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30797 APPUCANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY HUII.DING.ELECTRICAL CITY OF CUPERTINO PLUMBING.MECHANICAL BUILDING DIVISION APPLICATIONIPERMIT BUILDING 1ROAHCT IDINTIFICA'1'ION PENMIT NO. 30797 O7Q7 - SANITARY NO. APPLICATION SUBMITTAL DA'Ri BUILDING ADDRESS: - /O 5<5" Ave 10 OWNERS NAME: 1110NG CONTRACTOR'S NAME: LIC 0: NIC Crna,utrr'' y ARCHITECf/ENGINF.ER: LIC NO: A IDR /`SVVa7`^-L/T 0. KANAA CONTACT. .L1 Pec 6 BUILDING PERMIT INFO -L•�N+ Q Consultant Fees Paid by Applicant(]oilier) LDG F!LI!Cf PLUMB MECH LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE JOE DESCRIPTION 1 hereby aftrte Nat 1 am licensed under provision.of Chapter 9 commencing rt,00 with Seetinn 901x1 of DlvislonJ nftho Rosiness and l'rnfeasinns Code.and mylicenxe is RESIDENTIAL; �F 1.. to full fmcaand effect PERMIT ISSUANCE 0Shkywl ❑KITCHEN REMODEL. �UU License Eli s- Lic.p Apl'LIANCES-RESIDENTIAL El ADDITION [I PLUMBING RE-PIPE �.)a� owe Clnwctor - ElMULThUNLT El STRUCTURAL CHITECI-S O[CLARATION PANELS ^ MODIFICATION OZyZ I undermand my plans shall be used as public records 1 UPT0200AMPs `L ❑INTERIOR ❑CHIMNEY RI7PA1R O Licensed Pmfivoutnul 201-1000AMP IMPROVEMENT OWNER-BUILDER DECLARATION OVERIBO AMPS BATHREMODEIJREPAIR ❑DEMOLTION W6 I hereby affirm that I um exempt from the Contractors Lia me Law for the []OTHER JpS,O y U felmsing av eta.(Section 90)1.5,Bashes,.and 11 fessinny Code:Any city nr coumy SIONS EL13C'I'RICAI. fu a LL I" whim squires to Permit to construct,alter,impnrve,demolish,or repair any structure pompom its issuance.alm requites theapplicant for such Permit to file a signed statement SPECIALCIRC / SC. (Inichoi,ji,emad,purvaccoullimprovwonsofthe Commcmrsi.icemel.ow(Chap;er9 COMMERCIAL; QC (commencing with Scalon"/llgB of Division 3 of don 13usiaxs and Professions Cale)or TEMP.ME': P 6 6 c C that he is,tempt mcrdrum and the basis for the alleged as.....don.Any violation of D NEW BLDG/ADDITION [D DEMOLITION v Section 7031.5 by any applicant for a pemtil subjects Ne applicant m a civil penalty of POWERDEVIt. S �^ gNrp ❑FOODSERVICE not marc thin five hundred dollars(SNO. IMPROVEMENT F� D1,as ownerof the property,ur my employees with wager as their sole compensation, SWIMMING P00 L F.CfRIC OTHFiR y wdldo Nework,and the structure is not intended proffered forsd904.Business 90Business µ14m and Pmmo,ions Crile:The Cnntmeme.License Law docs not apply m an owna,of LLITS-SWITC FS-FIXTURES p'6 property wilt,builds or improves thereat,and who does snail work himself orthrough his own employees,provided that such improvements are not intended or offered for NEW RF.SIDCNTI L ECTft SQ Cr. ,ale.If.hswevea the btildingor impmvcmem is said wimin oneywof rompletit,n,the SQ,PC FLOOR AREAkgSI$Q.F[ � ser-M1uilder will hove the burden of pawing that;he didnn;M1uildor improve ryaapfsale,. v I ❑1,as owner of me property.am exclusively commeting with licensed amorson a to construct the project(Sec.70,14,Business and Professions CndC)Tha Committees Li- use Law does not apply to an ownaot properly who builds or improves thereon,nnA QTY P. �I IN IT PCE �4 who contracts for such projects with a mmracmds)licensed pursuant to the Contractors p License law. PERMITISSUANC ❑lute canton under Sea ,13&PCfmdtistcmnn ALTER-DRAIN&VENT- 'TEN(FA) a Date 'ION ms`s WORKER'S COMPENSATION DECLARATION BACK FLOW PR Owner OTI3Cf.DEVICI3 r hemhyoffnn audio penalty of"perjury ono 14the