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30584 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY - + CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. 30584 {A O ^ w BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. LU�l8 BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE a�ssa fr�ZO-9� OWNER' AME: , PHO F.: RA RME:" LIC NO: I-X,-4ff a G Q NAC CONTROL# RC ITECT/ENGINEER: LIC NO: ADDO S0 CONTACT. PHONE: - BUILDING PERMIT INFO s✓� �� p� ❑ Consultant Fees Pald by Applicant(Initial) BLDG LECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION C 0 O 0 1 hereby affirm that 1 um licensed under prnvisiom of Chapter 9(commencing QTY' ELECTRIC PERMIT FEE JOB DESCRIPTION �Do wifsmarm ofDmvision3oftheB�ninessandPnfessinn.lady Jmyliccnseis m� in full forms G /- 07 PERMIT ISSUANCE RESIDENTIAL �UL) License Class Lic,# 0SFDWL ❑KITCHEN REMODEL ��ul Dole Tontmcmr�_ APPLIANCES-R[SIDENTIAL ❑ADDITION t;,y �q/ (�f/��yARCHITECTlture' �A-"its ��yyg��g,� ❑PLUMBING RE-PIPE ,yO 2 Iundersund myplana shall beusedmpublic records/ir•�+0� PANELS 0MULD-UNIT OSTRUCMRAL Z`0UP TO 2W AMPS MODIFICATION F•.h.,FW Lmenacd Bofensmonal 0DtTERIOR HIMNEY REPAIR OWNER-BUILDER DECLARATION 301.1000AMPS IMPROVEMENT IS W 6 I hereby strumshot 1 am exempt from the Contractors License Law for the OVER]"AMPS 0 BATH REMODEUREPAIR 0 DEMOLITION SG 3 L OF following reason.(Section 703 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL Cl OTHER Rl LL Oye wInch maims a permit to construct.alar improve,demolish,or repair any almonate mJ priorto is issuance,also iequircvhe applicant Permit to file u signed statement SPECIAL CIRCUIT/MISC. <E that he is licensed pursuom.mthe pmvisiormanhe Contrumrs License law(Chopmr9 IYOp (commencing with Section 70)()af Division Sof the Businessland Prof cions Code)., TEMP.METER OR POLE INS T COMMERCIAL- that6 L m he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION „,m Scedon]031.5 by.ny applic.nt for a permit subjeax the epplicam to o civil penalty of POWER DEVICES H 2 Y not more then five hundred dollars(SSW). _ ❑TENANT ❑FOOD SERVICE =Q ❑Llathe worof Mek,and propcny,reOr myemployas-with wages fortheir ( ee compensation, SWIMMING LF.CTRIC IMPROVEMENT ^o will do.hework,ands:The Curc is I.e.tended License La-ffw ad dos not apply to an,Business WOTRandProfessionsGude:The Contreereo License law does not apply m lar owner of OUTLF7S WITCHES-FIXTURE$ propemsy who builds or improves thcrton,.nd who dos such work himulf ar through his awn employees,provided Nat such improement.eR no.imchum ar offered for NE ESIDENTIAL ELECTR SQ PT..]a.If.howver the building or improvement is old wiNin one year of comple.ion,.he ORAREA 5/SQ.FT.owner-builder will have Ne bunlch of proving Na.he did not build or improve(or par- 0 Dpose of sale.). ❑1,as owner of the propcny,am exclusively comrec.ing with licensed commnom to TOTAL: construct the project(Sec.70W Business and Professions Cale:)The Contractor's Li- cense Law docs not apply 10"owner of propeny who builds or improves!hereon,and QTY, PLUMBING PERMIT FEE ®� �/1 who contracts for such projas with o commctor(s)licensW pursuant o,de Comtvcmr's 6� License Law. 1190 0 l am exempt under Sec. ,B A P C for this mown PERMIT ISSUANCE - CITY OIL GUrtHIII o Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE �� 1 hereby affirm under penalty of perjury one of