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00030107APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY LICENSED CONTRACT OR:S DECLARATION 1 hear, affirm that 1 an, licensed under prov&ions of Chapter 9 (armmermi g with Section 71X10)111' Erosion Sof the Business and protassium Gdc, and myliccase is infall fame nd ff �L [-�� i,iccnse Class Lic.p D^tem- -- � Cumm7 ARCHI'TECT'S DECLARAII N undemnd my plans shall be used as public records Irs CITY OF CUPERTINO PERMIT ISSUANCE BUILDING - ELECTRICAL PERMIT NO. Licensed Pmfccxionol OWNERBUILDERDECLARATION 1 hereby affirm don I um except tonin the Commmors license Luw (or the following ream. (Semon 70115. Buante,s and Pmfcxsinm Coda Any city or seely whim requar, , a permit to constmel. alter, impors demolish, or repair any'wenrc prion I. s .Ju q theapplic Iformer pcmitl fl `b d:'I ncnt th an I' ernN p licensed isms idConnector,'L L (Chapter 9 (commeming with Section 7000) of Division 3uf the Basincss and Prom,itso Code).1 that he is exempt therefrom and the heels Ibr Ibe alleged exeamder, Any violation of Sc tiun7031.5 by any applicant for a permit subjects the applicant,, v civil Part of not mo¢ then live hundred dollars ($500) LJ 1, usuwnernflhe Property, or my employees wild wugesuv NeirsolewmPenwtian, will Iodeework,andmeseuemml.x eat imendedorofferedRussia (Sea 704LThomas, sad ProTeW...x Code'. 'On Contmctorx License Law does nut apply to an —an, ut property who builds or improves thereon, and who docs such work himself orthrough his own hopleyeas, provided that such Lnpmverear s am not intended or offered for sele.if, however, the building or Improvement Is sold within oneyear of cumplmion, the twerTmilder will lex a dre burden of proving thm he did art build anmprovc rnr pur- APPLICATIONIPERMIT CAI PLDMBINJECT SOOOI BUILDING DIVISION SPECIALCIRCUI'UMISC. TEMP. METER OR POLE INST. IFEE, TFIC BUILDING PROJECT IDENTIFICATION SWIMMING POOL ELECTRIC OUTLETS -SWITCHES -FIXTURES NEW RESIDENTIAL ELECTR SQ Fr. SANITARY NO. APPLICATION Rl19Ml'1'TAh DATE BUILDING ADDRESS QTY. PLUMBING PERMIT PERMIT ISSUANCE ALL ER - DRAIN & V ENT- WATER (EA) Owner Da¢ 583 0 IORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT. DEVICE OWNER:SNAME: PHONE: 'T :'OR" !)pM1@' q IC�' 7� ler NIC CON TROL# •- �� 3' ❑ _ ARC)n IECT/ENGINEER: - LIG NO.. '.. .�w2.�-.7 _1 i,� r,1' iss�.� M S.3 ❑ Consultant Fees Paid by Applicant (Initial) C�OZ a�� a yUU m41 f m z oz --M LICENSED CONTRACT OR:S DECLARATION 1 hear, affirm that 1 an, licensed under prov&ions of Chapter 9 (armmermi g with Section 71X10)111' Erosion Sof the Business and protassium Gdc, and myliccase is infall fame nd ff �L [-�� i,iccnse Class Lic.p D^tem- -- � Cumm7 ARCHI'TECT'S DECLARAII N undemnd my plans shall be used as public records Irs QTY. ELECTRIC PERMIT PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP TO 200 AMPS a Y,9; C C w d xL O L U YI a W y F;�Od E�,>•..ii �{yvp0 d 4 C (.. W w L Licensed Pmfccxionol OWNERBUILDERDECLARATION 1 hereby affirm don I um except tonin the Commmors license Luw (or the following ream. (Semon 70115. Buante,s and Pmfcxsinm Coda Any city or seely whim requar, , a permit to constmel. alter, impors demolish, or repair any'wenrc prion I. s .Ju q theapplic Iformer pcmitl fl `b d:'I ncnt th an I' ernN p licensed isms idConnector,'L L (Chapter 9 (commeming with Section 7000) of Division 3uf the Basincss and Prom,itso Code).1 that he is exempt therefrom and the heels Ibr Ibe alleged exeamder, Any violation of Sc tiun7031.5 by any applicant for a permit subjects the applicant,, v civil Part of not mo¢ then live hundred dollars ($500) LJ 1, usuwnernflhe Property, or my employees wild wugesuv NeirsolewmPenwtian, will Iodeework,andmeseuemml.x eat imendedorofferedRussia (Sea 704LThomas, sad ProTeW...x Code'. 'On Contmctorx License Law does nut apply to an —an, ut property who builds or improves thereon, and who docs such work himself orthrough his own hopleyeas, provided that such Lnpmverear s am not intended or offered for sele.if, however, the building or Improvement Is sold within oneyear of cumplmion, the twerTmilder will lex a dre burden of proving thm he did art build anmprovc rnr pur- 21VER 1000AM OVER IIXXIAMPS SIGNS ELEC'T'RICAL IMPROVEMENT SPECIALCIRCUI'UMISC. TEMP. METER OR POLE INST. POWER DEVICES SWIMMING POOL ELECTRIC OUTLETS -SWITCHES -FIXTURES NEW RESIDENTIAL ELECTR SQ Fr. 