30538 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. O
BUILDING DIVISION APPLICATIONA°ERMIT PLUMBING
DING I1.1�
BUILDING PROJECT IDENTIFICATION
38
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DA'I
/o ��r 25To(v p�e� GdPEcr�✓v 9S-D4 �,,C1,16
OWNFR:SN�gMF: ' PHONE: CONTRACTOR'5 NAME: LIC NO:
� --JO?/� ', <!,#,&6- e-10e�Ixr,1/.✓`D K// /��� SQ NIC CONTROL#
ARCHITI:CT/ENGINEER: LIC NO: � 1-4 ' J. DG 7a'�•�WD. FiN/✓0 ❑
CONTACT: '/ PHONE: BUILDING PERMIT INFO
/p//�r�O (/�, l"S �j r� ,/LIDO ❑ Consultant Pees Paid by Applicant(Ionone, L LECT PLUMB MECH
lJ�/G''+LIICENSED/C\ONNTRAC FOR'S'DECLARAATION y 7 QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Ch.tar 9(commencing
wo,QMZ wird Semon 901)(BaDlr61onn 3.Rhe Baoro,,,und Prum,,mnx Clp dm fc JOB DESCRIPTION
a�� infullforceandefttn RO Y'enx is PERMIT ISSUANCE RESIDENTIAL
GF.UZ U License m S l.ic.# `' 4a3 D SE M, CHEN REMODEL
NQS Dam�Commnonr AI
APPLIANCES-RISIUENI'IAL �� ❑ADDITION PLUMBING RE-PIPE
I--ps��' ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
z O,�Z I understand my plans shall be used m public records MODIFICATION
0z_ UP'TO 200 AMPS
F�2 F W licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
CYC; OWNER-BUILDER DECLARATION 2111-111(NIAMPS ROVHMEN'f
C Q 1 hereby affirm that I am exempt from the Contractor',License Law wine OVER["AMPS REMODEL/REPAIR DEMOLITION
K
OL U following omour.(Scni...I7p3 1.5,Business and Pmle,sinns Cade:Any city m,mmly SIGNg ELP.CIRICAL OTHER
LLI LL y whicM1 requires a are m construct,aloe,.impmv,demolish,or repair any rWclam
O�
prior to as issuance.also requires the applicant for such permit to file a signal%amawnt
rn SPECIAL CIkCUIT/MISC.
C�Q� that he is licensed Punuanitothcpmvisionxofthe Contractor's LicenseUw(Chaptcr9
ty�,�� (commencing with Section 9,.1010 of Division 3 ofthe Business and Professions Code)or 'rEMR METER OR POLE INST COMMERCIAL
6 cfy that he is exempt therefrom and the basis for the alleged exemption.Any violation of
W_,N Section703I.S by any applicant for a permit subject the applicantto a civil penalty of POWER DEVICES El NEW BLDG/ADDITION ❑DEMOLITION
at more Nan live hundred dollars($500). []TENANT CFOOD SERVICE
❑Las owner of the primacy,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
F
Y�1 Its willdode work,andthe sductmcis antimendedureffered forsalelSce.?044.Business DOTHER
and Professions Code:'Hm Commerce,License Law dues urn apply m an owner of OUTLETS-SWITCHES-FIXTURES
,unfairly who builds or improves!hereon,and who donentt
,such work hirlf or through
re no
his own employees,provided that such improvements at intended or offered for NEW RESIDENTIAL ELECTR SQ Ff.
sale,If.howevoq the building orimprovement issold within one year ofeumpletlon,the .FLOOR AREA S/SQ.FT.
none
r-builder will have the burden.!Proving that he did not builds improve for pur-
lxiacofealeJ. /
1,as ownecof the propmsy,am exclusively comments with he need contractors to TOTAL:
construct the project(Sec.oan Business andProfessionshe buil,,,,ii The Grmmrem,Li- 1
cense law ecesn.t apply loan owner of pn,pcny who builds or improves Nemnn.and QTY. PLUMBING PERMIT FEE
I
contact tin such,ratans wird a cnmranor(s)IicenseJ,urvuant m the Contmnnr'x 1996
C2I..I law. PERMIT ISSUANCE /yJV
❑1 nm exempt under Sec. ,B&P C for This reason
ALTER-DRAIN&V ENT-WATER(EA)
• Owner Dace "'1 NAfAA'fION
Woo our,'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
thereby
.m1widfimtCenaltynrtalCryuve of thefollow ingdcdker's Cx: `J v
❑IM1ave ono will initiation.by ection acme of he Indo.sole.I.,hicr smkcr's,eaf the
DRAINS-Fl,OOR,ROOF.ARF'A,COND.
