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S 3011 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO. BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3011 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE i,"Irl \_�� kvtl'Nktf /Z _( . OWNER'S NAME: PHONE: CONTRACTOR'S NAMfi: LIC NO: Ir-n` - 0-15 I ``^ ' s 1T s NIC CONTROL# "CHITECTIE EER: LIC NO: ADDRESS: W L ❑ _IIAsVAAl A,.c. S CONTACT: r 11 #y�1(p• Z PHONE: BUILDING PERMIT INFO EWJ�np Ce, ❑ Consultant Fees Paid by Applicant(Initial) RhDG EC PLUMB 1S r -7 M ❑ ❑ LICENSED CONTRACTOR'S DECLARATIONcizz QTY. ELECTRIC PERMIT TEF. 1 hereby affirm mat I am Tressed under pmvanom of chapter 9lbnmmenning JOB DESCRIPTION WOOwith Senrcea JOeBlDbisam 3 ofine Business and and my lormen is ��0 SFDWEWDF LJ KITCHEN REMODEI. 1cf00 0 l� PERMIT ISSUANCE �pU Liwnse Conn APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE yQa Dn¢ 7VSD ��--�' �Oy gRCHITs,ros UECLARAcord, PANELS ❑MULTI-UNIT El STRUCTURAL Z O w Z I undersmnd my Plans shall be used vs public records MODIFICATION OZ�M UP T0200 AMPS El INTERIOR ❑CHIMNEY REPAIR F W Licensed Professional 201-100DAMPS IMPROVEMENT E]SWIMMING POOLS ^^��' OWNER-BUILDER DECLARATION i%11yy Q 1 hereby affirm that 1 nm exempt from the Contractors License Law for the OVER 1000 AMPS ' [I BATH REMODEUREPAIR El DEMOLITION �65�O W U following ha eum(Section]IH 15,Business and Pateessions Coco de:Any city or ,,only SIGNS ELECTRICAL El OTHER t++ WO y which mquimv o permit m Construct,alter,im,or e,demnlish,yr repair any swemre d� pro tits issuance,nce,al. acquiresthapplicantf Ipermit t fl signed statement SPECIAL CIRCUIT/MISC. that he 1'cesedpursuantl Ih provisions of the Contractor L law(Chapter9 d U g with Secret,]000)orDlvis 3 f,hC Btnimcc, adP f:.jam Cooko or TEMP.METER OR POLE INST. COMMERCIAL: per. o yOa� mal he is exempl them mm and the Into,fur Ne alleged exemption.Any vade icn of ❑NEW BLDG/ADDITION ❑DEMOLITION ae,"'+„N Section 7031,5 by any applicant for a perne,mbfeas the applicant m a Civil Pe JyP POWER Df?VICES` ❑TENANT ❑FOOD SERVICE >y nor more than Five hundred dol0m(S500). IMPROVEMENT C d ElI,as owncrofine propcny,or my enhployces with wages Ss lheiranlc compvn xian, 'SWIMMING POOL ELPATRIC ir�K p5.0 will do me work.and the aructurc is not insnded proffered for sale(SecJ044.6 i ❑OTHER 3 m sad Professions Code:The Conaxdora License law does not apply to nn ow v TLF,TS SM4TCHES' FI r F. property who builds or improves thereon,and who does such work himself ort gh his awn employees,provided that such improvements are not intended or offer d for 'SI NTIAL E ,T S sale.If,however,the building or improvement is,sold within one year of completi SQ.FT.FLOOR AREA S/SQ.FI'. tweer-builder will have the burden of proving that he did not build er improvn f pose MsCU.). ❑L a ow r of the property,am tselaslvely Contracting with licca co I r , m AL` construct the project ISCC.70TL Business and Professions Cale)The Cnntnnm8s IJ- nse,Lawdoesnolapplymanownerofpropre,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE who contracts nonsuch p jeers with accroccmr(s - nand parsmmm the Contractors License L. PERMIT ISSUANCE. ' ❑Lam exempt under Sec. ,B&P C for this reason ALTER-DRAW&VENT-WATER(EA) - VALUATION Owner Doc WOR KER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE `�Sd� 1 hereby affirm or der penalty of perjury one.1'he following declario r re: ❑I have and will maintain a pontificate