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30657 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING: ELECTRICAL PERMITNO. �O BUILPINGUIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL DIVIDING PROJECT'IDENTIFICATION 657 BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE - Caffey � CFtied.2'ca.1 �3uXlc�l�h6 � .. OWNER'S NAME: PHONE: CONTRACTOR'S NAME: TIC NO: N,IAO %ASNLG 'F_wcp u� N(C COMROLN ARCHITECT/ENOINEC WC NO: ADDRESS: ❑ IR as, Sw Soc&jvd s!- tr-j C1410") CONTACT: PHONE: BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLD ELE. PLUMB MECH Nti\fie C1c�\IT 415.91-1-9RaO ❑ ❑ LICENSEDCONTR CTOR'S DECLARATION Q.I,y ELECTRICPERMIT FET? 1 hereby affim,mat I am IiansW under Provisions of Chapter 9(cnmmendn6 OB DESCRIPTION O00 with Section7")of Division3 ofthe Business and Professions Cale,andro (tense is �.k FU'W F in full force and a—�1 ffkt, y PERMIT ISSUANCI: v RESIDE.N-TIAL. UZ�2 LicenseCru Lica-M- - `� ' ❑SFDWL ❑KITCHEN REMODEL �nty Date Can,. APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-PIPE I.M o ARCHITECT'S DECIARATION ❑MULTI-UNIT ❑STRUCTURAL PANELS Z O 4 1 understand my plans shall he read as public records MODIFICATION OZ` , UPTO 2M AMPS NTERIOR [I CHIMNEY REPAIR [.r�FU Licensed Professional - 201-I000AMP5 IMPROVEMENT OWNER-BUILDER DECLARATION q�y C 6 1 hereby affirm that I am exempt from the Contractors License Low for the OVER I(HeJAMI'S [3 BATH REMODEUREPAIR [I DEMOLITION pd 3 S U following meson.(Section 703 I.S.Easiness and 14ofessions Code:Any city or county SIGNS ELECTRICAL. []OTHER Cwhich requites o permit to emmn¢t,.her,improve,demolish,or repair mry stre,mrc poor to issuance,also requires the applicant for such permit o the asigned statement SPECIAL CIRCUIDMISC, r�A } that he is licensed pursuant to the provisions of the Contractor's License Low(Chapter 9 .,-N- CIO wormy,...unit withSceion71.1 of Division 3 ofthe Business and Professions Code)or TEME METER OR POLE INST. COMMERCK(� g that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION z�4LL• Section'U,'by aay applicam Jr.r a permit"objects flaw upplicannnn civil penalty of POWER DEVICES . ❑TENANT ❑FOODSERVICE m marc wthan e f vat hundred dollars(SSW). IMPROVEMENT y7R �Leaownerk,rid thesom,or myemployees d wimwages r their(Sm. (W,B sines, SWIMMING PIX)L ELECTRIC F❑ and dothewons and themucor.isnot rs LiceedoroRedos of apply to an Business ' ❑OTHER and Professions Curb:The Cos there's License is ,do saes not apply s if owner of OUTLETS-SWITCHES-FIXTURES N O p gp his own who builds or improves thereon,i and who does such work himself or through tl—IV ,his own employees,e bottom, such improvements are not untanned or offered for NEW RESIDENTIAL EL[CTH SQ FT. ownef,hnwevegll hveth ng orimprovementissoldwnd noneild or improve SQ.FT.FLOOR ARE 96 E] erbuilJer will have the burden t,f proving that mind not build or improve for per- DEC 12 1 96 Esse oasaleJ, ls�n W ❑ Las owner of the property,am exclusively contmeing with licensed contractors to TOTAmicauL. C Li- move La does not (Seeapply loan 4. offoodrty,who h i all buidsor imhe Contractor's Li- CITY UF WPEH INV cemselawducor such plyman with a cofpmperty whosedpouant to the Contractor's QTY, PLUMBING PERMIT FEE V who commas for such projects with a cnmrueor(s)IittnuJ pursuant to the Cantmmor's License Law. PERMIT ISSUANCE ❑I am exempt under Sec. ,B&PCfalhixmlom OwnerDate ACIER-DRAIN&VENT-WATER(EA) 2 �VrArLI❑ATION affuWORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE JO© I hereby m under .at,,of perjury one of the following declarations :F1 ❑I have and will maintain a Certificate ofComenua.self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES 'TYPE CONSTRUCTION station,os Provided for by Section 3700 of the LOM,Cale.for the performance of the well for which thin permit is isxaed. FIXTURES-PER TRAP Cl 1 have and will mainmin Warker's Compensation Insurance,as required by Section 37M of the Labor Cole,for the performance of the work for which this Permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN liel"lyApensation Routine canierand Policynumberme: I \J er Rc Policy No.: I GAS-EA.SYSTEM OVER 4(EA) 1 CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTCEPTOR BUILDING DIVISION FEES sectmeneed but he completed ifthe Mmut is forone hundred dollars IS UTO) GREASE TRA(' or less.) PLA NCHECK FEE Ic.nify that no meperforn,uncc ofshat