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30236 APPLICANT TO.FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. I�323Y6 O/�^/N BUILDING DIVISION APPLICATION/PERMIT PLUMBING-M1fECHANICAL BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS! ©��� \ (y SANITARY NO. APPLICATION SUBMITTAL DATE 0i xi� O ER'SNAME^E{g Gigm� 1/�\JY���i��rP7;1�E�:�,—r/�0no CO�QN9CfSN'S NNfM' LICt'�laG r��� - Cp'rR{71LI•may--�E�ICv�eL � r Yd' NIC CONTROLN �ARCHITECT/ENGINEER: LIC NO: A 0! y��� I6� p ❑ I�JI[ � LL lIF CONTACT: PHONE: BUILDING PERMIT INFO Rilo S3� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT• NIECE !-- 6v v ❑ ❑ U ❑ LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby vfrom than I am licensed made(provisions of Chapter 9(commencing JOB DESCRIPTION k�Q lecZ with Section of Division 3oflnc Business and Prrfr,,oana odeandin licenseis WO wi y PERMITISSUANCF. RESIDENTIAL, n full force and a t. 8 X SFDWL ❑KITCHEN REMODEL aUj LicenseC 1.icN APPLIANCES-RPSIDENTIAL Has Dane Contractor ❑ADDITION E)PLUMBING RE-PIPE Q ARCHITECTS DECLARAI'I(. PANIiiS F.7 to - ❑MULTI-UNIT '�STRUCfURAL Z O I understood my plias shah be used as public records MODIFICATION O Z UI'TO 2M AMPS g..yl"IOi( License)Pr�fessional ❑INTERIOR ❑CHIMNF,Y REPAIR g3 OWNER-BUILDER DF.CLARA'1'ION 201-I OOU AMPS IMPROVEMENTN0 ac 1 hereby uffinn than 1 um extend!from the Contractor's License Law for the OVER 1000AMPS [IBATH REMODEUREPAIR ❑DEMOLI'T'ION t1U whfollich grcas n.aper Permit ad construct, aftmeas er,improve, ve,dmoli CWr:Any city or county SIGNS ELECTRICAL DOTH. F 4.O[- which requires n Permit re cnnswer,corer.improve,demolish, file repair any statement Ts prinnoslits cenedpursare tot he peathe visions o forsuchr rminoicenseaw(Cutemene SPECIALCIRCUIT/MISC. that he is licenscJ pursuant!robe provisions of the Cnmmcnor's License Luw(Chapeer9 (commencing with Section7")of Division 3 of the Business and Professions Code)or TEMP.MHTHk OR I'OLEINST, OMM $ IA that Iia Is exempt thcrefmm and the hook far the alleged exemption.Any violation of � Section 0o3L5 by any applicant Toro pemtit subjects the upPlicem noacivil penally of POWER DEVICES ❑NEW BLDG/ADDITION ❑DEMOLITION } art mom man five hundred dollars($500), ❑TTiNANT ❑FOODSERVICE C ❑I,as own<r of the pmpcny,or my employees with wages es their sole compensation, SWIMMING POOL I:LELTAIC IMPROVEMENT will do the work,and die structure is not intended oroffered fmsole(Sec.'/1144,BusauSa ❑OTHER c.3 and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES property who huilds or improves thereon,and who does such work himself or through his own cmployaes,provided that such Improvenems aro urn intended rr olfeteJ for NEW RESIDENTIAL HI.ECTR SQ ieL sale.If,however,the building or improvement iserld wilhicare,car of comphtion.the !SQ.FT.FLOOR AREA $/SQ.FT. caner-builder will have the Imar enof proving Nat hedidnmbuildorimproveforpur- pose of side.). ❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: construct he project(Sec.7044,Business and Professions Code:)The Companies Li- cense Law does not apply to an owner of property who huilds or improves thereon,and QTY, PLUMBING PERMIT FEE h •e•"" ' who omtmax divsuch Projects with v eomntemr(a)fircowil pursumnuo the Conouaor's Ellam Law. PERMITISSUANCE U 231996 ❑ lam<xonpd male,Sec.. ,B&Fefor this ason Owner Dare ALTER-DRAIN&VENT-WATER(BIG VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE CITY lir uUr T-III INV 1 hereby ffor