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S 3312 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PI! ITN, �] /� 11,DING DIVISION APPLICATION/lul PLUMBER; NECIIAN'ICAI. 3 2 BUILDING PROJECT IDP:NTI T TI(IN y BUILDINGADDRIiSS.. SANITARY NO. APPLICARON SUBMi ITAL DAM A 2 -1-qg OWNER'S NAME' II(1N& CONTRALTOR'S NAME: T o NC CONBOE.N ARCIPTECrIFNGIN UR: IC NO: ADDRESS: ❑ I �. CONTAM. PHONIi: BUILDING PERMIT INFO Consultant Fees Paid by Applicant(Initial) HLDG ELECT PLUMB MECH Ga 30N K1 1�(0 � ©— Ei C' LICFSSED CONTRACTOR'S DECLARATION QTV ELECTRIC PERhin 1:17H o 7 1 hereby wain dul 1 am Imensad ander provisionsm Chapter o(n lemon aing JOB DESCRIPTION EScGi.900 aDrnsiam Joffe Bu,i.avand I4nfetsami..Cdr,andmy laccase" r RFSIUENTIAL 1- w' PIRMfr ISSUANCE 5WF in lull fmsc and dfai rJ Q 0SFI)WT, ITCHF,N REMODEL -guUfnz [)at< canueclm APILIANCIS-RESIUFMIAI. []ADDITION ❑%.Uh1NING RE-PIPE IITFCPS DECLARATION PANEIS ZO ❑AtULTbUN1T ❑SfRUCfURAL l A,`nZ I umlenstad mypims shill hens inpubbe namds MODIFICATION OZ-� UP TO ZIX)AMIti ❑INTERIOR ❑CHIMNEY REPAIR F�FI] LJccmed Pmhwiamal 201-100CANIN IMPROVEMENT C]SWIMMING IOOIS �".J OWNER-BUILDER CVRAHON OVER 1001)AMPS ❑HATH REMODFIAITAIR El DEMOLITION 5 C Q I tureby afGmt that I am exempt from the Cnnlreda.a Liccn,e Law Ger the X 3 a IU f,Ibling ram..($mlion OBJ LS.Buxint¢t ad Pmfnsiw Cuk:AnY city nr away SIGNS ELECTRICAL ❑OTHER W y which rea,ruos a Permit m conorucl,than,improve,c lirtt,ar repair any smtemre Pam to its lswatre,also ltyaimt the applicant fm seen permit In rile a ognud statement SPECIALCIRCUR/MISC. Eby,. Wal be is teen dpmruanlat the pmviocosof link Comilacor's liana Law(CIl9 u�i�QO fcmmm�ein6wiN Sl900!11 oflFvision Jnflhc HusinassenJ l'mrcuiamVCa.br)w TEMP METIER OR RILE INSC COMMERCIAL. d a e tY Inet he is exempt therefrom and Ina Iasis f«Ibe alleged excmgiun.Any vipmiau of ❑NEW BLDG/ADDRION ❑DEMOLITION Fla.xx Seniom 9011.5 by any appicam for a permit aobjau the applicant m a nvil penallyer POWER DEVICES ❑TE\ANT OEOOD SERVICE rW mom dun Eve bunds"Ital(53)(1). CIMPROVEMENT ❑ L:Nntwpertll the prupenyorinycmployaswilM1 wagesns heir VHecontPanVlion, SWIMMING I'O(lI.ELECT will Mtlsewurk,a.d,, The nine iamvmLice Lawdate, sale,I,t us Bumpers O ❑OTIIF.R W�- M Pny hi,a CUUor The Cont,lbere r Laccase law Daus not apply Is w,Iter M OfITIETS-SWITCHES- FI)"NRES �' pt,own Rahn huilJx m imlmwas cheroot,mil who akv,men sons d,d aaf 1 I edfor nix awn o-,t e Provided an aaeh n.an is old w o2 ou iMardcl Q alTerul run NE:W RESIDENTIAL FEECER S()ler. sole.If.n�twa�m.mehiiklingmiioprntntem i,atdd natal.oto rranr canmlwin.,the SO 17.FLOOR AREA SnQ.Fr. nenluiRer»w nava de,hander,of(natin,Inas be did Ira hada m imlaave for pur- P;m ofwlc.). ED 1,as nwler of the pmPeny,am exclusively contracting with licensed corn ecmtx to T r410 1 construct Na Moen(.Sec.90IY1,Business sod Profusion,Cde)'Doe Cominsetar's lit rease Laos,des notapply ,,mow.erof pr,,,oy who bt/dd„r intrust,thurnn,amt QTY. PLUMBING PERMIT FEE who canaaets f«such projects with a contnttorta)Iiamed Panuant m Inc Cmduscmr', _ 1'u°nw law. I PERMIT ISSUANCE J Q 0Iam-rump order Sec. ,B a P C for Iii,mason Older Dam ALTER-DRAIN AVPNr-W'ATER(EA) VALUATION WORKERS COMPENSATION DECLARATION HACK 11-OW PROTECT.DEVICE I hereby alfinm antler penalty of perjury noo,l the following declarations: I neve and will andruuina Cenifcateot Cmreattow1-inwrc