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30800 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO - rry ' BUILDING•F,I,F.CI'RICAI. . PERMIT NO. 30800 � O O O O 'NUILDING DIVISION �' APPLICATION/PERMIT PLUMBING-MECHANICAL f 'I J o BUILDING PRDJFAT'IDENTIFICATION ' ' TY _ n r SANITARY NO.. APPLICATION SUBMITTAL DATE �r��`L4 VTQOOrr In 14913 . O E SN ME ' PHONE: C NTRAC OR'S AMEN LIC NO'. Wo�dr .NC, .( r "s 'i 5 .' I'T'S 5 /c -c ot» ,RITC sNGINBLR , LIC NO: �pDDR 5y, 'I�, 44 5I /'aQ 21VRA e CONTACT: - PHONE: - ,0 1. BUILDING PERMIT INFO f no O Q Consultant Fees Paid by Applicant(Initial) . - BLLDD�G. ELECT ,PLUMB ;�e MITC�H LICENSFOC 1' ACTURS DECLARATION QTY ELECTRIC PERMIT FEE. I he by affirm m t 1 d under pr f Ch pie 9(commencing JOB DESCRIPTION = _' {O{A�C) with 5 I ]OOO)of D, n3 ultra Basin s Professions Cod d -1 Fw0 fall f and effect yicense is PERMIT ISSUANCE Q " of Lcet. la. Lc.» 5 001 ❑KITCHEN REMODEL APPLIANCES—RESIDENTIAL � W Dam Contractor ADDITION PLUMBING R&PIPE Fly ' ARCHITECT'SDECLARAT N ❑MULTI-UNIT "^ ,OSTRUCTURAL ` PANELS' 'Z O 7,. ,"^ I d island my pl s sM1all he uiW as puhlie recs+Ns '• s. - MODIFICATION ' vv� ,OZ:f � - I' UPT0200 AMPS � O -F� +C] [I CHIMNEY REPAIR`FW 'L tensed Profeseuanal. INTERIOR, .,Ii I, 2nl;In00AMP5^ "" IMPROVEMENT `pts;,! �$G -r OWNER tlxempER DECLARATION. OYER I(gOAMPS , - ❑BATH REMODEUREPAIR [I DEMOLITION a 1 hereby affrm on I con exemptfire.s an the Cessions C d L 1 far the iq5 O U follow ng reason (Section 7031.59 Business end Professions Code:Any city r c poly -SIGNS ELECTRICAL ❑OTHER W a.O F" which requires a permit to construct,alter,improve,demolish. repair any s0uuure -- r. rn p,ort ituance I o 4 're the f h permit t Flux statement grad r" SPECIAL CIRCUI'UN ISC 'y - ✓ Ihth ll red pusttanuo theprovisions fth Commodes uL (Chpter9 4 62 DO (oat enc g 1hS t 9001E fD' .ia 3 Dhe Bumessdnd Profs! nscde)ar TEMP.M2TER OR POLE INS T. ACp1 A' d p,e C Ihut he s exempt therefrom and the basis for the alleged exempt Any violation of -, - ❑N �M/Arb� ❑DEMOLITION m les, Section 7031.5 by any appl a f p I s lh t Ih old t t Penalty f POWER DEVICES W"7�j, �»»� rn lIC1LIYODD SERVICE yyuCC�l,�dse ❑hmis Lmowren th T h d Pdrady Marym(y5e5m110p)l e agefe th let m fn, - SWIMMING POOL E(.CLTRIC , r IFLN Tnthe work, ands t I t intended r offered alpBusiness 1-1 OTHER m and f n Code:The Cont L Low does t apply to an woe of OUTLETS—SWITCHES FIXTURES Property who huilJs nrwitnesses ffioaaanJand wb.does khinsdfothrough employees, irovidentified, uitiipements a aot imtonJeJ nroffere"ur y NEW RESIDENTIAL ELECTR SQ IT. sale.If,however the buildingor unarwerwint is sold within one year ofeampletio the t, „'SQ.FT.FLOOR AREA y $/SQ,FT. owner coulderwillh the human f provingthth dA not build or improve for par, 0' - pose f s ae). territorial L f the property,am exclusively c ri g"w licensed contractors la ' T O �,s onst tilopio)eeSex.30,14 Business Pofes. ns Coda)The Confidences Lt. -nseL d snot apply to en woe fprpny fi huilAe, p th reun,anJ QTY. IPLUMBINGPERMIT I FEE S a w1memeardardifernwirprojechwalt mhr t r(s)licensedpum pursuant Contractors - Lia use L r PERMITISSUANCE{' r 1 ur exempt under S_ac. - ,B&PCforthisnarom - •" '+ ALTER-0RAIN&VENT—W (E UAT Owner hate VALUATION WORKER'S COMPENSATION DECLARATION BA CK PLOW PROTECT.DEVICE I hereby affirm under penalty ofperjury one of the following declarations 'lq� rte,• I Inve and will maintain a Cardinale cf Consent in self-mance for Worker's Comped- DRAINS-FLOOR,ROOt,AREA,GOND. 