of Consent to self-insure fin-Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION taboo as provided for by Section 3]00 of the Labor Code,for he perfarmunoe of the work for which mix permjl is issued. FIXTURES-PER TRAP S1 have and will maintain Worker's Compensation Insurance,as required by Section Jofine Labor Carle.far the perfmmwee eftb,work for which this pemhit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCCOROUP APN My Wo' Co action lnmmnw Cartier and Policy CYWo' T's Can IFI-�����'ONyFROM W��b30' GAS-EA SYSTEM OVER COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCE K �C� UILDIN©DI VISION FE&S _ (This,tv,,knecralet be Completed ifthe permit isfmaEmmpddollars(5100) t - - orIn..) GREASE TRAP �J PLANCHE E Icerf,finum the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.204 not employ any p s any man er {o�b�,( subjeet m the W aknm'Conniamfil Y ,`� smjon laws h bfo Date n It�1 1`I�e WATER HEATER WNENTIELECTR ngt GA Q Applicem � f 1J/J •/ - GRADIN y NOTICE"10 APPLICANT.If,ofter tanking this Cer ifcate of Exemption,To shoulJ Wq'1'F.R SYSTEM/TREATING f7SOILS FEE H 5 become subject m the Worker's Compensation provisions of the Learn Code,you most �t� forthwith comply with such pmvisiensor this permit shell be deemedrevoked. WATER SERVICE. Q z CONSTRUCTION LENDING AGENCY NEW kF.SIDENTIALPLMB. SQ FT. -.� PAID Dam Receipt# V O I hereby affirm thanhe.is i vast Clear lending a envy for the performance of me work for which this permit is issued(Sec.31y eCJ W Leaden's Name TOTAL C) ULeveler's Addres s TOTALi certify thin f have ad this application and store that the above Information is BUILDING FEE V71 correct.l agree to Comply with all city and county ordinances and.state mwsrelating ah QTY. MECHANICAL PERMIT FEE U G building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE above-mentioned property for inspection purposes. PERMIT ISSUANCE, 3J. fb ELECTRIC FEE (We)agree to save,indemnify and keep harmless the city of Cupertino against r liabilities,judgment.coats and expenses which may in any wayoccrue against said City ALTER OR ADD TO MECH. PLUMBING FEE to nsequence of the.mating of this permit APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNH'(TO IU0m CFM) MECHANICAL FEE ( O SOURCE REGULATIONS. f AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTIONTAX Signorine of ADdicartAi mmemr Date EXHAUST HOOD ONMUCT) HOUSING MITIGATION PEE HAZARDOUS MATERIALS DISCLOSURE. Will the applicant or future building occupant store or handle hazardous material HEATING UNIT TO 100,00 BTU) as defined by the Cuper m Municipal Code,Chapter 9.12,and the Health and Safety q Code,Spain.25532om? HEATING UNIT(OVER 100,00)BTU) h 2 ❑Yeso VENTILATION FAN(SINGLE RESID) PAID Date Receipt mink Will the applicant or future building occupant use equipment or devices which emit minorities air Commitment,fitment,as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU) TOTAL: District? BOILER-COMP(OVER 100,SX)BTU) ❑Yes )E No 3 70 (have read the hazardous materials reyuiremenls under Chapter 6.95 of the Cali- AIR CONDI'1'IONER �Q ISSUANCE DATE (� fomia klwhh&Safely Cade,Sections 25505.25533 sad 25534,I undersmnd that if the NEW RESIDENTIAL MEET. SQ.FR /y y , A Im Up,does not currently hast u I I,that it is my responsibility,to notify the occupant G. `I l/ fet�e quir^emeas which n sl cohost prison issuanw ofu Cerifhateof Occltrpm; I I I t �y _ Ow mmi agent r I ( © ISSUED BY: OFFICE