30953 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO. O
BUILDING:DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL.
BUILDING PROJECT IDF,NFIFICA'1'ION
953
BUILDINGADDRESS: SANII'ARYNO. APPLICATION SUBMI'MAL DATE
088,5-Ions 1/•10 RdK> 2 C,u lwo 1_29_9y
OWNER'S NAM PHONE NAME: LIC NO:
LLS ONE: C NTR5-321 iSoo lfisliWwr. ClotagoLuoybiNIC CO`;jKOLX
ARCHITECT/ENGINEER: LIC NO: AI DRESS: ❑
yet D e¢ -s6*94 zwl oK I N
C NTACI': AECIIIIJ44 SPHHOHNE: BUILDING PERMIT INFO
4Ab-366-1b" ❑ Consultant Fees Paid by Applicant(Initial) BLIA ELECT PLUMB MECH
O . _ \J ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby i firm that late eecnsed under provisions of chapter 9(commencing JOB DESCRIPTION
DoZ Ih Scction]IXXpofUivisi.r3of the Businessand Professions Cacheand my license is RESIDENTIAL'
BIO= wt PERMIT ISSUANCE
aL--- mf:set Cleand effect. S91 ❑SFDWL ❑KITCHEN REMODEL
VV Ltccnse Clexs Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ti a a Uatc comranor
F,Dy RCHITECTS DECLAkA'1'101 PANELS ❑MULTFUNIT ❑STRUCTURAL.
Z C H Z 1 underswed my plans shall be toed as public records MODIFICATION
ay—Q UPTO200AMPS ❑INTERIOR El CHIMNEY REPAIR
W Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARAT
IYY OVER I"AMPS
C3 BATH RB:MODEVREPAIR [_1 DEMOLITION
tY IY Q I hereby affirm that 1 am exempt from tb<Centim
eter's for IM1e
ko1U fallowing rcocnn.(Section]OJLS.Business and Professinnr county SIGNS ELECTRICAL ❑OTHER
which 4 permit t construct.alter p demolish, structure
Cpriori t al q st pplc' tf r. hp tatenenl SPECIAL CIRCUNUMISC.
'�'tlt1nnyyy thath 1 dp a t the pr ns fth C I Ihapter9
�CQO (commencing with Section 7")of D' to J of the Business dProfes ns Code)or TEMP.MEi'ER OR PoLE(NST COMMERCIAL'
d d-Z that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
y Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEV IC[S
❑TENANT ❑FOOD SERVICE
t more than five hundred dollars 15500).
�ZQ ❑ 1,as nwnuntl the properly.nrmycmployecowith wages asthcinnlemmpensatinn, SWIMMING POOL ELECTRIC PROVFiMENfTIAU
�1 will do the work,and thestruemrc iInotimendedorofl'orN Wm
misvle(Sec.]I ,Busins OTHER 0j fm-
W m and Professions Code:The Cmamaor'x License Law does not apply m an owner of OUTLETS-SWITCHES-PIXTUR
a 3 pnaprny,who builds or improves thcmon,and who dotes such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECFR S FT.
sale.If.however the building Or improvement is wait within one year ofrompiniun,the SQ.FTFLOORAREA VSQ.ET.
owner-builder will have the burden of proving that he did not build I,,impmva 61par- pp
pox of sale), nI%
❑1,as owner of the prolxny,um exclusively cunnacting with licensaJ eonnocmrs u, IOIAI
onotma the project(Sec.7044,Business and Professions CmdeJ]he Conaacters t -
senseUseoesnutapplyloanownerofpropenywhobuildsorimprovesthrown.and QTY, PLUMBING PERMIT FEB g REC'
whocontraccs for such projects with a conlTachms)llCCnan
ed punuann the Commcmr's
License Law, PERMIT ISSUANCE
FI I am exempt under Set. ,B&PC for this reason
ALTF,R-DRAIN&V EN I'-WATER(EA) ,U T 1
Owner Date.
