt] BOILER-COMP(OVER 100.000BTU)
I have real the hazallous materials AIR CONDITIONER ISSUANCE DATE
reymmmcm%under Chapter 6.95 of the Cali.
furor-Hedhh&Safety Code,Section,25505,25533 unit 25534 1 unlcnwnA that if the I NEW RESIDENTIAL NIECH SQ.FT. I
Budding d«s no currently have a tenant,lhatan my rc+ptmvibdtty ice notify the n r....
" of the requirement,w hash muv ho mer poortntsvuearc oft Cenifieme ofOo.,ncy.
Owner or authorized agent Dee TOTAi��p-
SSUEU BY
OFFICE ' '