h4lowing declumtions: `�V1 •I D l have and will maintain a Certificate ofConsem to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA.COND, TORIrS TYPE CONSI'RUo7GON sation,as provided for by Section 37W of the labor Code,for the perfome nee of the work for which this permit is issued. FIXTURES-PER TRAP I have and will nmintam Waikato Compensation Insurance,us rcqui red by Section GAS INC.4 OUTLETS 3 of the labor Code,for the perfmmaace of the walk far which this permit is issued OCC.GROUP APN My W. sic pens is I^sumnc C" lanky No, u�a GAS-EA.SYSTEM-OVER4(HA) .10 Came Pnld PNa.: CERTIFI TI:OF EXEMPTION MOM W ERS' GREASFJINDUSTRL WASTE IN'FERCEPBJR COMPENSATION INSURANCE BUB. I ISION FEES (This vection need all hecompldeJ ifine pcnnit is fosse hundmlJollurs( INE GRHASETRAI' PIANC3IECK FEC I certify Nm motile peHnrmencet,fine workforwhich this permit is issued,l shall SEWER-SANITARY-STORM CA.200 Ff. - f1 not employ any Fcrsnn in any manner m as m become subject m the Workers Compen- ENERGYFEE G. 'Oz xolmr Lnws.f Califmda.Dai. WA'I'i!R HEATER WNENT/ELFC,R GRADING FEE z Q Applicant NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEWM RATING [-+ h hocome suhjecua the Workers Compensation provisions of the Lalwr Code,you must SOILS 113E �i fnrthwhh annply wi;h such provisions lir tills permit shall Fv dcmned revoked. WATER SERVICE a � CONSTRUCDON LENDING AGENCY NEW RESIDENTIAL PI.MB. SQ.ET. PAID I herebyaffir that than,is.emamaion lending agency fm the performable of Uera Recei U the work for which J,y ono is",'-ad(Sec.3M7,Civ.C.) C) U Lenders Name `fin _ AL. U Lender's Address TOTAL: 1 cenll'y that 1 have rand this upplicaipn and sate that the above Information is BUILDING PEE by comxLlagree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE 1 LIS r U 7z building conswetion,and hereby audaiee reptesenadves of this city to enterugm the clava-mentioned property for Inspection purposes. PERMIT ISSUANCE ELECTRIC (We)agree a sour:,Indemnify slid keep harmless the City of Cupertino ugui t liabilities,judgments,costs and cxlxnus which may in any way accme againstssi,1C ;ARORADD ) PLUMBING FEE in consequence of the granting of this permit. 111111...... , APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000 CFM) MECHANIC FF.F. SOI'///kkfCH REGULAT 'S. f Ay�/,�O //.74 07 AIN HANDLING UNIT(OVEN IQ(NIOCi M) CONSTRUE TAX so to Signnaturcof Applican Contractor [/O'r•OaI 7- EXHAUST HOOD(W/DUCT) HOUSING MITIGAT NFEE HAZARDOUS MATERIALS DISCLOSURE Will Ne appli...Iorfumre building oc'cupsm stureor handle leaurdous mmenal HEATING UNIT LTO I X0.000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,nod the Hoath and$;,rely HEATING UNIT(OVER job NO BTU)Cale,Seetlon 255J2N)P D Yes ❑No VIINTILATIDN PAN(SINGLE RISM) PAID pole ReceiptN Will me applicant or future building occupant use equipment or devices which BOILER-COMP(JHPOR 100,000 BTU) emit h trardous air contaminants©defind by the Bay Arca Air Quality Management TOTAL: District? _ BOILER-COME(OVER 100,000 BTU) D Yes D No I have taad the havadcus matad.],mquiremems under Chapter 695 of me Cl AIR CONDITIONER ISSUANCE DATE forma Health&Safety Cade.Scallions 25505,25537 and 255)4.1 understand thus d the NEW RESIDENTIAL MECH. SQ.Pon building does notcurrently have to tenant,mot itis my rc,,aibility nm notify the occupant _ of the requirements which must be met prior to issuance of a Certificate of Occupancy. Ownermauthoriaadsgent Dem ;1'(yfAL: LSSUED BY: - OFFICE