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
O 006 Q 0
1 hi amrm under penally of perriary one of the following declarations:
I have and will maintain a Ccnificateof Consenuo self-insure for Workeh Counties- DRAINS-FLOOR,ROOF,AREA.GOND. STORIES TYPE CONSTRUCTION
tion,as provided for by Section 3100 of the Labor Code,for the performance of the
r which this permit is iasa.I. - FIXTURES TRAP e�/y„
wo AM
�ve and w11I ode.fon he Performance
Ca ce of the is Insurairk for hi h required by Section
3]Op of the LnMm Ede for performance of lM1c work for which Otis permit is issued. GAS-EA.SYSTEM-1 INC.40U'TLETS OCC GROUP AI'N
My Wfrkdy C`Igpe_sytolL rqt� ePolcy No.: r e: GAS-FA.SYSTEM-OVER 4(CA)
CERTIFICATE OFEXEMPTION FROM WORKERSGREASFIINDUSTRL WAST1iINTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thikscetionnecd not her nntploted Etbepeouni,Ruomehumbaddnllars(511X)1 GREASE TRAP
nr lass.) PLANCHECK FEB
I exroytbat intheperfammuseofthework for which this permit is inured,lnhall SEWER-SANITARY-STORM EA.200 FT.
not employ any parson in any manners as to become subjan m the Workers'Co clam- ENERGY LYE
Q Z cation Iawsof Calibtmia.Dae WATER HEATER WNENTIELECTR GRADING FEE
Z 2 Applicant
tV/�J NOTICE TO APPLICANT:If,after making this Ccnifnac of Exemption,you should WATER SYS'I EMOREATING
S become subject In n1'
the Worker's Cmemadon provisions of the Lubar Code.you must SOILS PHC
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FE PAID
VQ (hereby affirm that therek a construction lending agency for the performance of Date Receigp
rhe work for which this permit is issued(Site.Ly)].Civ.C.)
IL Lenders Nano TOTAL'
V Lender's Addresv 'TOTAL:
} Wy BUILDING FEIi
I codify that 1 have read this application and dale that IM1e aMwc information is
F h correct.)as=to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE
V Z building construction.and hereby V->,4117
xnmtivcs ofthocitymcmere,wi Ore SEISMIC FEE
abovrmemioned property Bit sex. PERMIT ISSUANCE(We)ugme m saveindetnp hanrics,the City of Cuperinu againstELECTRIC f>ER
muY in any way acALTER OR ADD'TOMECH, PhUMBING PEEA PLICANT NDERS AN SAPPLICANT UNDERSTANDS COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO IO.IXp CFM) MECHANICAL FEF.
SOURCE REGULATIONS.
q AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCIONTAX
Signature of ApplicanVContjM.nip.
ac EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEL:
H, ERIALS I IISCI.OSURE
Will the applicant or g occupant store or handle hazardous marenal HEATING ON IT(TO 100.0X0 BT U)
as defined by the Cupeninn de,Chapter 9.12,andthe HeahM1 and Safety
Cade.Section 255320a)? HEATING UNIT(OVER 100.0on BTU)
❑Ycs VENTILATION PAN(SINGLE RFSID) PAID
Will thea licanl or future huildin tux a ar devlcm which Uma Receipt p
pp gnccupun quipmcn cUMP(}HP OR 100,000omit hazardous air con inuumns u^ fined by the Bay Arca Air Quality Management BOILER 100,000 BTU) IOIAL:
Dnrml] BOILER-COMP(OVER 100.00)BTU)
❑Yes
I have rc:ul the bssuckas aatarials ymmm mI under Chm%rr 6V5 oft1m CAi. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code.Semens 25. .255J3 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.P1'.
buiidingdt,vnnolcurcmlyhaveamnau6 tilisntymsponsibil'n rally the occupant
ofthenNuirenuntxwhichmunihemcl to iso eniliewe of Occupancy.
Owner or vuthorivrd ager Date TOTAL ISSUED BY:
OFFICE