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S 4401APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDNG - ELECTRICAL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL S 4'401 6UILDING PROJECT IDENTIFICATION' ° s. BUILDING ADDRESS - Loa " 2 ��x. SANITARY NO. APPLIC IONS BMITTALDATE 7 8 OW ER'S VIE: PHONE: 1 rnV CO TRA By AME: LIC NO: NIC IC-ONTR N , ❑ . ILL ` �/ C11 /ENGINEER: L C 0 ApDR S.: 1' I G / 1 /\ �f CONTACT: PHO E: .r -••'BUILDINC'PERMIT,INFO alb r/ (_AY-+/rlLIC/EENSED ❑Consultant Fees Paid by Applicant (Initial) BLDG ELEQT PLUMB �Mf.•EsC�sry /^y��'— •1Gaj- "'—'� CONTRACfO DECLARATION 1 hereby amtm [ba[ I am IicenaeJ anile prsav'siona of Chnp[er 9 (commwoing 1 QTY. ELECTRIC PERMIT „ FEE I i.. t ,10B DESCRIPTION with Sectmd7000)mf Division 3 ofthe praises, and Professions Code,andmy license is in full force and effect License Class Lic.N Date Commemr RESIDENTIAL, ❑SFDWL - ❑ KITCHEN REMODEL ❑ADDITION LI PLUMBING RE -PIPE ❑MULTI -UNIT ❑ STRUCTURAL MODIFICATION PERMIT ISSUANCE �4-640 APPLIANCES - RESIDENTIAL. d ET'SDECLARATION Cax ow as PANELS UP TO 200 AMPS ❑INFERIOR ❑CHIMNEY REPAIR Lcen A r assonal201-IOMAMPS O ER-BUILDFR DECLARATION 1 hereby affirm d . [ 1 am exempt from the Contractor's License Law for the following reason. (Section 70315, Business and Professions Gide: Any city or county IMPROVEMENT E] SWIMMING POOLS ❑ BATH REMODEIIREPAIR ❑DEMOLITION ❑ OTHER OVER 1000 AMPS SIGNS BLOC'I RICAL which requires a permit to consumer, alter, improve, demolish, or repair any structure ' ,if red, ismorec..sn requires the appltoam far such p ornitio file aligned statement SPECIAL CIRCUIT/MISC. that he is licensed pursuant Ire the provisions of the Cmara diev License Law (Chapter 9 TEMP. METER OR POLE INST. ❑ '"'j - DGIApO1TY ❑MOId (commencing with Station 0000) of Division 3 of the Easiness and Professions Code)or that he is exempt therefrom and me basis for the alleged exemption. Any violation of POWER DEVICES Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of n LLQ—� ❑NODS not more than five hundred dollars ($500), C]L as owner or the property. or my employees with wages as their sole cmmpensmiun, will do the work, and the structure is not intended or offered for sale (See, 044, BusineseL1 Professions Code. The Contractor's License Lew does no apply to an owner of 1 Eland VEMENT SWIMMING POOLELECI'RIC OUTLETS -SWITCHES -FIXTURES © V property who builds or Improves durrin, vnd who decision work himself or through _ his own employees, provided that such improvements are not intended or offered for sale If, however, the building or lmpmvemem is sold within one yearor comp]aian, the wnervbuilder will have the burden of proving that he did not build or improve for put- NEW RESIDENTIAL BLECTR S6 PP, Q. FT FLOOR AREA O'y . $/S.PT. pose opiate.), ❑ 1 f me property, am exclusively connecting will Ih licensed codract lo AL:' como- 1[h p j t(S 7044 Business and Pmfe. Code )The Connvemr L nseL d (afPlyr n fp pe ly h h'Id or lmpmves lherwn J r� - - - s QTV.. PLUMBFN IPE IT- '- 4'. FEE whoa nwcisfirsmhpnjestswth(air unr(s)Icenaul pursnnvno[he Convvemrs s's' % PB RMI'T ISSUANCE License Law. ❑ I am exempt under Sea , B & 1' C for this reason - DRAIN&VE -WATT, Owner DataAITI?R ,VALUATION O O WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty off jury one of the following declarations: I hmcatrd wtllmaimatna Certificate cf Cnnsenuo self -insure for Worker's Confer- smion, as