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S 3835 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-EI.FCI'RICAI. PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3835 BUILDING PROJITC`11'IDENTIFICATION BUILDING ADDRESS: SANITARY NO. APPIACAI']ON SUBMITTAL DATE 22?13ICaGcocS E2T uo �/--(� OWNER M-�L(h Qlj C@YI Q-d� 4JADO PHONli: CONTRACTOR'S AME: LICNO: NIC CON'FROLx RCHITECTUENGINHER: LIC NO: ADDRESS: ❑ nKAs ulO VJJV L- 3 a Lrrsoa�c Sl 9Yz3 ON'1'ACE PHONE: BUILDING PERMIT INFO 197 69-6 4 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ©� G3' [?I 0' LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE Thereby alum ma I am Framed order mavEdan.ar Chapter 9(eomirmi JOB DESCRIPTION uWu!es=O, wall see daniotAgofUivki 3mnhe Baauss and Pode,ions code,rod illy license iPERMIT ISSUANCE x Sv RESIDENTIAL Fifull force vnd effect. S tyi- s ❑SPDWL [I KITCHEN REMODEL QUU License Class Lic'x APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE Q W Dara Cormacmr ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL. 1"w Z unJeomed my plans shall bellied.,publics lid, PANUS MODIFICATION '-2��G UP TO 200AMPS E3 INTERIOR C1 CHIMNEY REPAIR SNF; Licensed Professional 201.11X0 AMPS IMPROVEMENT C]SWIMMING POOLS y�, OWNER-BUILDER DECLARATION Y OVER IOM AMPS ❑BATH REMODE1JREPMR (]DEMOLITION y tX < 1 hxmby M.that I am camind from the Contractors License Law for the g O L U fallowing reason.(Section]0315.Business and Prnresdnns Code:Any city oceeonty SIGNS ELECTRICAI, ❑OTHER R1 �+ +13 CiliaFi whT,h requires a permit to comsime6.11m,improve ,.denmhdm repau any strucame w 4 pror t its issuance,also requires the applicant for men Italian to file a signed smtemrm SPECIAL CIRCUIT/MISC. E Y that he is licensed Forward in the provisions of the Committees Idealism Law(Chapter 9 yy Co (commencing with Section 7")of Division 3 of the Business and Profession Code)or "rfiMP.MM-ft OR POLE(NST. COMMERCIAL: m 0.c C than he is exempt therefrom vnd the basis for the alleged exemption.Any violutinn of ❑NEW BLDG/ADDITION ❑DEMOLITION m Scotian 7031.5 by any applicant far a permit subjects the applicant(oil civil penalty of pOW h EVICES Ell ENANT ❑FOOD SERVICE =O not more than live hundred dollars($500) O IMPROVEMENT ❑ I,as owner of the Tempt or my employees with wages as iheirsole compensation, S C ELECTRIC ❑OTHER E. will do the work.and the structure is not intended or offered for sa.,(Sees—Business st aim and Prolusions Cold, he Contractor's License Law docs not apply to an owner of OUTLETS-. CHFS-FIKTUR prnprnY who builds or Irq+mvcs thcmnq and who Aws such work himself(it throughis /� his own employers,provided ohm such improvcmnns arc nal maraded lir t B . -a NEW RESID ECTR SQ y sale.If.Wswcol the building or improvement is said within one your incompletion.the SQ.lT.Il(l(IR AREA L5Q.Cr. oxner-builder will have the burden of proving that he did not build or improve for par- /�� poxc of sale.). ❑ 1,aser o ownf the properly,am exclusively contracting with licensedo � Y/G b scomm tor+ / X t O _ �/� . � AL: ��I +�3 msurm the project(See.9044,Business and Profcwnnns Cnae:)'I nc Gmi......... ayreyl sm law dons not apply to national f,roi who builds lir improve,thermal,and QTY. PLUMBING PERMIT FEE who rmaracn Transit pmjems with a mmracumb,)licensed plus uanOo the Commerce, License law. PERMITISSUANCE ❑ Ismcaamp nJ ov. �.Bca 11 for this mason ACT[Tit-DRAIN&VENT-WATER(EA) VALUATION r WGA P�LYSATION DECLARATION— BACKFLOW PROTECT DEVICE / p J 1 hardly affirm under penalty of perjury one of the fmlToming declarations: 36 O o(,J (have