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30756 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY . CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO. 3 O 7 5 b BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL J< `h BUILDING Pitoxcrr IDENTIFICATION � BUILDINGADDSANITARY NO. APPLICATION SUBMITTAL DATE q' RES 8--7ZL0 (L6 1•-"sry'� OW NI' ;SNAG H: PHONE: CONT IDRME: LIC ND N/C CONTROL# ARC CT/• NEER: LIC NO: p DRESS411�: ❑ ♦. I" ahv�k&" - 7 �jip CONTACT: - p nPHONE: 0 - -,31,1N43 BUILDING PERMIT INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH ❑ ❑ ❑ 1� LICENSEDam ON Ilicensed R-S DECLARATION QTY ELECTRIC PERMIT FEF. I herehy alfirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION O2Z f Secnion]OIIIB nfDivision3nf the easiness and Pon slim sCode'anJ mylicenu is RESIDENTIAL: �2O �� /y3 PERMIT ISSUANCE. ❑SFDWL ❑KITCHEN REM OGRE full trans and c roan. A 3 �UU License Clara we Cmuror i, APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING Bit PIPE b-7i ., Dnnam b- As shall he use DECLARATION PANELS ❑MULTI-0NIT []STRUCTURAL Z O y� � 1 understand my plans shall be used as public recnNs MODIFICATION OZ—, UP 10210 AMPS 0INTERIOR ❑CHIMNEY REPAIR r4�q Licensed Professional 201.1100AMPS - IMPROVEMENT LL •� OWNEWRUILDER DECLARATION Had IINOAMPS ❑BATH RIiMODEVREPAIR 0DF.MOLITION 1 hereby affirm that I am exempt from the Coraclor's License L. far the ymw U following recon. Business and Professions Cade.Any city or county SIGNS ELECTRICAL ❑OTHER GF- which requires a permit nm amens,alter,improve,demolish,or repair any snrnme prior to its issuance,also requires the applicant for such permit lm file a signetamement SPECI AL CIRCUIT/M ISC. yNut he is licensed mr, unat tofba provisions of Gmmmnnr'e License law(Chapter 9 � p0 (commencing with Section 7000)of Division 3 ofnhe Business and Professions Coul TEMP.METER OR POLE INST. COMMERCIALa a i,�1 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION Section 7031.5 by any applicant for a permit subjects Napplicant e applicano o civil Finally of POWER DEVICES '7�sy non more than live hundred dollars($500). ❑TENANT ❑F001l SERVICE F� ❑1,m ownerrof lhem.penw yornry employees with rpa,.x their sole conmpensation, SWIMMING POOL ELECTRIC IMPROVEMENT will Jo the work,and me sare uctis not intended orofferrd for sale(Sec.70,14.Business ❑OTHER 3 m and Professions Gyle:The Contractors License Law does non apply mon owner of OUTLETS-SWITCHES-FIXTURES property who builds or improves thereon,and who does such work himself or through his awn employees,provided that such improvements ore not Intndeo or offered for NEW RISIDEN'I'IAL ELECTR SQ Irl'. sale.If,however,the building or improvement is sold within one year ofcomplction,the SQ,PI'.FLf�R AREA $/SQ.Icr owner builder will have the burden ofpmving unit he did not build or improve for pus- is h poseofsaleJ. - Y [ 1,os owner of the property.um exclusively contracting with licensed comaracmrs to TOTA ' /". instruct the project(Sec.]844,Business and Professions Code:)'I he Contmemu's Li- cause Law does not apply to an owner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT EEE AN ` 3 RfC'D who commons for such pronn projects with a conor(s)licensed pursuant to the Contractors License Law. PERMIT'ISSUANCE Uf- ❑ 1 am exempt undcr Sec. ,Is&P C bur this reason UUrrk 1 Owner nate ALTER-DRAIN&VENT-WN'ER(EA) VALUATION- WORKER - WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1 hereby affirm under penalty ofurnmy one of the following declarations: ❑I