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B 0390 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY / CITY OF CUPN RTINO BUILDING-ELF,CI'RICAL PERMIT NO-00390 0 3 9 0 BUILDING DIVISION APPLICATION/PERMIT PIAMBINGCT IBIANIC91. 001 IIUILDIN(:IB(IJI:Cq'ID4:N'I'IF'ICA'1'I(IN BUILDING ADDRESS: SAKE FARY NO. AI'I'LICATION SUHMI'ITAL DA! l'2a ! 0c�a�/�J a� P,o ft D Z a sWNIiILS NAME iL, JAeoA5 PHONE CONTRACyI)It;S NAME:ev�� LIC NO: NIC CONIRf)1,q L-LL/s .Cllr lGCr/IiNGINEER: LIC NU'. ADDRESS: ❑ oN'IACT: I-I ION17 BUILDING PERMIT INFO O (�N L i1_ 2/�� L .6�/ El Consultant Fees Paid by Applicant(initial) BLDG lie PLUme MOH LICENSED COKE RACEOR/:SDDECLARNIIIONN �YJ / UTY. ELECTR IC PER IT I'EIt JOE DESCRIPTION 1 hereby,Rion that I am licensed under provisions of Chapter 9(Immuc"cing ZWZ with Section Division of the Businessoid Professions Cale,and my license is RESIDENTIAL C W m PERM I'r ISSUANCE H full fom:cial effect. OSFDWL O KITCHEN REMODEI, 9UU License Class Lic.x APPLE ANC17S—RES IDENTIAL []ADDITION [_1 PLUMBING RE-PIPE 9ZUW Date Comrdmm ❑MULTI-UNIT OSTRUC'IURN, ANCHIFECT'S DECLARN'ION PANIJ S F m Z © MODIIICATION N Z 1 uaiersmnJ my plans shell M used as puM1lic recoNs OZ�O UPT02W AM11PS GOINCERIOR ❑CHIMNEY REPAIR Licensed lhoftesmorml 201-10NIAMPS ��,,IMPROVEMENT SWIMMING POOLS ^'; OWNER-BUILDER DIICLARAI'[ON OVER IOW AMPS rJ HATH REMODEIAREPAIR �DEMOIAI ION gend 1 hereby a1Bnn that 1 ono exempt from'the Cormacmr's Liemtse Law fnr the ❑(Y]'HER X 36 U (nllnwing reason.(Section]031.5.Business mW ms Prefevoi Clair:Any city is,county SIGNS ELECTRICAL W y which requires a permit to causttnct,alley,improve,demolish,or repair any suuctum 6 prior to its issuance.also requires the applicant for such Permit o file amlinedsmtemem SPECIAI,CIRCUITIMISC. 'but be is bicensod Pnwmnt to the pmnoon,of the Contractor's Liume law(Chapter 9 vvy' (commencing with Section 7000)of Division 30 the Business o 11'mf..ion,Code)or TEMP.MEF ER OR POLE INS COMMERCIAL: A.pW�,o that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'f10N t%�N Surma 9031.5 by any applicant for a Permit%objects the applicant to a civil Penalty of POWER DEVICES OTENANT FOOD SERVICE > t}ore than rive hundred dollars 055th). IMPROVEMENT Fqd awns dare propcny,ae my mnpluyccs with wase,us neuronic cv.olloo liaq SWIMMING POOhI?hELTRIC will,)the wark.laddirdrucwfe is mtincended nrolrered forodel So 7094,It....exs OO'I'IIIiR Ud o W an and I'mfcssions Cade:The Comructnr's LicenseLawdeer nm apply o an mvner of OVfLIi'1'S—SWITCHES—FIXTURES property who builds to,improves thereon,and who does such work himxlf or through his own employees,provided that such ammunitions are not intended or offered for NEW RESIDENTIAL ELECf8 SQ PE SQ.FR FLOOR AREA 5/SQ.IT. 'ole.it.however. be haildmgnr nuprnvemcmt i, dd within one yearofmun,11clum,the owner builder will have the buNcu of proving that he did nn'build or improve lin put- case ❑ 1,as owner of the propeny an,exclusively comracting with licensed cnmmnurs to construct the project(Sea 70.14 Business and Rofesoons Code:)The Contractor's Li- 'xl.aw docs Hol apply mint owner of prnpeny who builds or Improves there(m,and QTY. INC,PERMIT FEE. who,Hounds fur such pro cors with u conauno'(,)licensed purmanuo the Contractor's License Low. PERMIT 5 p K P C fur this reason O 1 um exempt un Sec. ALTER—DRAIN.h R VALUATION 11:7WORKER'S N DECLARCOMPS .ATIOATION BACK FLOW PROI'IiCT DF,VICL I hereby affirm under Penalty of perjury one of the lihllowing declamtionr I have