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30573 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT Na. O BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL BUILDING PROJECT IDENTIFICATION BUILDIjG D Ca lS Kok SANITARYNO. APPLICATION ATE ]SUBMITTAL D OWNER'S NAME: �•..1LEA. L._CI'110N13; CONTRACTOR'S NAME: LIC NO: a• a� NLS R L Z LV N/C CON ROL M LI RCHITEC)ENGINEER: LIC NO: ADDRESS: - ❑ CONTACT: -PHONE: BUILDING PERMIT INFO ❑ COnSWtant Fees Paid by Applicant(Initial) BLDG SECT PLUMB MECH ❑ ❑ ❑ All that EDCONTRACnderpOti DECLARATION QTY ELECTRIC PERMIT FEE 1hereby affirm NatTamftheBdundernd Professions Code, 9(mmmenseis JOB DESCRIPTION 0,_0 with Seerce and of 0ivisionlafne Business and Pnsfeasium CNe,and mylic<meis RESIDENTIAL: 0,_0 in full(amass-.Beet. PERMIT ISSUANCE a F� ❑SFDWL [I KITCHEN REMODEL <UV Littnac Class Liana <axDace _Contnaor APPLIANCES-RFSIUENTIAL []ADDITION ❑PLUMBING RE-PIPE f„po,t ARCHITCCPS'DECLARATION PANELS ❑MULTI-UNIT []STRUCTURALZ O n^ 1 undcrsNnd my plans Nall be a used a public e mix MODIFICATION OZ—O UPT02WAMPS - El INTERIOR ❑CHIMNEY REPAIR f-4 t; UcW Rfem ensaonW - 281-IOIIOAMPS IMPROVEMENT, trSS(dSS❑J OWNER-BUILDER DECLARATION OVER IBM AMPS. - O BATH REMODEUREPAIR ❑DEMOLITION I hereby affirm that I um exempt firmanthe Cgmmctorthe's License Law for c x36F following...(Sectom 7031.5,Business and Professions Cade:Any city or countySIGNS ELECTRICAL ❑OTHER hi YY11=LLON¢ wch requires a permit to construct,alter,improve,demolish,or repair any strunum ones to its issuance.ha requires theapplicont formch Permit o fileaaigncdatammcm SPECIAL CIRCUIT/MISC. p. Netbeislicensedpursuantm the Provisions fthe Contractor's License Law(Chuptcr9 MID (commencing with Section 7000)of Division 3 of the Business and Profeuions Code)or TEMP.MIDER OR POLE INST. COMMERCIAL: X R y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ElNEW BLDG/ADDRION ❑DEMOLITION ul u• Seeden 7031.5 by any applicant for o#,met subjects Ne opplicvm m o civil penalty of POWER DEVICES zy not more than five hundred dollars(S500). [:]TENANT FOOD SERVICE 111,as owner of Ne property,or my employees with wegcs ns their sok rompensatinv, SWIMMING POOLELECTRIC IMPROVEMENT f=.O will do the wnrk.and theatmente is not intended oroffercd for sale lSecJ04•i.Business ❑OTHER 0 0:M_ and Professions Code:The Contractor's License law Nes not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELCCTR SQ FT. sale.IL however the building or improvement is sold within one year ofcomplemn,the ' SQ.FT.FLOOR AREA S/SQ,FT. ovant,builder will mottle,harden of proving that he did not build cr improve for put- pose ofsaleJ. _ 4 E]has owner of me property.ton sdusively nrmruning with licensed cnmmcmrx to 1 st �'•, consume,the project(Sce.7044,Business and Professions C(xlu:)The Contractor's Li. cense Law does not apply roan ownerof property who builds or improves thcrcon,and QTY, PLUMBING PERMIT FEE ��� •f who contracts for such pmjccm with a contranor s)licensed purism,to the Commune's License Law. "• - L, E]I asst egnapl ander Sec. ;B 6,P C for this n PERMIT ISSUANCP. r 19gF�' _yU./ I u' Ower �� - t ALTEk-DRAIN&.VENT-WATER BKA) •' sL�VAIAATION WORKS COMPENSATION DECLARATION��— BACK FLOW PROTECT.DEVICE "Thereby afErtn under pemhy of perjury ane nl the following JMumtions: I have enJ will maimaina Certificate of Cuneem road Ginsurc for Wurkern Compen- DRAINS-FLOOR,ROOK AREA,COND. sation,as provided for by Section 37(81 of the Ubor Code,for the performance