and will maintain a CeelEcae of Conserv to self-insure for Worker's Compel- DRAINS-FLOOR,ROOEAREA.COND. STORIES TYPECONSTRUCf[ON scion,as provided for by Section 39(X1 of The Labor Code,for the permnnrnec of the work forwhieh Nispermit inismnJ. FIXTURES-PI7R'I RAP "1 S�C/•y- � ❑1 have and will maintain oversees Compensation Insurance,as required by Section 2 5A&_lc c 3100ld the labor Cale,for the perfmarance.fdom work for which thin permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AIN My Worker's Compensation Insurance carrier and Policy number arc: Carrier: Policy Nn: GAS-0A.SYST17NI-OVER 4(EAT �J �6/(/�Q/O CERT I ICAI ti OP EXEMPT[ON FROM W ORKIIRY COMPENSATION INSURANCE GRflASEINDUSTRL WASTE WE ERCEPTOR BUILDING DIVISION FEES ('(Tis section need not becompleted ifdopermit is formic hundred dollars(SIM) GREASETRAP lir less.) PLANCHECK FEC I vainly that in the perfornanmdthe work for whichthn permit is issued,l shall SEWER-SANITARY-STORM BA.200 FT. m ncment ploynny panyma u nnson,mbcamnesnbjat to the Worker,'Compca- ENERGY RTE o54ta• g0 �Z satinlawsofCalibmaiu.DamWATER HEATERW/VENT/ELECTR GRADING FEE Z Applicant NOTICE TO APPLICANT:If,after making this Cenifcute of E.annoton,you should WATER SYSTEMPREATING F "N" hecomr subject to the Workers Con+pensation provisions of the alba Come,you must SOILS FEE �+ ti fanhwith.....lily with suchpmvisinns this permit shall he Jrenmd revoked. WATER SERVICE D] lir a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.I.T. PAID le �� U O I herebyallirm that Them iso umwm smn lendingagency marble rr perfonancenf Dae Receiptp W the work lir which this permit is issued(Sec.3099.Civ.C.) Under',Name (' TOTAL ❑ U Iciii Add.,, TOTAL: } G I certify that 1 have read this application and thb state that e arvr informational it BUILDING FEE y 5 QC contact.I.,.a to comply with all city and county ordinunces coalition,laws reining m QTY. MECHANICAL PERMIT FEE ! UZ building cenaruction,and hereby..thorrse teprawntativcsofthns city toenterugm the SEISMIC above-mentioned property lilt inspection purposes. (We)agree o,oma indemnify ani keep harness tilePERMIT ISSUANCE?City of Cupertino against ELECTRIC FEE •33 hahiilms,judgmems,costs and expenses which may in anyway aceramgairnt said City ALTER OR ADD'IOMECH. nwqucnreafthegranOngmfflik permit. PLUMBIN 'Ii k/,��/ 3D APPLIC�ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNTTCFO 10.0nCFM) MECHANICA.FEE SOURF,Ii G . TIONS AIR HANDLING UNI'F(OVER 10,(XX)CPM) CONS'T'RUCT[ TAX immrc of Appy /DnT�I/ EXHAUST HOOD(W/DUCF) HOUSING MITIGATION FEE HAZ RDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant stare or handle imitations material HEATINGUNI'f(TO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safmy Code.Section 25532m)1 HFATING UNIT(OVER l,d,mX)RIG) ❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAT]) Data Receipt N Will the applicant or future building occupant use equipment or devices which emit Th....dns air co ..minmts as Joined by the Bay Arca Air Quality Management H01LF,R-COh1Y(LHP OR 100,000 BTU) TOTAL District? BOILER-COMP(OVER 100.000 BTU) ❑Yes L]No 1 have MW the hvallous materials 2quimplann under Chapter 6.95 of the Cali AIR CONDITIONER •1 / ISSUeFE DATE forma Health A Safety lisle,Sections 25505.25533 and 25534.1 understand that lithe NEW RESIDENTIAL MECH. SQ.ITT S^ 2 "U IC-1 FuilJing urrcnt ly have a fewm.That it is my T'rsponibifty r+....dytheorcupant - yyc nftne. ui`tents which man be met briar n+rsxuarce mfr Candela ntQ S cane. O TOTAL: •TOe /�/..7�x..�,ac�-( O autnorixd agrn Dam ISSUIiD BY. OFFICE