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S 2900 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONL� CITY OF CUPRRTINO HUI IDING.ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATIONMERMIT v1AMmNG-h4NMENI IFIU - - BUILDING PR(IJ I:CT IIIx:N'IIRICA'I'ION SANITARY NO. AI'PLICA'110N SUBMITTAL DATE BUILDING ADDRESS, to/o til l '60b 9 OW NER'SNAMH: Pill CO�NTJ2ACfOR'S ;ME N LIC NO: g NIC /] CO ROhM ARCHITEC IFN01NEER. LIC NO. I D O Ns �� � ,a'/, ❑ 1 2 78 FDmvfx-W=" PHONE: `� BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH 9Zo -ofo`Z. 2' ❑ ❑ �LICENSED CONTRACI OR'S DECLARATIONQTY ELECTRIC PERMIT FEEJQB DESCRIPTION a10rn(bat 1 am licensed under provisions of Chapter 9(commencingZ• 0(1of Division 3nrmc Businessand Professions Code.and my license is RESIDENTIAL:() PERMR ISSUANCECFl-lieu. y ❑SFDWI. ❑KITCHEN REMODEL <—U -e L(1 Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE yG2 Contract ❑MUf.TI-UYR El STRUCTURAL ARCHI'I'[CTS DECLARATION PANELS ~v=iani Z I to dersmnd my plans shall beused n public records MODIFICATION cZ-G UP TO 100AMPS ❑INTERIOR ❑CHIMNEY REPAIR P:4LEZLicensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS �y ; OWNER-BUILDER DF.CLARA'I'[ONOVER!"AMPS ❑HATH REMODEL/REPAIR ❑DEMOLITION ffim tY Q 1 hereby at that I an exempt from the Contractors License Law,for the ❑OTHER Xd V following reason.(Section 7031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL which requires a permit to construct.utter,improve.demolish.or repair any surcture �L�o Prism L'' nca ul: q e'Ihe PPI t1 such Permit II .g d.l'Iement SPECIAL CIRCUIT/MISC. �pd;!(y tnathe licensedpursuantt th provisions Ito e t or License L (Chaptery OOMMP,RCIAI: ly..GC (co n' b bh Seu t71XN11 fD'Jct x ofth Inasiruss andP f:.' Code)or TEMP.METER OR POLE INET. ma he is esempl Therefrom amt he bads brother mingled cxemrl nn.Any vmlmmo of ❑NEW BLDG/AUDITION ❑DEMOLITION X hL Sermon 90031.5 byany applicant sur a permit sort the applicant to a civil penalty of POWER DEVICES ;KENANT ❑FOOD SERVICE [[[4---1••• t more thin live hundred dollars($5(d). IMPROVEMENT EJ 1.as ownernfthe 11.1cl.rr,my employees with wages av lhrir wla comlamolion, SWIMMING POOL ELECTRIC F El OTHER will do the work,and sl lb lire structure is not intended loolorer,ale(See 7144.Bovil ly m and Professions Cale:The Cmnnowtor's License Law Joos not apply Tr Ire owner nl OUTLETS-SWITCIIF.S-PIX'I'ORES property who hit ilnprovca thcram,and who dors xuch work hinxsalf in Ihrnugh his own employees,pmvidcd that such insprtwc.ans an not Inwodal or ancrod for NEW RINSIDENI[AL ELEC'TR SO IT. sale.If,however,the mildingor improvement ishold widrooncyeurofcnmpletim,the _ �Sq.FWM;00RAkEA, $ISQPL . builder will hove the burden o1' ha(the did nal huild or ire forput- Plate pmdl„g parer pm- ID puss of al If 1: 1,os owner of the See.7 y,am sines and Professions with:)The convectors - construct a the esoproject(sec.t an Nadirs and d, hu ha Codcp Tim Conaacton,Li- clause i- c o cLaw ontrdoeanmarply.ts itharmfpmano wire se'd purrimproves thcrerctory and QTY. PLU ER T FEE Ap(1 2 2 1999 who eommns for such projects with n contr�anr(s)licensed pursuhnf m the Contractor f f� License Low. PERMIT ISSUA E lam exealfQtnder Sm. ,R&P C for this reason ss66�� ALTER-GRAIN&VE T. 7 VALQATWN Owner Onte WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE D Q� 0 1 hereby affirm under Penalty of perjury one of the following declarations: vv ❑I have and will maintain a Cerrificafe of Cmnnenuo self-insure for Workers Council DRAINS-FLOOR.BOOR AREA,COND., S RIES TYPE CONSTRUCTIOI .satlon,as provided for by Section 3710 of the Labor Code,for the performance of the walk for which this pe.'It is ishurd. FIXTURES-PF.R TRAY ❑I have and wi mai tum Worker's Compensation Insurance,as required by Sell OCC.GROUP faP?L� 31W ofth Le Cod for the unaeoflnewnrkfn, 'ch I ”Itemtitistsord. GAS-EA.SYSTEM-IINC.40U1'LITS y hly Wnrkc in u ` 'eclmr, dYm nlicy r 6fE / GAS-EA.SYSTEM-OVER 0 Cattier. olicy No: CERTIFICATE 'EXEMPfION/y(1RI JjR 07 GREASMNDUSTRL WASTE INTERCEPfON COMI'PNSATION INS{4fAA�V,�!((�V �II�> BUILDING DIVISION FEES ('llsiss«tion need nmhcomplelad if the permit ix foronehundred dollen(EI W) GREASETRAP PLANCHECKFEE or Ir".) I I cariry that in the performance of the work forwhwit this permit is issued,l shall SEWER-SANITARY-STURM RA.20)FT. not employ any person in my manner so as tohector subj«Oo the Workers'Compen- ENERGY FIiE OZ xatirn laws of Califomir Date WATER HEATER W/VENT/F.LECTR GRADING FEE z Applicant to NOI'ICF.TO APPLICANT:If,after finking this Cenificae of Exemption,you should WATER SYSTEMOREATING SOILS FEE [.•. I"I become subject.the Worker's Compcmation provisions of the Labor Code,ynr must a H forthwith comply with such provisionsor this permit shall be deemed revoked WATERSERVICE CL Q CONS'TNUCf10N LENDING AGENCY NEW RESIDENTIAL PLMP. SQ,F1'. "ID Upk lotwyd'fimOh Permit i issued( eetinn len ding agency for the performance of F the work lar which Chia permit is LrmeJ lSce.31X)7,Civ.C.)U Lenders Name TOTAL:UIsodursAAdre.r 0•I I certily that l hove read this application-all swat Phot(he above information is to crrecl.I agree it)comply with all city and county oninances:ml,state lows'drung to QTY. MECHANICAL PERMIT FEE SEISMIC FI U building ennsmmtion,nnd hereby onhorucreprcaemanwesof do'city,In enterop'm the above-mmntiomd property I'll inspection purPrre", PERMIT ISSUANCE r S© ELECI'I C (Wa)ngu Ir save,ru ennily anal keep hanuleha he City of Cuperlmn agaimt Ilobililieu.judgmcon.antsand rgmnsm w,ichmoy in any way nccmmmitoladd City ALTER OR ADD TO MFAEI. PLO I{I 'E in come'newe of the gmmi g"I(his front APPLIF,A,I01 UNDE SEE DS NO WILL COMPLY WITH At.(,NON-POINT AIR HANDLING UNIT TO 10,000 CFM) MI H, 'AI 'E f SOU REGULAI' t AIR HANDLING UNIT(OVER IggN)(NMI CO S' UCfI( '1'A% Signature ofAp iwm ant actor Dala EXHAUST HOOD(W/DUCT) HODS GMITIGATION FEE IIA7IARDOUS MATERIAIS DISCLOSURE. Will the applicant or future building occupant amreor handle Lai Mous.-aria] HEATING UNIT TO 10(1,1X0 B'IV) as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety HEATING UNIT(OVER 100.010 B'I'U) Code,Section 25532(0)! El Yes tfNo VENTILATION FAN(SINGLE RESID) PAID Date Receiptp Will the applicant or future building sccupant use equipment or devices which BOILER-COMP(3HP OR 106,00614) emit haramous air conundrums as defin al by the Hay Area Air Quality Manageourn OTAL District^ _/ BOILER-COMP(OVER 100,000 BTU) ❑Yes Nu AIR CONDITIONER ISSUANCE DATE 1 have real the h ode S s noes 2!55 requirements order Chapter 695 of the Cali- formaHel gthoes&tema Code a tion 25505.25533am eal35534.I in that the NEW RESIDENTIAL.MECH. SQ.IT. Q naaamP� Icmrtnn oven in foal itL.r real'rmxinirtym nr4ry me occupant � �� 1 IV'torriemetns a t prior to issuvnce of a Certificate Of Overflow, Owner or ambo ed agent Da¢ I OT I f ISSUED BY: OFFICE