the following declarations ❑ I have and will maintain.Certificate of Consent to self-insure tar Worker's Compen- DRAINS-FLODR.ROOF ARPA,COND. all ...as provided fnr by Semion 3]W of.he Labor Core,for the penimmmce of the STORIES TYPE CONSTRUCTION hich Nsu is permit is issued. FIXTURES-PIER TRAP ” or have and annndd will moinminJWao�rker's Compensation Insurance,as required by Section mosentmessolk CMy ame rNad rt Ko c mT POINfnr wb+chis pera'tt,is issue GAS-G.SYST M-OVER �C.GROUP APN CERTIFICATE OF EXEMPTION FROM WORKERS'//G/7( COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INH MR or less.) (This socdneGREASETRAP on ed not he completed if .it is for one hundred dollars(SI W) BUILDING DIVISION FEES I cenify that in the farmance of the work for which this PLANCHECK FEE z net em In on any permit is issued, en. SEWER-SANITARY-S MEA.2W FT. p y y person in any manners as m hecnme subject the Workex'Cnn.p°n- ENERGY FEE cation Laws of California.Date WATER HEATER W NT/RLF,CTR O �O Applicant GRADING FEE 0 NOTICE TO APPLICANT:If.rs afterCommaking n is COloolonsuofMLaborExemption,( you should WATER SYSTE HEATING CFai become subject to the Workers Compensation pn+visionx nl'.he Labor Ctsue,you must SOILS FEE forthwith comply with such provisions or this permit shall In deemed revoked. W Q WATERS7 ICE ' p, CONSTRUCTION LENDING AGENCY PmZ NIiW ,SIDENTIAL PCMB. SQ.FT. PAID V0 I for by which thi Hermit i issued( ecti0lending agency for the performanceof Date Receipt it LT. (~ the work for which this permit is issued(Sec.109],Civ,CJ U Lender's Name a TOTAL: yy.W Lender's Address TOTAL: L, pr 1 cenify that 1 have read thirty and coup and dinla the the shove information mining ix BUILDING FEE GG Vl eomeL lAgree.o comply with all city end county ordinances and sem laws mining to QTY, MECHANICAL PERMIT V imovengathated m,nd herehyuuthon prposeemativa ofthis city Incn.erupm the FEE SEISMIC FEE s� above-mee)isju properly foririnifyonpurposes. PERMITISSUANCE ✓ (We)agmen m cove,indemnify and keep harmless w City of Cupenino id Cit t ELECTRIC FEE lieemselmorr ofthesmsts nindm alis es pennitch may in any way eccroe against said City ALTER OR ADD TO MECH. A consequence NDEgranting of this per mit PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10,0110 CFM) SOURCE REGULATIONS. MECHANICAL FEE ' AIR HANDLING UNIT(OVER IBOW C CONSTRUCTIO Amgnawrc of AppbcmtlCanRDOU Data EXHAUST HOOD(W/DUCTI HAZARDOUS MATERIALS frame lard) HOUSING MITIGATION FEE Willthee Cticentor,flumebuildingCode, Ciomnareorhondle Health usmamnal HEATING UNIT(TO 1W,IXgB ) m defined io the Cupenino Municipal Code,Cheerer 9.12,and the Health land Safety Code,Section 23532(el? HEATING UNIT(OVER I ,(100 BTU) 0Yes ON. q� VEMILATION FAN NGLE RESID) - PAID/ Will Ne applicant or future building occupam use equipment or devices which DoleRec44g Remit hawdousah,<omm�drants as defined by.he Bay A.Air Quality Ma...cme, BOILER-CO (3HPORIM."BTU) -� Distdn? - TOTAL: El ❑No BOILER- MP(OVER 10BOW BTU) ee 1 have readtheh.aardous interns acu4emcnu under Chainer 6.95 of the Celi- AIR DITIONEN —w fo h&Safety Code,Satiom 25585,25533 atM 25534.1 undersand.h.t if Jit ISSUANCE DATE J 'ng haveamnanL dmt it is my rtspomihiliry to notify the occupant WRESIDENTIAL MECH. SQ.FT. (th ust be met prior m issu.nm of aC/ca.ufOccu cy - ZA i LG( OwrerorauN uA Date TOTAL: ISSUED BY: OFFICE