fm Workers Cmnprn- DRAINS-FLOOR,ROUP.AREA.COND, S'IORIIS 'LYPGCONSTRUCHON aaliun,:u pmrvidd lar Fy Saf�nt 99IXI,r the IdMr Cdu,far the�Hurmvme of tue wank far which that Permit is issued. L IIX'IVHI:S-PER TRAP O ❑ I have anal will maintain Worker's Cmtpcnwt'ton Insurance,as reaaired by Section 37100. EWnor Code.for the paformar,aeofthe wod for h.,h has Isom'i,ixwad, GAS-EA.SYSTEM-I INCA OUTLETS O OCG.GNOUI' APN h1Y N' C�rp{'�� I vd Pol' M nc GAS-EA.SYSfIN-OVER 4 GA) Courtcb fes. Policy Na. CPRTIIICATEOhFJi FAII'fION FROMW heS COMPENSATION INSURANCE GREASFJINYUST'R L WAS]' :RCEPI BUILDING DIVISION IEtS Qhis rectknndmv becmnpinHl l(IM1drrntit i,Erane bumnnl Uullors(31(XI) (1NL'ASI'.'IRAP I or It.,)I PLANCIIECK FEE, Itnnify loot in the pen,na'mceoftMwork farnation lni.vµ.nn in—d,],hall SEWER-SANITARY- h ZOBI rot eroPloy any Peron in any manner w m to thecnin,wdcG In ane Warrants ComPeo 11JERG1'Fl:li s O Z Valu.11—ofC.11111171111.L}te WATIiR IIFATIiR wNr, Cf 1 GRADING IEIIi 0 App nnI h NOTICE'FO APPLICANT:1E,alter nursing hdi cenifrds of U3tvmpdan,you bound WATER SYST'AVI'REA REAMING (•' bcamme sub ret m the Worker,Gen lion f nhc LyMrz Cdc,yon Walt SOIIS It:L raMwiN aeras 1' 'N ouch ryovnxiora or Ihia rental — 0 py xi fermi)atoll he alcc.rd recused. WATER CI:RVIC�a/ LA. CONSE'RUCfION LENDING AGENCY NEW RFSIDRJOAL PLMB. SO.14. PAH) U O I hereby xffmt tlwt t hem iso can,Imniunl vWinga,mey Imine perdrnwrxv orU. 1 e NttriPIY dte work far ssmah this permit is nasal(Sec J)9I.Ci.�.C.) 0 (• E.ctder'x Nance AL y� U I< rx Addbes, rA D UJ L eerily that I have tad this vpplicatkn ad sole dent Ilse shave inrwma ion a BUELE N T I-' v] conren.I agree m comply wins aE city and county mdinunns a;N sha;c lows relaing m Ql'Y. MECHANICAL PERMIT FEE U ,Z building earmaretian,and hereby authorize repemntatives of this city to enter utero the SEISMIC 'E 0 adrvcnwmiaied p"'uy for i.grasu purpasay. NI MET ISSUANCE r S (We)agrm In ooe,indemnify and keep harms.,the City of Capmloo a.,iasl 1!LECT .FliLS a 3 liahilitic..jdgmenc..nuts wJe.apu. »Tien may in any waiy accnlle againw.vid City ALTER OR ADD TO MECH, in se,luetcc of dte granting of phis permil. PLUMBING 'iE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IB,M)CFMI Cl SOURCE REGULATIONS. FIECIIANICAI.FEE a AIR HANDLING UNIT(OVER 10"Xii)CIM) CONNTRUCf10N TAX Signature of ApplicanoCnmmnor O,uc EXHAUS]'HOOD(W/DUCI] I O HOUSING MITIGATION'FRG HAZARDOUS MATERIALS DISCLOSURE Will tie applfcom oa lamas sm1dingawcurumI,uaeor handle hazmshatanamerid 1 EATING UNI'I'(TO 100.000 BTU) at defrseal by tie Cuionion hbmieiNb Cde,Clupler 9.12,and Inc Rooth anal Safvy Cock.Seeri,n^ Vz(a)f HEATING ONrr(OVER Hll 11]O) E)Yea El No VENT ILATION FAN(SINGLE RESID) PAID WE the a li� t a future huildin Ilam Raeipi at pP van g oy the Bay Air Quality Management HOILER-COME OHP OR IW,OfI)BTU) emit eazard(Na yr caatamirwfs m debased!by the Bay Ana Air Quality Managrnenl )iaPicf! L 11 ❑Ycc ❑Nn BOILER-COMP(OVER IOfI,(gfl)TUI AIR CONDITIONER E M1nve neat TEs hanardaus ntacnielV rnryircnmty alar LTafncr 195 of Tc Cali- I $DANCE DATE fom'va Health A SafclY Calc.Sacvimv 25505.255JJ ad 23511.I malrn>tanni mat amts, NEW RESIDEbITIAL MECH. SO_Fr 2 budding ales air eu�mly Rate a tmwu.trot it is my n.pn.sTalhy m mdfY Tetuvu mnI arae myui,ertetrx whim nuR lx nor l.;,rmia.tta,ter oraeenirtaete ofu�y. Owner a amtrriaN agent Duty ISSUED BY Q OFFICE