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30282 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT L. 30282 NO. BUII,DING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICA BUILDING PROJECT IDENTIF'ICA'TION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE DO PPl'Wn V01+N 0APHREIIJO "tel i•� O ' 'SNAME: © VHONE: TR CT H'S ME: LIC N¢ NIC CONTROL# \R T CI'ENGI SER: I.ICyVf�N T. � H \�� a .a��•y� iy� ❑ x/tVpyl (/V_ 3 CONTAC �f BUILDING PERMIT INFO O�C 7 (J ❑ Consultant Fees Paid by Applicant(Initial) p1,DG ELECT PLUMB MECH LICENSED CONTRACroRS DECLARATION QTY ELECTRIC PERMIT FEE IJ��Jy�_ '•O-Qs` I hereby affirm that I ata licensed under provisions or Chip lr 9(commencing JOB DESCRIPTION �aZ with Scaion](100)of Divi,inn3of the Business and Prolesdom Gale,and my license is RESIDENTIAL: F-O p PERMIT ISSUANCE W-F- in force and cRect. ❑SFDWL ❑KITCHEN REMODEL <-U License Class Lic.N NQDane Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE ARCHITECTS DECLARATION F.7 N PANELS ❑MULTI-UNIT ❑STRUCTURAL Z py Z. I uederamnJ my plans shall IN used as public records MODIFICATION pZ_a UY'1'02W AMPS ❑INTERIOk ❑CHIMNEY REPAIR W Licensed Pmfts,swoal 201-1000AMPS IMPROVEMENT Q OWNER-BUILDER DECLARATION OVER ItXX1AM1'$ ❑BATH RfiMODE1JkEPAIR ��iMOLITION C C Q I hereby affirm that 1 am exempt from the Contractor License Law for the R V XaX Q a V following rases(Section 7031.5.Business and Professions Code:Any city orc^unty SIGNS ELECTRICAL ❑OTHER W 3 a y< which requires a pemul ,,construct,tire,improve.dan..lish,m repair any nrmare F u-OJ prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/MISC. 'I;!{� that he is licensed parmaln to the provisions of the Coommon'%License Law(Chapter 9 W�Coo (,.inmmneing with Suction 7030)of Division 3 of the Business and Professions Code)or '1'EMIIMETER ORPOLE COMMERCIAL, man a e�' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section by any applicant far a p monstibReathe applicamm a civil penally of POW17R DEVICES ..y not more than five hundred dollars(g51XU. ❑TENANT ❑FOODSERVICE H Z} IMPROVEMENT Fl SWIMMING ownerofthe propcny.or my emPloYecs withwagesas their sok compensation, SWIMMING POOL ELECTRIC will do the work.and the strumum is not intended or offered forsale(Sec.Jfl4L Business ❑OTHER L3� and 1'rofwsm Cook:'Do,Contractor's License Law docs not apply no an owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his own employees,provided that such improvement are not intended or offered for NEW RESIDENTIAL F.L'C� S sale.If.however.the huildingorimprovement is sold within one yearofaompletion.the SQ.FT.FLOOR AREA VSQ.IT. wnerbuilder will have the burden of proving that he did not build or improve for pur- ,ow of cafe., ❑ 1.as owner of the property.am exclusively contracting with licensed ceramic.to o^suucnhe preject(SUJ614,Business and Profession CNa)The Conuacmr's Li- - - censeLawdoesnotapplytoanownerofpropertywhobuildsorimpmvesthemon,and QTY. PLUMBING PERMIT FEE who contracts for such projects with a contractors)licensed penuam to the Contractors AUG 3 Last Low. PERMIT ISSUANCE 1996 C] Iin exempt under Sce. ,I3&P C for thisreas^n VV JV Owner ALTER-DRAIN&VENT-WATER(EA) l 11 r la Vs,r VALUATION Dae WOR munder'SnaltyoCOMPENSATION UECLARATIUN BACK FLOW PROTECT.DEVICE I hereby affirm under Penalty of perjury one of the following W Workers Co ❑IM1ave and will for byetion 37me or[tie Labour Coot