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B 0216 (2) ,t. ,'APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO, ` - BUILDING-ELECTRICAL - PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, s000� - 1�y(Q0216 BUILDING PROJECT IDENTIFICATION BUILDING PRESS, SANITARY NO. APPLICATION SUBMITTAL DATE `' a,3/5 NjerN LANCA. ' Si.' E,Q ^ NG 01 O/ 2 '0 Cj OWNER'S NAME: _ PHONE: CONTRACTOR'S NAMEDiCIC : LIC NO: I N 'KIS (909)916-65"97 L• L. 6i[J �Q /Artt-- NN/C CONTROL# CHITECT/ 3505 lc l c t R ENGINEER: LIC NO: ADDRESS: SRN R kAMQA .'I�xsa ' ❑ NTACT: PHONE: - - BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH . El ❑ El LICENSED DECLARATION QTY ELECTRIC PERMIT FEE' I hereby affirm that 1 stn licensed under provisions of Chapter 9(commencing , _ JOB DESCRIPTION OCz with Section]000)of0ivisinn3of the Business and Professions Code,nndm license is' •Er DO y PERMIT ISSUANCE 'RESIDENTIAL: - i i fell force and efect. U U�[� License CI ss r Lic,a ��6 IJ ❑SFDWL El KITCHEN REMODEL y 7j{i1,Date Con[raAPPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE a' ARCHITECTS DECLARATION FPANELS ❑MULTI-UNIT [_1 STRUCTURAL O O'�Z�' I understand my glare shell be used as public records p UPT02WAMPS F 4Eq•'W PAIR Licensed Professional s [:1 INTERIOR ❑SWIMMINGNEY POOL 2i4 OWNER-BUILDER DECLARATION 201-IUW AMPS IMPROVEMENT SWIMMING POOLS YGl' I hereby affhm Nal l am exempt Baratta,Cc amounts License Law for the OVER IWO AMPS ❑BATH REMODEUREPAIR El DEMOLITION 3 W F following reason.(Saniun]031.5.Business and Prmfessions C,vle:Any city or county SIGNS ELECTRICAL ❑OTHER (7 sn which requires aroma m consrmcq alter,impmve,demobs or repair any nmcture n ffnn�' p6mirwibissuance,also requires the applicantfmsuch pa, file asigre nommen SPECIALCIRCUUMISC. , t^071n y thin he is licensed pursuant the prmvisions ofrha Con cine'. 'cense (Chapta9 — GO (commencing wiNS a 7000)of Uivision3ofrhe s c dPr ..inns Cude)mr TEMP.METER OR POLE T. COMMERCIAL; a p.o y that he is exempt th from and the bas�lw setup n.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section]031.5 by yapplicant fragedjusr.t ap cant toacivil penapy of POWER DEVICL•S } nrmoreNanf v hundred dollars( W - - - ❑TENANT ❑FOOD SERVICE ❑I,asowner theprmpeny my s wage,ustheirsoleomeri' sauon, 'SWIMMING PO .ELECTRICIMPROVEMENT wdldaNew ,math�sv mrelsn nidmifired6usale(Seo.]044,Beninese ❑OTHER to 3 m and Profess' C°de Commawk License Law does not apply to an owner of OUTLETS .WITCHES—FIXTURES L properly whn bm s improves Nene and who does such work himself or though his own employee. provided Nat such impmvemenraare nar intended or offered for -NEW IDENTIAL ELECfR SQ FT. sole.If,howevegth building°rimprovemem is sold within oneyearofcomplenon,the SQ.PT.FLOOR AREA VSQ.FT, caner-builder will ve the burden of proving that he did not build or improve for put- . t pose mf sale). ❑ 1,as owner of the remarry,am exclusively contracting with licensed contacts.to TOTAL: co,anus the project(Sec 7044,Business and Professions CO.,.,The Conaacmr'a- cerise Law does not apply to an owner of property who builds or improves thereon,and QTY j'PLUMBING PERMIT FEE who contmcs fortieth projects with a cm etacmr(s)licensed pursuant name Contractor's License Law. PERMIT ISSUANCE ❑I am exempt under Sec. ,B&PC for this reason Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION - ' WORKER'S COMPENSATION DECLARATION - BACK FLOW PROTECT.DEVICE V I hereby upon under penalty of perjury one of the following declarations: • I have and will maintain a Certificate of Consent to self-insure for Worker's Camper- ,DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPF,CONSTRUCTION kation,as provided for by Section 3]00 of the Labor Code,for the performance of the N/ k for which this Permit is issued. PICTURES—PER TRAP WI have and will maintain Worker's Compensation Insurance,as required by Section 