have and will maintain a Certificate of Consemuo self-insum for Worker's Compete DRAINS-FLUOR.ROOF,AREA,COND. STORIES1'VPE CONSTRIIC'I'ION siona as provided for by Section 3710 of the Labor Code,bur the performance of the work lou which this pared is issued. FIXTURES-PER TRAP ❑1 have and will maintain Workers Compensation Insurance,as"fired by Section 3100tuflhe her de,for the perfon ance of the work for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN M nrke ' n u oa amome cancer and Policy u m •r a' rrt Policy No.: GAS-EA.SYSTIN-OVER 4(EA) C• TIFICATE OF EXEMPTION FROM WORKERS-80I IS ZZ4 COMPENSATION INSURANCE GRI:ASEaNDUSTRL WASTE INTERCEPTOR (This section need non M completed iflhc permit is for onehundred dollars($100() BUILDING DIVISION FERS m,les,) GREASE TRAP PLANCHECK[ZEE t I certify tem in the perfnnmance oflhe work forwhicb this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manneriar s m bscomeeubjea to the Workers'Co.,.. ENERGYFEH Z O ration laws of California.Dale WATER lIfiATER WNENT/ELECI'R 7 V) Applicant GRADING PEIi G NOTICETO APPLICANT If.no, thismakingCisions of of Hxemptiodyou umain Wq�THR SYSTEM/TREATING a , homes subject to the Worker's Compensation this provisions of the Labor Coke,you must SOILS IEE � 'forthwith comply with such provisions or this permit shall be deenud revoked. WATER SERVICE Q CONShat ereis a TIONLleGAGENCY NF,W RfS1UEM'IAI.PLMB, SQ,FT PAID U O fhereby which roe Permitm ississued construction lending agency forthe purfnnnvnco of Dom Receipt It (~•t the work for which this Permit is insuN(Sec 309],Civ.CJ O U Lenders Name TOTAL.: 1<ndcr's Addreaa TOTAL: CLI certify the 1 have read this applicmin i and am¢that the above information is BUILDING FEE comet,met.l agree to comply with all city and county ordinanecs and.stme laws rclming to QTY. MECI IANICAI,PERMIT FEE U Z building construction.and hereby authorize representatives admix city loentcrupmade SEISMIC FEF. abmve-memuoned property for inspection purposes. PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Capetian against ELECTRIC PEE Iiabil dies.judgments.costs and expenses which may in any way.came against veto City ALTHR OR ADD'I'0 M F.CH. in eoeequence of the granting of this permit -PLUMBING FEII , APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITF O I0,001 CFM) SOURCE EGU TIONS. l MECHANICAL FEE ♦ '',r3•�["f 1 AIR HANDLING UNIT(OVER I f"CFM) CONSTRUCf10NTAX Signature of Appli UConvactnr Daft 1 EXHAUST HOOD(WMUCT) HOUSING MITIGATION Il3E AZARDOU TERIAI S DISCLOSURE Will the applicant or future building mmcupant store or handle hveNous mmerial HEA]'LNG UNIT(TO 100,000 BTU) e defined by the Cupertino Municipal Cade,Chapter 9,12,and the Hcahh and Safety . Code,Section 25532(n)] HEATING UNI"P(OVER 100,000 BTI!) F-1 Yes F-1 No VENTILATION FAN(SINGLE RFSID) PAID Date Receipt# Willthe applicant or fns a building by the nt use Bay Are. unt tardevicesemint BOILER-COMP(3HP OR 100,(00 BTU) •mit hamNnus eir cmmmninams as Defined by the Bay Arco Air Quality Management TOTAL: Dieviefl ❑Yes F1 No BOILER-COMP(OVER 100,0100 BTU) L have read the hazardous mentrials onpiremems under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE fnmin Ilcalth&Safety Code.Sections 25505.25533 and 25534.1 understand that if the NEWIt iSIDENTIAI.MECH. SQ.IT building does ml cumm0y have.ferric,that it May responsibility t notify the mccopanl v of the requirements which must he met prim m i...sure of Ceticcu ficale of Opancy. Y Owner.1mm nixed agent Dat TOTAL: ISSUED BY: OFFICE