'TOTAL la ccof' h,) L its owner of the p:npcng an, exclusively contracting with licensed nnnmaar, to :n'tmet the project (Sec 704L. Business and Profession' Cuda) Ino Conaccom'a Li- seL^w docs not apply to an ownerof property who builds or improves thereon, and who contracts former projects with s canlrunortq licensed pursuant m the Co^tmcmrs License Law. I ant exempt under Sec. .B& P C for this reason QTY. PLUMBING PERMIT PERMIT ISSUANCE ALL ER - DRAIN & V ENT- WATER (EA) Owner Da¢ IORKER'SCOMPENSATIONDECLARATION BACK FLOW PROTECT. DEVICE I hacby afr cr under I c^ahy of perjury one of me following dedamtinnx: Ihavc end willntautain a Ccdifioam of Continuo selfTiosum for Wurkcr's Compal- cation, ns providh rnr by Section 37119 of the Labor Coda fur he perfurerace nt me k Icr whim alis permit is lotted. �rl have and will maintain Worker's Compensation Insurance. uv, requirul by Section Onto of the Labor Cure, forth^ performance of the work for which this permit k dsucd. DRAINS- FLOOR, ROOF. AREA, COND. - PER TRAP GAS -EA. SYSTEM -I INC. 4 OD11 ,ETS GAS-EA.SYSTEM-0VBR4(EA) My War'mi"'IncuIace'cr:and Policy y�tPYTq��f m IYIi/ D� Cartier: n Policy No..,r_ CEI I'1 CATH (IF EXEMPTION FROM WORKLRS' COMPENSATION INSURANCE GRF.ASEANDUSTRI, WASTEINTERCEPTOR CRT ASE IRAP (Thi—caueneed not bwnnplcted if the permit is f ane hundreddellars($IEW z Icvs.) lecnify That ,able this the Woker is i sucdishelf be kfor nal amps. any parson in any innnner sn as m became subject m the Workers Cnmpen- persn me any member as .'erten L.xws nl'Cnlbnmia. Date SEWER -SANITARY -STORM EA. 200 FK CTR WATER HEATER WIVENTIELFRAIRHANDLINGUNII ZApplicant fin !� W VQI (~ O l�/1 V C) NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you shouldSYSTEIvVTREATING bwnnc subject m me Workers Compensation provisions of the Labor Code, you must Lodhwhh comply wilh,I,,b porenionso, this permit shill be dccmulrevoked. Q CONSTRUCTION LENDING AGENCY herebyeffirm that there is u conwaction lending agency for performance of the work for which this permit h issued (Sec. 3047, Cie. C.) SERVICE RESIDENTIAL PhMH. SQ. W. ULcnJer's Name Lc^der s Address I ccdity than I have muddles sppli.m'mn and state mat the dwve information is f rend agree me�mply with all city nnJ county urdimmces and stale laws rclmingmMECHANICAL � building comlmefmn,nad hereby Iranian,m,v,entmivc,aihis city theater upon the TOTAL: PERMIT aMwc-mcnuu I'd prnperty It in"areml pumas,,. fWe) agree msava indemnity and keep harmlers meClty of Cupedino against ishllitic,.judgmctns, costs and expenses which may in any way accrue against said City ISSUANCE OR ADD' TO MECH. UNIT 11,000CFM) at uequcnce of the granting et 1111, penult. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI, NON-POINTNDLING UNIT(OVER Il1.01X1 CIM) SOURCE REGULAHONS. �m�NDLING �� HOOD(W/DUC'TIHAZARDOUS Signature at Apphscm Cummemv DateST M ATERIALSDISCLOSURF, IWill Publdicanl nr famm building aeeupent snacot handle haeurdou, meardsiNG m defined by the Gapedmo Municipal Code, Chapter 9.12, and me Health end Safmy Code. Section 25532(^)'! UNIT (TU 10(1.00t113'TU) I IPATING UNIT (OVER Ig1,fX1I1 BTU) RESID)Will ❑Yes at"P,, me appbam u, Cme building.,.Pont use equipment ur devices whichCBHP h:rmrdnus air contaminants as defined by the Bay Area Air Quality Management OR RX),000 BTU)mt =FAN(S[NGLEN(SINGLG (OVER IIXLOIXI B'I U)Ya,ER1 tric! have read the hmmdous materials requirements under Chapter 6,95 of the Cali- fomia Ilcabir & Sal cry Ctde, Sections 255115. 25533:cid 25534. 1 understand that if theIAL building does nal currently haven meant. that it is my responsibihly'(I many the ouupant ofarc btdrentc^t, wlachnRwl Jx mer plot to issuance If- Ccdificnc of�mp_mcy� MF,CIL SQ. Irr. FEE DING PERMIT INFO LIiC'r PLUMB ❑ ❑ RESIDENTIAL: ❑SPDWL ❑ KT I'CHFRRRMODF,L ❑ADDITION ❑ PLUMBING R17 PIPE ❑MUI:TI-UNIT ❑Sd'RUCTURAL MODIFICATION ❑IN'T'PRIOR ❑ CHIMNEY REPAIR IMPROVEMENT SWIMMING POOLS ❑ BATH REMODEIARI!PAIR ❑ DEMOLITION ❑ CH HER 7NEW CIAL DG/ADDITION ❑DEMOLI'THIN CFOODSERVICEEMENT LOOT RF.A S/SQ. Irl'. FEF. v VALUA'T'ION 2(VC2 "_- STORIES 11'i'YI'P. CONSTRUCTION BUILDING DIVISION FEES PI,ANCI HECK FEE ENERGY FEE GRADING FEE SOILS FEE PAID Dwc Rcw'TI# TOTAL: BUILDING IIIi FEL SIiISMIC PIiE ELECTRIC ITE PLUMBING FEE MECHANICALiEE CONSTRUCTION TAX HOUSING MITIGATION FEE PAID Dale Receipt# I OTAI.: OFFICE s DATE