3700ol'the Calver Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLET OCC.GROUP APN MyWmrker's Cgqmmp�cnw?Insumnce carrier and Policy nyy{mpbb��ale - - -ZZL / Cartier /V F11�L Policy Nm.: GAS-EA.SYSTEM-OVER 4 HoG ' d CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASMNDUSTRL WASTE IM CEPTOR or leas) (rN A ction needed be,amirriat t ,ad if the permit is for..w hun had dNlars($100) GREASE TRAP BUILDING DIVISION FEES PLANCHECK FEE 1 certify par in the performance of work fur which chis permit is issued,I shall SEWER—SANITARY—. RM EA. FT as t not employ any person in airy manner so as o becomem subject the Workers'Compete- ENERGY FEE z cation Laws of California.Data O Applicant I WATER HEATER W NT/ELECTR Btq ING FEF. rjl NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYST ll'RF.AfINC Ll become subject to the Worker's Compensated provisions of the Labor Code,you must SOIL E forthwith comply with such previsions or this permit shall be deemed revoked. WATERS ICE p ✓O CONSTRUCTION LENDING AGENCY NEW SIDENTIALPLMB. SQ.FT. 'PAID 1000 I hereby affirm that is a cousrmcrion lending agency for the performance of nte'aarpt# L4 H rho work foe which this permit Is Issued(Sec.3097,Co.C.) Q U Lendan,Name " TOTAL: W Lenders Address TOTAL: J Ca I cenlfy that I have read this.,platinum and sate that the above information Is ti ycorrect.I agree to comply with all city and county ordinances and state laws relating t° QTY, MECHANICAL PERMIT FE 7 E UG building construction,and hereby aeaaire representatives of this city to enter upon Ne SEISMICFEE O above-mentioned pmpdry for inspection proposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupenlno against, ELECTRIC PE liabilities,judgmenls,cosrs and expenses which may in any way accrue against said City ALTER ORADD TO MECH. t In consequence of the granting of this permit.' PLUMBIN E APPLICAN" NDERSTA.NDS NO WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT 10,100 CPM) SOURC LAT N MECHAN A FEE � c AIR HANDLING UNIT(OVER 10,000CFM) In ��,� CONSTRB ION TAX Slg�treAPpbl nn tfo Date EXHAUST HOOD DirMUCT) HOUSING TICATION FEE HAZARD�f GS MATERIALS DISCLOSURE Will the applicant or fufbrebuilding oecupom store or handle hazardous material HEATING UNIT(M 100,000 BTU) as defnvil by the Cupertino Municiyyyel Code,Chapter 9.12,sad the Health and Safety Codq Section 25532(a)R HEATING UNIT(OVER I(10,( TU) ❑Yea VENTILATION FAN(SIN RESID) PAID Will the applicant or future building occupant use equipment or devices which Data Receipt N emit hazardous ch ro i minen[s a, defined by the Bay Area Air Quality Management BOILER—COMP(IHR 100.000 BTU) 7"A District? o BOILER—COMP VER IW.11f1(1 BTU) 1 have reed the haznrdmue materials requirements under Chapter 6.95 of the Cali- AIR CONDI NER q p ISSUANCE DATE fomla Healthg lows&Safetyra Coda.Sections 25505,25537 and 25534 1 understand that if the NEW R DBMIAL MECH. SQ.FT. �- Z O buildingdoesi c ntly haves moat Ithm t[isrrny responsibility to nmtify the acupdn I rcquir nen hie Prost me pdmt gsuance �fe Corthiereaof Occupancy. °X H fi Owner m odmde ear Date TOTAL: ISSUED BY: OFFICE `sa 3u ifc 'zascr ;atiir�.�rav :3..V� FAr(YG37 .a7-ruD SIv�V'1',1 1.t1`ra 13'x 491 PATIO Coven ONLY W/TgoER To ao, 5 _ l � PL N ou sE 4 � l 1 i l 1 13� R E D21VE wq`1 SJILVE ClLU6TOME0.: Dlcu 7N FANTINO • 8-a316 CAILTA %LANCA ST. NPERTINo CA . gb01y C4o9) A45- G697 I ¢ p _ .� rb (n. ry trr unrMt! F� a�• m_ BRA F. ( n':• - Yi sE ca :E3 Com) IIr' �-�••-� _yy E•4 'r-i_¢ W o- Ra ' ' { FaF �I'" .SR I -• '% 91 I ,�� ^f I °°Q� 7 la l` - �C•1 En I� t-� I I :$ xF• ,_-� eP q'. 7 ^� E P2 r— I x O i ? xA y D I'S Fc° `111 g . 7 wl Fz n B J 7.e . 011y. p yi + rD Cl s fll: f O CL EF�x8945e J aD a gi 1 j Yee :@• Gi Rill ii. • al % I"A I�.EgI via el X nr IAgI l IR `EI il gF f U' •:: ��• R^I L .I�•�E t` IRg� j I r•. r RI�I ^° " . 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