wormer or hick thi for by I,moi 391,of the Labor Code. rNe performance of the STORIES TYPE'CONSTRUCTIOP
work have
this airniin orkerrd. FIXTURES-1'ER'IRAP
I have and will mdmain Workers Compensation walk far
hi h rcyuircd by Section
P00 of the Labor Cute.for performance of the won.#for which thisµunit is issued. GAS-FA.SYSTEM-I INC 40UTLErS OCC.GROUP pPN
My Worker. •nx lion �� carrier and Policy(ether afgq� �/
Carzicc �a s _Policy No.: Zq6 9' V GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE 017 EXEMPTION FROM WORKERS
COMPENSATION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR
(Ibis section need not becomplemd ifthe proul is forum,handledeollars(S IBI) B ILDINC ]VISION PEES
or Ices.) GREASE TRAP
PLANCHECK FF.'
Toy tiny perm the perany memory
of the work for which t1i0 to W is irs ConaNn-edI'luall SEWER-SANITARY-STORM EA.200 FT.
oat employ any person in any manner w as to become subject m the Workers Compen- ENERGY Iml
FEE
OZ Applulaws of California.Dare WATER HEATER WNEPOPELECTR
Z 2 Applicata GRA
oDING
.�. NOTICE TO APPIICANT:If.after making this Cenifiam of Exetnplion,you should WATER SVSTLMREATING
a > bru me object t.the Worker's Compensation provisions of the Lalan Code,you most /I'
a Qfonhwim comply wah,ch pmvi tmn .,,his ,..shall he droned msok,l, SOILS
,coni WATER SERVICE
CONSTRUCTION LENDING AGENCY 7z NEW RESIDENTIAL PLMB. SO.Fr. PAID
L) IMreby affirm the there isac,nslmction lending agency fonh perfnmmncc onf On Receipt#
[L — the work far which this permit is issued(Sec,3097,Civ.C.)
Leader',Name
F yV lender's Address TOTAL. TOTAL:
1 citify that 1 have read this application and state that the above information u BUILDING -E
V) correct.l agree to comply with all city and clmay ordinances and state laws rcmcng to QTY, MECHANICAL PERMIT
U Z mildingconswclion,and bemby:mthonne representatives ofthis city lorntnupon the FEE SEISMIC E
love-mcmioncd Primate fof insµni.n purposes. PERMIT ISSUANCE
(Wc)n em.wvc,indemnify amt keep harmless the Ciry of Cupcnino agninnl F.LECTRI FEE
' ilities,ju menta.cons and exµnses which may in any way accrue against sail City ALTER OR ADD TO MECH.
seen cecamegmmin,.f Nrspennit. PLUMBIN FEE
A C T UNDERS' YDS AND WILT.COMPLY WITH ALL NON-P N' AIR HANDLING UNITJO 10,000 CFF,
SO EGULATI .S _rl - MECHANICAL FEE
d��M(.✓p � �(f Q �/9 AIR HANDLING UNIT(OVER 10,00(1 CFM)) CONSTRUCTION TAX
HAZARDOUS 5igaamr o pmliaO - J Date EXHAUST HOOD UVMUC)
t1AZAUS MATERIALS DISCLOSURE. HOUSING MITIGATION FEE
Will ,.the Cupertino
no Muni building e,Chant rstore 9.12,handle Health us mammal HEATING UNIT(rO I W.OW BTU)
as definedio the Cupcnino Municipal Cede.Chapter 9.12,and the Health and Safety
Code,Section 2553$ap HEATING UNIT(OVER 100,000 BTU)
❑Yes ON.
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt#
,mil homodonts atr enmaminune,as dVfu ed by the Bay Arca Air Quality Manegemmn BOILER-COMP OIIP OR 100,000 BTU)
District?
❑Yes 0 N BOILER-COMP(OVER I W.000 BTU) TOIAL
I have tend the havaokmv materials rNmucmetu under Chapter 6,95 of the Cali- AIR CONDITIONER
Rome Health&Safely Code,Sections Z505,25533 and 25534.I understand Ilial if the ISSUANCE DATE
buildingd does not currently have amwm,ohm it i. bilis mnotif Ne coca o NEW RESIDENTIAL MECH. SQ.fT
smymstons' Y Y Pan
/regain..which mux!he met print to k,mrrue of a Orthicon,of Oaumai
er or omh.n oed agent Date TOTAL:
ISSUED BY:
OFFICE