and will maintain a Cciificam of Cmewrdto self-imam for Worker's Compri- DRAINS—FLOOR.ROOF.AREA,COND. Sy Rp_q TYPE CONSTRIICTIC Lon,to,providal our by Section 3900 u(thc Labor Code,for the perfomuclu of the uk lie which this Permit is issued. FIX TUBES—PER TRAP �3""00 1 have and will maintain Worker's Compensation Insurance,as required by Section GAS—P.A.SYSTEM-1 INC. OUTLETS of the tabu QalO Tonle performance of the work for which this permit isissue]. OCC.GROUP /'AI'N Windoex Compensation Insurance carrier and Policy number:ue: GAS—EA,SYSTEM-OVER J(EA) 3bfricc Policy No.: CliIGETICATF Oil EXEMPI[ON FROM WORKERSGREASIPINDUSTRL WASTE IN'I1iRCFM OR COMPENSATION INSURANCE ROB-DING DIVISION PEGS (Thissction need not be completed if the Permit is for one hundred dallors(8100) GREASE TRAP PLANCHECK FEE or less) I,,yan,th:ntnthe pAaclum" ufac work„ ,bec for subjectch permitisiss'Coumpa0 SEWIiR—SANITARY—STORM 13A.2W tT. ENERGY PEIi not cn'piny any pe'snn in any manner nn m In M1aonw subject m the workers'Gsmpcm z ration Laws of Caliform.Done WATER 1112ATER W/VENETLECI'R GRADING FRIT ZO Applicant t zr ti NOTICE TO APPLICANT:If,all making this Ccnificam of Exemption,you should WATER SYSTEM/CREATING SOILS FEE F' Iwxrane subject to the Worker,Cnmpemation provisions of the Labor Code.you must u Ihnhwlth comply with such Prov lions or lhla permit,hal l be deemed revoked. WAFER SERVICE = PAID CONSTRUC"HON LENDING AGENCY NI?W RESIDENTIAL PLMB. SQ.tT. a z O U e Receipt x U O l hereby affirm that is a construction lending agency for the Performance W E—' the workfor which this Permit is!cited(See.3097.Gv.C.) TOTAL'. .C) U Lender's Notre T } UJ Lender's Address BUIIDIN 113E D 0 a 1 certify that 1 have mad this application and state that the above information is f' y cmect.Iagree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMI ME: (0 U z buildingcomstmction,and hereby authorize reposentahves of this city¢tenter upon the abou-nattionedpt,feny fur lmslocc'ion Impores. PERMI'1'ISSUANCE ELF IC FEE (We)agree to save,indemnify and keep hornless the City of Cupertino against liabilities.judgments.costs and expenses which may in any way,ante against said City ALTER OR ADD TO MECH. PLUMBS GFEE in comequence of the grooming of ibis permit. API'I.ICAN'I'UNDERtifANDS AN /ILI.COMPLY WE fit ALL NON-PO1Nr AIR HANDLING UNIT(TO 10.00()CFM, MECHANI LFEE SOURC 7 13'11.AfB)NS. �r AIR HANDLING UNIT(OVIiR IO.INO CFM) CONS'1'RUCfION'fA% Signawrt of ApplicanUCommnor u Date EXHAUST HOOD(WIDUC) HOUSING ME HGAfION FEE HAZARDO : 1ATEiRIALS DISCLOSURE Will thoapplicout or furor Ilding occupant nom mr llndle baaum rdou, ateriel HF,AII NO UNI I'f1'0 I W,0N)111 U) mlinertin ded by the Cupo Muneipel G'dc Chapter 9.12,and the Health and Safely HEATING UNIT(OVER 100.IX0 BTU) Cede,Section 255]2(:0^ [I YO, El Not VENTILATION PAN(SINGLE BESIDE PAID nam Re(:oipt x s Will the applicant or t'umre building occupant use cqulpmemt or device,which BOILER—COMP TORP OR 100,(0X)BTU) hvafdous air cumaminams as defined by the BaY Arca Air Quality Management I. mrict” BOILER—COME(OVER 100.000 BTU) ❑Yee ❑Nu HIR CONDIT10NIilt ISSUANCE DATE 1 have read the baode Se ii on,d 5 5 15533 an under C 1 and rsta til the Cali Z ^� • fnmiu IicalN&Safety CaR.5alinns 255(15'5533 and 25500.1 unJen'mul'hat if the NEW BIiSIDENI'IAL MECH. SQ.IT. 7 building docs noreurrcn0yhavc.I tit, it.myres7rosibility to notify de(zcupant of the 9uire E 1'kh mustb 'p nn is cofaCa ca¢nf pancy. Qwncr or autborivad agent Date ISSUED BY " OFFICE