of the STORIES TYPE CONSI'RUC I'[ON worCfor which this permit is issued. FIXTURES-PMTRAP - ❑1 have and will main in Worker's Compensation Insurance,as required by Section 37Wofthe Labor Codi,forthe performance mine work farwhich this permit is issued. OAS-EA.SYSTEM-1 INC.400TLETS OCC.GROUP. APN My Workers Compensation Insurance carrier and Policy number are; Carrier. Policy No: GAS-EA.SYSTEM-OVER 4BEA) CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEBNDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE or lootBUILDING DIVISION R?&9 (This section need notbocemplued if permit is(atone hundred Jollan(gltlg) GREASETRAP _ PLANCHECK FEC Toy any that in the any mnertotara the work for which his theWisissmallraCo shall SEWER-SANITARY=STORM EA.200 FT. oat employ any Canon in any manner to as m became object the Wnrkcri Camper- ENERGY FEE Z sation Laws of California.Date z O Applicant _ - WATER HEATER WNENT/ELELTR GRADING FCC rIn NOTICE TO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEMRREATTNG a , become subject to Ne Workers Compensation provisions of Ne Labor Code.you must SOILS HE 17a forthwith comply win such provisions or this permit shall bo deemed revoked. WATER SERVICE Q 7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FT PAID V I hereby affirm that there is o construction lending agency for the performance of Date Receipt# IL H the work for which this Permit is issued(Sec.3097,Civ,C.) a. -� O Lenders Name TOTAL: V Lenders Address TOTAL: tY's'y 1 certify that I have mad this application and also.dol rte above information is BUILDING FEE V) commit.I agree to comply with At city and county ordinances and since lows relating in QTY, MECHANICAL PERMIT FEE U 71 buildingconswction,and hereby amhorise represenlsrives of this city too nerupon the SEISMIC FEE above-mentioned property for inspection p,gnses. 'PERMIT ISSUANCE 6 (We)agree m save,indemnify and kap harmless the City of c.,nin.against ELCCTRIC FEE liabiliries,judgmentr.costs and expenses which may in any waysccrue against said City ALTER OR ADDTO'MECH. in coment ence of the gaming of this Permit, PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT G70 IO,008 CFM) SOURCE REGULATIONS. MECHANICAL FEE 1 AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signumm of Applicam(Comraaor Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store at,handle hazardous material BEATING UNIT(TO I Ext"BTU) , as defined by the Cupenioo Municipal Code,Chapter 9.12,and the Health and Safety - Code,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU) . ❑Yes i]Na 7 VENTILATION PAN(SINGLE RESIDj PAID Iola Rcccipl# Will the applicant or future defined occupant useequipmentAir Qu or devices which mit hvmNous air contuminanu as defined by the Iluy Area Air Quality Management BOILCR-COMP(3HP OR 100,00)BTU) TOTAL: osmn? I NOILER-GDMP(DVER I(AI,O(AI BTU) . ❑Vex No . I have read the humdous materials requirements under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE min Health&Safety CNe;Sections 11.105,25533 and 25534,1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. 71the ilt ing dma tim curenlly hme n mmmrL that it ix my rexpmsibllity a notify the recupant r requirements which most h.ma Peart.exurom As Cemdenmeffkcupancy. EE� wner m omal ansed agent Dols TOTAL: ISSUED BY: OFFICE i I I 1 i� m_a ! N ! 5 CR nca '�Z 1 pN.'p I©:, I - : - ; --t -�- -'. - - -- ' ;- { -9V - �- I k m ID ' � I � I 1 � � f Ii •, ; q; I � I I ; l j I I 1, I ' t 1 � ' I - I I I i 1 ,