sumfor ,dinicae, of DRAINS-FLIX)R.ROOHAREA,CONE. STORIES TYPE CONSTRUCTION .neon,as provided lin mi Section 3]INI of We Labor Gide,for(lie perlinmm�,c nl the work for and this Permit is issued. FIXTURES-1'13k TRAY Fl 1 have and will maintain Worker's Compensation Imumnce,as required by Section J]IXl of the Luhor Cnde,(Dobe perfonnunce ofthc work lin which this permit lx issued. GAS-fiA.SYSTEM.I INC.4OUTLETS OCC.GHOUL' MN My Worker's Compensation Insurance carrier and Policy number art: Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) CERI'IFICAT E OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES ' (Thin xcdion ncnl oatbecnmpkmJ ifthe permit is for one hundrtJda1lnm(5100) GREASE TRAP or lesc) PLANClIIiCK PEE Beam(}that ro the to,compromise,,a,dr, theemnewhich this per mit is issued. shall SEWER-SANITARY-STORM EA.200 Ff. I nrn employ any person in any manner sn us m become mbjen¢r the Wnrkus'Co.,.--C [?HERGY FEE OZ nation laws of Coliforms.Date WATER HEATER WNENT/ELECTR GRADING FEE z O Applicant y NO'T'ICE TO APPLICANT:If,atmr making thio Certificate of Exemption,you should WATER SYSTEMIRFATING a ' become subject to the Worker's Compensation provision.i of the Labor Cade,you must SOILS TEF. Lt,l forthwith comply with such previsions or this Permit shallbe deemed revoked. WATER SERVICE Q '2 CONSTRUCTION is.e UN Lion lending NEW RFSIDFN'TIAL I'LMB. SQ.IT. i'AN 5 Z Date Receipt x V I hereby affirm that them iasued(See.30lending agency for the performance of 11. (•-' the war,No which this permit is issued(See 9119].Civ.CJ 1 Lender's Name TOTAL: L) Lender's Address TOTAL: W BUILDING FEE lw I certify That 1 have real this and and sac that the above pas xclutmn ix V cordingco recto comply with allcitycounryorative%osand swan kwtrupingm QTY. MECHANICAL PERMIT FEE U � building connrvctinn,and hereby authorise rtprtxemmivea of this city mentor upon the SEISMIC FEE ahovementioned property for inspection purposes. PERMIT ISSUANCE agree m save,indemnify and keep harmlem the City of Cupertino against ELECTRIC FEE lieQblg.men' costsa se which ntay inunywroeagainssaidCity ALTER OR AUUTO MECH.the o' ng omitPLUMBING FRE UNDE FA ' . .D WILL CO LY WI 1 ALL NON-POINT AIR HANDLING UNIT'(TO 190011 CFM)GU ON MECHANICAL FEE AIR HANDLING UNI"r(OVER 10.000CFM) CONSTRUCTION'I'AX ign' reof ApplicanJComractnr Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Willits,appliemilm future building cecupantsmreor handle hazardous mmmrial HEATING UNIT CFO 100.000)BTU) as deiced by the Cnpertinn Municipal Cole,Chapter 9.12,and the Health and Safety Cod.Section 25532(a)] HEATING UNIT(OVER 10IJNXI BTU) MYes ❑No VENTILATION FAN(SINGLE RESID) PAID p:de RCCCIpIM Will the applicant or future building occupant use equipment or devices which t hit andous air contaminants as defined to the Bay Area Air Quality Management BOILER-COMP LIHP OR 11X1,0l1(16'rU) T DinrictR - BOILER-COMP(OVER I(ma)(10 BTU) ❑Yes ❑No 1 have read the hazardous materials requirement under Chaprer6.95 of the Celli- AIR CONDITIONER ISSUANCE DATE. forma Health&Safety Code,Sections 23505.8533 aM 8534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT. building does not currently have a tenant,that it is my responsibility to notify the occupant \�a��/ars/Jj�j/��•+���/� of the"mor rants which must be met prior to issuance of a Ceniticae of Occupancy. Owner ur authorized agent Date TOTAL: I ISSUED BY: OFFICE