work l'orwhich this Permit isissued.Ishall SEWER-SANITARY- RM FA.2W FT. nm employ any pe o in any ma Isxase pg�my!K*13o me Winkeri Crimper- ENERGY FEE pion Luresnf 'm ia1)at 1 1♦//N WATER HEATER ENTELECfR Applicant GRADING FEE NOTICE TO A PL CANT:IT.after making This Certificate of Exemption,you should WATER SYST. TREATING (•" become subject I.he Writer's Compensation provisions of the Labor Cale,you must SOILS 17EE Lit forthwith comply with such pmvidons or this pernh Atill hedeemedrevoked. WATH MVICE Q CONSTRUCTION LENDING AGENCY NG RIiSIDENTIAI.PLMB. SQ,IFI PND U O Thereby affirm that there isaconnrunion lending agency for performance of Date Receiptp Li. I-+ the work for which this permit is issued(Sec.3097,Co.C.) Q U Lenders Name TOTALUj : lenders Address TOTAL: gid I certify that 1 have read this appheininn and sat¢that the above information is BUILDING FEE O In correct.l agree m comply with all city and county ordinances antl state laws relming m QTY. MECHANICAL PERMIT FEE t� U.7J.. MildingermomennnanJhereby Outharize rcprcsenutives of lhisci,,to ementrymthe SEISMICFEE N above-anerlonard property for inspection Imposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE Iiahilities,judgments,costs and expenses which may in any way acesne ugainstsaid City ALTERORADDTOMECH. nscqucnce of the granting of this permit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING IJNITffO IO,WXCFM) :�SOURCE REOUTATIONS. MECHANICAL FEE AIR HANDLING UNIT(OVER H0CONSTRUCTION TAX nature of Applicano'Contracmr Date EXHAUST HOOD(W/DUCT} HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE. Will the applicant or future building occupant store or handle hazardous material I MATING UNIT(TO IW,WO 'U) as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Hc:mM1 and Safety Coact Section 25532(0)? HEATING UNIT(OV Ip6N10 BTU) ❑Yes C]No 'q'! VEXF (SINGLP.RF.SID) PAID Will then applicant or future building occupant use Dale R ntpt N PP b e ryuipmcmtor JManaement gO1LER- IP(JHP OR IBUB)0 BTU emit hazallom air contaminants ss defined by the Boy Arta Air Quality Management ) District? TOTAL: ❑Yes ❑No BOIL -COME(OVER 100.100 BTU) _ I have read the herardoes Materials requirements tinder Chapter 6.95 oI'the Cali- AIR CONDITIONER 9 P ISSUANCE DATE fordo Health&Safety Cole,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECU, SQ.ET. building dtxx no curten0y have a renwn,the it is my rtspnnsibility to nmi(y the acuPant of the requircm.ms which must M ma priano issuance of a Canif¢ate of Occupancy. ' Owner or authorized agent Date TOTAL: ISSUED BY: OFFICE ONI1H3dno d0 UO 1N3Wlb'vd3O N01103dSNl'COl9 9661 3 w SNI ;.1 7 Bal zIH - r •NwW /M �•Tvrvd s zry C, (`tom '119' �'ds•DCII d 91'1�� �1e1 ZSs� ap�"d�s3/YDJ ce -e'lop X , `sial 11414% /IH - •o „II�� 1 ''� 50r1� +x3 'i9 C. r4"ml.;1CJ �ro�q v1T H;ltvlmj/lml 1Qc1 •�O,�I�tS � H vW aL rwm 060 /71 (�.u.� � clw g,a,M•wH � cal �brur�l , Ca) �.Is��i R 18 43EiaAj ns)lvtuOx uos!PnH •A8 �1 •31V4 � .' ; _ /A166 e�wo�i�e) Q� olsl3uoij uas • o—ma)-ON 133COad Y/1Ia��L7 '1'0 1i'OiIA �aagsPuo�aSoo4 GS L5 • T��C ' SANTA CLARA COUNTY CONTROL NUMBER CENTRAL FIRE PROTECTION DISTRICT � cri � AR, c 14700 WINCHESTER 130ULEVARD PERMIT NUMBER UG 5 9Po p�'� LOS GATOS, CA 9Ci030-1818 (408)378-4010 TE SERVICE SINCE 1947 FAX(408)378-9342 PLAN CHECK No. PLAN REVIEW COMMENTS CODE/SEC. SHEET NO, t� Vlc`-J of FLA�15 To E.Y_ 1a !\POM 5/zd- a y R C Lc!i e G GJA C.LL- ' © MoDtF`/ C-* 15-7/k)6 F/2C SPl2/A,)kCL12 SYSTEM /tS A) tCE55/f 2 y TO J 4,LJ G'vpsT/�UC T/o tl, • L/[C"SCb Fr/2e ,Qa T GT/O u eou �2.fc7or2 9f/AI.0 Sudw, r To 'TNE Ftr2t D PA2rr+e�u9 3 5G"rS oa �No/' !7/Z/Ft.J/065 , A Cor1/--7e. e D �ERHrti iA�'PC/C.47."A/ /p-IYu �/7F'� /C�4f3GE Fe E5 Fo/2 2E Y/E'tj ! /0A T o QE/Z6o2H / uG THE 4Jo/2K, • /2 Nl/+ IuTkln� e4C doOZ €tttt ZA�eD coA1sT2Uc�"ro /1. lP�/IJpOtaJ5 ;wmj6 GoaRtvol 5,/1440 SE 3�y {/out2 Fltz_e- T?-A-j -"u, �jj°P2odt� nK,4 'Y 3OIL D/Al6 PERr�/T- $aejAl L /Aa/[ C e✓lT/l f}Bo1/E Cor+HE+�-S r/JjQIOR, ;'O F/AJA L- /Al�JP6C y'loAJ ,/J�URISp PLANS SPECS NEW REMODEL AS CONST.DESCRIP. BY -yam 1� DATE j)q PAGE/ Cup � U El 9, � ��L!�.'7 V� miozbo /2//,/ 'L —I_OF� SEC./FLOOR OCC OCC.LOAD AREA ARCH/ENG/CONTRACTOR/OWNER A K � 7 NAME OF FACILITY LOCATION q r-QRLI H A. 2� CN(b :4.-J A) D,UIO 23660 V�/7 Serving West Valley Cities of. Campbell, Cupertino, Monte Sereno, Saratoga, Town of Los Gatos, and Adjacent County Areas