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30468 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO. 30468 BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL. BUILDING PROJECT IDENTIFICATION BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE 2._2/x7 � 0t LIC NO: WN PHONE NIVIEEIR CWv�#t7 / LI-7 N/C CONTROL# BEEFCB ❑ CO♦N�TAAACT^T:f..7aa/777'7777'72��l�� ''// P-3 D P NE: rpJ L BUILDING PERMIT INFO 1IM / T�( ^37(�-7 (0J c ❑ Consultant Fees Paid by Applicant(Initial) t ELECT PLUMB MUCH u' - LICENSED CONTRACTOR'S DECLARATION _ ❑ ❑ ❑ I hereby mnan that 1 ms licensed under provisions of Chapter 9 commencin QTY ELECTRIC PERMIT FEE y,2 p [ g ]OB DESCRIPTION Hwith Salon 70oB)of Division 3 of the Business and Profeasintu Cade,and my license is o w PERMIT ISSUANCC RFSIDFNTIAL: U infall force and�{Ik,It/-� / 0y- '�2,f" ❑SFDWL ❑KITCHEN REMODEL. �V[J License Class - / Lic.M (D APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE I-.Z Date Ccmtmrtor Z�Oy ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL. !/1 F4 1 underamnd my plans shall be used as public recoNs PANELS MODIFICATION OZ UPT02W AMPS [I INTERIOR El CHIMNEY REPAIR Pint Licensed Professional201-INI AMPS IMPROVEMENT OWNER-BUILDER OECEARATION OVER Iqp AMPS ❑BATH REMODELIREPAIR ❑DEMOLITION p{y, 1 hereby.(firm than 1 an exempt from the Cssions Coca License taw for the' NNNFFF- �(a 6 F followingreason.a (Securer 7onstr Business and Pre.de Professions Code;Any city m county SIGNS ELECTRICAL O'T (Intl] LL which requires n pemtit re conswm,aIle improve,demolish, fi repair any swnurt "3 p mt�oiitsiss�ance,alsoreyuirestheapplicemforsuchp mitmftleasignedsmten t SPECIAL CIRCUIT/MISC. / p. that he is licensed pursumno the provisions of the Contractor's License Law(Chapter 9 CSO (cam acing with Stage.7000)of Division 3 of the Buslnessand Professions Canada, TEMP.METER OR POLE INST. 'COMMERCIAL: a o n that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION , ❑DEMOLRION -^„y Semion]OJLS by eny.pplicmt forepermit subjects the applicant mvcivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE. not more dun five hundred dollars($500). IMPROVEMENT Las ownerof the propcny,or my empinyees with wages ns rh<ir rale campensmion, SWIMMING 11001.ELECTRIC O will do the work,and the structure is not intended oroffered for aide(Sec.70,l4,Business DOTTER and Pmfes imis Code:The Canuactor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES 3 r progeny who builds m improves Hereon,and who does such work himself or through - - his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECTS SQ PT. auk.If,however.the building of improvement is sold within one year of completion,the SQ.FL FLOOR AREA VSQ.Fr. owner-builder will have the burden of proving that he did not build or improve for pur. Pace of sale.). - ❑h as owner of the proper•am exclusively contracting with licensed contractors m TOTAL: ., o conamort the project(Sm.7W,Business and Professions Code:)The Contractor's Li- censeLaw does nmapply lo.n.wner of proprny,who builds mimproves Hereon.and QTY. PLUMBING PERMIT FEE �]r, who contacts for such projects with a comractor(s)licensed pursuant o the Contractors GE3 �� Liccnu law. PERMIT ISSUANCE ) •/�fy1 lam exempt under Sec. ,fl&PCfor thisrtawn L/�Vr 19g Owner Date ALTER-DRAIN&VENT-WATER(EA) 'r Vtt_VALUATION WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I QI41 IA� I hereby off rra under penalty of perjury one of the following declarations �(]Ih.ve and will maintain nCenifcmanfConsemmself-inurcfor Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND. air..ax provided for by Seeder 3700 of the tabor Code,for the performance oEthe STORIES TYPE CONSTRUCTION work far which this permit is issued. FIXTURES-PERTRAP C I have and will maintain Worker's Compensation Insurance,as required by Section 3700.f the Labor Code,for the per(omunce of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN My WorkexytTOmrgrr AdJaturanu came rend Policy nuurbag ':L1, r,- My Wo R�91'-14'R�'��--.ter �a'''e'��wll Policy No:�S T-I GAS-PA.SYSTEM-OVER 4(EA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASE/INDUSERL WASTE INTERCEPTOR BUILDING DIVISION FEES (Otis action need net he completed if the parkins(crone hundred dollars(81001 GREASE TRAP or less.) PLANCHECK FEE I certify that in the Performance of the work for which this permit is issued.I.shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner so as to become subject to the Workers Compen- ENERGY FEE ,Z turner Laws of California.Date OWATER HEATER WNEEFLELECTR O Applicant GRADING ME - r~Ni NOTICETO APPLICANT.IL after making this Certificate of Exemption,you should WATER SYSTEMITRFATING become subject to the Worker's Compensation provisions of the Labor Code,Ever must SOILS PIJ7 foMwith comply with such prom visions or this permit shall be doal mvoked. WATER SERVICE O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.EL PAID I hereby effrm Hat Here iseconswdion lending agency for the perfo....of Data Receipt# LL tr the work for which this permit is issued(Sec.3097.Civ.C.) (~ Lunar'/s Name TOTAL: O V Linker's Add.. � - TOTAL: yI certify than 1 have read this application and state Hct the above information is BUILDING FEE W correct.l agree to comply with all city and county okinances and state laws relating to QTY, MECHANICAL PERMIT FEE yj U building construction,and hereby authorise representatives of this city to enter upon the SEISMIC FEE above-mentioned prepeny for inspection purposes. PERMIT ISSUANCE (We)agree to save,indm enify and keep hornss lethe City of Cupertino ugoinsr ELECTRIC FEE liabilities judgments.costs and expenses which may in my way neemo against said City ALTER OR ADD TO MUCH. in CM.. f ce of the gmntingo Permit. PLUMBING FEE APP IC n UNDERSTAN 5 AND VI L COMPLY WITH A L NO P NT AIR HANDLING UNIT(TO iffooll CFM) in . C A (11yr MECHANICAL FEE V��l AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX Sign re of ApplicamiCoonowbr Dna EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU) as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(.)^ HEATING UNIT(OVER 100k000 BTU) ❑Yes [D No VENTILATION PAN(SINGLE RESID) PAID Dam Receipt# Will the applicant or future building occupant use equipment or devices which •emir hacardaus air contaminants as defined by the Bay Are.Air Quality Management BOILER-COMPOHPOR Iffl,"BTU) TOTAL: Duract] CI year BOILER-COMP(OVER 100.000 BTU) ❑No r I hove rcaJ the hvakoa materials requimmems under Chapter 695 of the Culi- AIR CONDITIONER ISSUANCE DATE fomia Health&Safety Cole,Sections 25505,25533 and 25534.1 understaM dial a Ne NEW RESIDENTIAL MECH. SQ.FT. building does not currently have v tenant,that it is my responsibility in notify the oeca)unt of the requirememx which must be met prior in issuance of a Certificate of Occupancy. Owner or atmounred agent Dam TOTAL: ISSUED BY: OFFICE