under penalty of pe,a,one of rhe Endowing declamt bas: ❑ I have and will tauintvin a Cend cate of Cnnsenuo.wir-itisere for Worker's Cooper- DRAINS-FLOOR,ROOEAREiA,COND. STORIES TYPE CONSTRUCTION lion,as provided far by Section Thio of the Labor Code,for the performance of the work for which this Permit is issued. FIXTURES-PER TRAP I have and will maintain Worker's Compcaaminn Ins rantt,as required by Seetiom Tft.fffic LabirCWe,for Ne perfommanceofthe work fmwhieh this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS My OCC.GROUP APN Cancer nInsu ce carteradd Policy i Cvniee m d � Policy Nn.. ���' GA9-EA.SYS'!I!M-OVHR4(EA) CERTIFICATE OF EXEMPTION FROM ORKERS' GI2HASFlINDUS'1'RL WASTE INTERCEPTOR (This INSURANCE (This section cited not be cnmNmal if the permit e,lie one hundmldollars($Bio) BUILDING DIVISION FEES or less] GREASE TRAP PLANCHECK FEE Loy cry Naeln the perfianyru iter nl the becameork abjc this permit is issued,Ishan SEWER-SANITARY-STORM EA. IT. nor employ any person in any manner sn as m became suhjccno Ne Workers'Cnmpen- O � ENIiRGY FEE OZ cation Laws of Culifamia.Dote WATER HEATER WNENTMI-ECTR 70 Applicant GRADING FEE s-a C4 NOTICE TO APPLICANT:IL alief making this Cenillcme of Exemption,you should WATER SYSTEM?REATING a , 'Meome subjeer ro the Workers Compensation provisions of the Lbm Code,you must SOILS FEE profession comply with such prnvisiens or this permit shall be deemed revoked. WATER SERVICE 4 � U z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID UQ I hcmhyvlErn r pecout i issued(Sue.30 leading agency far the performance of Dam Rcccipn# Dw i" the work for which this permit is tuned(Sec.3000,civ.C.) Q U Lender's Name .TOTAL: Lender's Achim. y 1 mnify that I have read his application and area,that the strove infermetion is � BUILDING FEE rA comecn,l agree to comply with all city and county oNinancea and state laws miming to QTY. MECHANICAL PERMIT FEE U ,'Z building construction,and hereby authorize represemaiives afthis city to emeruponthe SEISMIC FEE abeve-mentimed property for inspection purposes. (We)agreemsuvu nide 'y dll-e ha-losstho CIlyof Cuperlinovg.iina PERMITISSUANCH ELECfRICFEE liabilities,judgments,costs an p sex which mayin any way engaina said City inconsequence he pe 0 o is permit. ALTER OR ADD gY)MECH. PLUM RING FEE APPLIC UND iR5 5 AND WILL PLY I�Al .;Nx;T qIR HANDLING UNITfl'Q 10,000CPM)SOURCL :GIi fl0 MECHANICAL FEE QAIR HANDLINGUNIT(OVERIO.o1N)CFM) CONSTRUCHONTAX Signa u.: VConaumor )mc EXHAUSTHOODOMMUCT) HDOSING MITIGATION PEh HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT CTO 100,01))BTU) vs defined by the Cupertino Municipal Code,Chapter 9.13,end the Health and Safety Code,Section 25532(x):' BEAT ING UNIT(OVER 100.000 BTU) ❑Yea No VENTILATION FAN(SINGLE RPSID) PAID Ualo Ravi i#. Will the applicant or future building occupant use equipment or devices which p emit hazvrdous air amtaminanrs as JcfinW by ehe Bay Arca Air Qualhy Munugunent BOILFR-COMP(3HPOR IDIOM BTU) L's aicc, TOTAL: C]Yea []No - BOILER-COMP(OVER 100,000 BTU) I have pawl the haradous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DAT funds Health&Safety Craft.Sections 25505,25533 and 25534.1 understand than if he NEW RESIDENTIAL.MECH. SQ.IT. huilding does nmcarcndy have a tenant.that it is my resl'onahilky to red theoxcupam of the requirements which muse be amt prior no issuance of v Cendicate of Occupancy. OwnerorauthonreJ agent . Date TOTAL: ISSUED BY: OFFICE