provided for by Section 3100 of the Labor Gide, for the perfomtznce of the ark for wbichthls panni( is Issued. ❑ 1 have and will maintain Worker's Compensation Insumnm, as requital by Section BACK FLOW PROTECT. F URAINS-fE00R, ROOF. t�s 5. STORIES TYPE CONSTRUCTION it -A) FIXTURES -PER TRAP 3100 of the Labor Cade, for the perfnrmnnce of the work for which this permit is issued. My Worker's Compensation Insurance Perennial Put icy number me: Cartier: Policy No.: GAS- EA. SYSIE.M-IINC.40 L'ES'S OC UP / APN 3k�-a2 �01 GAS-eA. SYSTEM- 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' I - COMPENSATION INSURANCI? ITh'mswtion need nm he complain tithe pentad is for one hundred dollars(EIINI) or less) GRFASFJIN TRL WASTE INTERCEPTOR "'�fI1ILDING DIVISION FLT •R' F. TRAP PLANCHECK FEE SEWER - SANITARY - STORM EA. 200 IT. I certify that in the performance ofthe work for which [his permit is issued, I shall not employ any parson in any manner so as to become subject to (lie Workers' Compen- ENERGY FEE `� s WATER HEATER WIVENTIELECTR cation Laws of Cadmium. Date Applicant GRADING FE NOUCE TO APPLICANT If, color making dds Ceni[imm of Exemption, you should become s.hjen m the Worker's Compensation provi cions of the Labor Cotte, you tan,( WATER SYS9'EMOREATING SOILS FE dump,irh wm,I, ori th such provisions sandhi, permit shut] be deemed revoked WATER SERVICE. CONSTRUCTION LENDING AGENCY I hereby affirm that (here is a cinsumction lending agency for the performance of NEW RESIDENTIAL FIVE. SQ. IT. PAID e( ReeeiplM the work for which this formal is issued Sec. 3097, Civ. C.) Lender's Name TOTAL: Lender, Address - TOTAL: BUILDING Ff 1 certify Ihat I have read this application and stale that the above information is _ correcd 1 agree tb comply with all city and county ordinances and state laws relating to consumption, and hereby sc heme, represeratives of this city m enter upon the QTY. MECHANICAL PERMIT perEiSEISMIC ME above-mancrned property for inspection purposes. (We) cgr.e msvve, indemnify vnd keep homeless the City or against /'yam PERMIT ISSUANCE 3 J7 i V " ELECTRIC FEE ALTERORADDTOMECH. PLUMBING FEE Iminifies,judgmenls,costs and expensca which may in any way acemeagains[mitl City in nsegnenceofihe,rami gn obis fernrit q1µ HANDLING UNIT (TO IO,Wp CFM) MECHANICAL FF.F. D APPLIC N ST AND WILL COMPLY WIT/A�g'N-POINT SOUR 'C A O AIR HANDLING UNIT (OVER 10,000 CFM) CONSTRUCHON TAX r r App isanVComm r Date HAZE OUS MATERIALS DISCLOS RF. tgnaan EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HEATING UNIT(TOID0,000 BTU) WdIIhe vpplicnd find.building..pant store or handle hazardous material as defined by the Cup (dem Municipal Code, Chapter 9.12, and the Health and Safety Code, Section 2553260? El ye, /1 Will the app]icatd or future building occupant use equipment or devices which it hazoNous air contaminants as defined by the Bey Arae Ain Quality Management ishic[? ❑ Yes HEATING UNIT (OVER 100,000 BTU) ' PAID Dale Receipt is L '7 L_ VENTILATION PAN (SINGLE RESID) - BOILERCOMP (3HP OR 100000 BTI]) , BOILER -COMP (OVER 100,00X1 BTU) AIR CONDITIONER' I have rmJthe hazard sme[uivls rcquircsnems under Chaflw 6. So [he Coli- ISSU//qNC6 ATE NEW RESIDENTIAL MF.CH. SQ. FT • fomla Head Sif oa S- inns 255[15, 25533 and 25534. 1 and tan toc if the buildin ( Ply , e tenant, that it ismy cofounder m nlfy enceupnm (/ 7L �� e( prim m issmnce of u Cen r y. / ISSUED BY: Dome I klausibon,clagent TOTAe: V OFFICE