'STORIES TYPE CONSTRUCTION cation,os provided for by Section 3900of the Labor Code,for the performance of the " work for which thisperm,ti- s issued, FIXTURES-PER TRAP ' . 1have ` andwill mnWorkerseInspma. esped by Section om-Ce,for thaincofthew fier,whichth permit is issued, SYSTEM- GA-S—EAi.SYSTEM-I INC.4OUTLETS -Itr OCC.GROt4Ly APN My Workers Compensation lusurance carrier Policy number ae Currier: - Policy No. GAS—EA.SYSTEM-OVER 4(P.A) CERTIPICATROFP.XEMPTION FROM WORKERS' ^ - COMPFNSAIION INSURANCE ^ GREASIIINDUSTI2L WASTE INTERCEPTOR' s IL1 NGDIVISIONFEE.S (Th' t peed theca opiated fthep tic t':f - neh Ired dall.ry($100) i - {. _ - of en Y. YP t rhe an m ace ofthe work SEWER—SAMTARY STORM PLANE E �, - Icer!try that the performance ' wh ch ilii.Tenn u. vs el lshull RM EA.20017 - ENE iter es b c m 5µb)e',i- the Woo,y,m should WATER SYSTP.M(fREATING GRA Y lE Z anionL Cvhfnmi Yte "'11 pen C)Q Applicant nk this a WATER HEATER W/VENT/ELECTR - GRADING FEE tF�—l• NOTICE. ICA i I( rutj Ie of Exton u n hcc.ina.uh/ct In the ke sComp Y previsions of the labor Code you must _ - SOILS FEE i fain Ili comply with suhp ' urlv`.th Permit shall he dee red revoked W,Q WATER SERVICE - "� CONSTRUCTION LENDING AGENCY '.1,NEW RRSIDEMfIAL PLMB. SQ.FT PAID a , UO Ib reby offirm that there sa convtrectio,i lend ng agency forlheperforman of Ume tpt» W the work f u.which pe rat i d Pi e.3097,Civ.C.) • L ddcrs N TOTAL. Lende Add - - I .. ,TO'14L O e.. 1k...,r, a, 1 certify th t I h read thisppb ndnn and slate that th ho f d ' � is BUILDING �.� 1ft, V) corredl g- i comply with allc'ty d county ordinances and site law telaungm QTY. MECHANICAL'PERMIT FEE ' U'� hulldingim slocoan,andh by authorize representatives of the city to enter upon the S&SMICP %+ O above-madboned prupery for inspection punposes. s. p (We)agree to save,indemnify and keep hannlc{s the City of Cupertino spend PERMIT ISSUANCE ELECTRIC FEE t Awl O habilities,judginents,costs and expenses which may in anyway accrue against said City` ALTER OR ADO TO SUCH. /+' in asequence ofine granting of this permit. - PLUMBING FEE PPLiCANT DERSTANDS AND WILL COMPLY WITH ALL NON-POINT ' I`s AIR HANDLING ON[I(TO 10,000 CFM)Oft A. - - OURCER/G) ATIONS' - T _ - MF,CHANICAL EE17 ' ���..x AIR HANDLING UNIT(OVER 10,000 CPM, F_ CONSTRUCTATAX nature fApplican t r - Dat. EXHAUSTHOOD,(W/DUCI') - // HAZ R OUS MATERIALS DISCLOSURE. - - HOUSING MITIGATI FEF Wi 7henpplic"I lure building occupant score or handle hazardous material HEATING UNIT(TO 100.000 BTU) ' as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety Code,Section 25532(a)9 _ - HEATING UNIT(OVER 100,003 BTU) _ o . [1yx No .. r. r -it - VENTILATION PAN(SINGLE RESID), PAID, , Will the plicurn I orfuture hurldtng occupant use equipment or devices which - , - • e Date - FReceip li I liberation,air comerairearins as decided by the Bay Area Air Quality Mdnagem tot BOILER' COMP(3HP OR 100,0110 BTU). .aiatOYae No BOILER yCOMP(OVER 100,000 BTU) d, O (have read the huzardousmnureis rcgmreanents under Chapter 6. of the Colt- AIR CONDITIONER r�1' ISSUANCE DATEY forma Health&Safety Cole,Sections 25505 25533 and 25534 16 dlevand diol If the NEW RESIDENTIAL MP.CH. SQ.FT' matching rh t modually have.tenant,that isou pmarbtlty m norry theoccupant . of the req 'em�t hich mustMmet pr or to ac fo Cerft caa of Occupancy ,. I Owner of amhrazed agent"' DateTO LOL ISSUED BY s 'OFFICE,