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S 1780 (2) APPLICANTTO FILL IFJ INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY — CITY OF CUP ERT]NO BUILDING.-ELECTRICAL Pr: ITN° BUILDING DIVISION APPLICNFIONtPERMIT PLUMBING-MECHANICAL J 1780 F77ISUII.31NG PROJECT IDENTIFICATION BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE 50 b AV/1-51, Cr�/'� o fS6/ OW "$NAME: � H: ^ IN1Vk0�NAMJ`/ ,.r/zOs LIC NO: 4/ 'V `!!/4 NAC/1 CONTROLp aAlh-tf-ti9 1;2,RCHITECTIENGIN .R:� r LIC NO: CONTACT: —7 PHONE: /�• V BUILDING PERMIT INFO 4©� aS 3� / 0 2� ❑ Consultant Fees Paid by Applicant(Initial) Bl.n[l & PLS MIiCH �` LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMhI' PEE Ll LI ©/ I herehy aRnn Ihm I am licensee under provisions of Chapter 9(commencing JOB DESCRIPTION Wiz with Secuum70shoflivision 3 of the Busiimssane Protexsiens Cale,snit mylicenve is �O RESIDENTIAL: W O p pl!RMII'ISSl1ANCli ge in full font and c1I'ul. ❑SFDWI. ITCHI!N RI!MODEI. GVU License Class Lic,p APPLIANCES-kESIDF.NTIAL ❑ADDITION ❑PLUMBING Rpr PIPE ,HQa DateConsular ARCHITECI-S DECLARATIONI'ANEI,S ❑MULT[-UNIT ❑S'IBUCTURAL z O y z I undenurn�l my plmis shall be used us Public records MODIFICATION O z.,Q UPTD30()AMPS ❑INTERIOR ❑CHIMNEY REPAIR FLT.; Licensed Profession.) 201-1000AMPS IMPROVEMENT SWIMMING POOLS 8 .�.1 OWNER BUILDER DF.CLARAI'[ON OVER IINN)AMPS EJ BATH RIIMODEVRIiPAIR ❑DEMOLITION y 1 hereby affirm Ihnl I stn exempt Gom the Contractor's License Law for the S a U following reason.(Section](U 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER 3 U.r"j which requires^permit to cumman,alar.improve.Jemalish,or repair any ser ca , — Fuy.O¢ pnmtoinicsb...erlsorequins lheapplieur,I...ch penniuo Ficitsignedamemc^I SPECIAL CIRCUMMISC. Kms•] that he is licenmdpursuanl to the provisions of the Contractors Lireese],a%(Chapter 9 �p0 (eanmancing with Section 7000)of Division 3 of the Business and Profusions Cate)or 'II!MP.MITI'P.R OR POLE INS'1'. CDMMERCIAI,: that he is exempt Ihcafrnm and the basis onto,alleged exemption.Any violation nl ❑NEW BLDG/ADDITION ❑DEMOLITION W..y Section 7031.3 by any applicant for a permit subjects the applicant to a civil pat of POWER DEVICES ❑TENANT ❑FOOD SERVICE y, of marc than five hundred Jnllan(S5W). IMPROVEMENT D I,rix ownerofthcpmpeny.nnny empinyus wbh wags as their sole compcnsminn, SWIMMING POOL ELECTRIC f� � will Jn the work,snit theswcturc is nolimendcJ oroOcruJ for sale lSec.]M4,Rosiness []OTHER W 3 end Professions Gyle:The Cnntradorz License Law Jaes not apply m an owner of r OUTLETS-SW'ITCIIIS-IlX'fURIS \ " pmpeny who builds or ,improves(hereon,and who docs such work hit^self or through his own employees,provided that such improvements are mol inlcnit I nr off 11 NEW RESIDENTIAL ELECTR SQ IT. sale.IL however,the buddingnr arTurcmenl k ad withincoteyearofuampletinn,the SQ.Irl(FLOOR AREA 3/SQ.FT. owner-builder will has,the harden of proving that he did cot build or improve for put- 'w 346 711,as owner of Me Progeny,cors n exclusively contracting with licensed com.foto TOTAL: nntnml the project(Sec.uA4,Busiaemm anti pmf¢vnia^x Ca..' -Cont......s Li- ceaseLaw does not apply it)anowner ofprope^y who builds or improves therean and QTY Pl.UMBINQqKtf&T FEE who contracts fm such projects with a carbacmr(s)licensed pursuant o the Contractors e� License Law, dmf . c B&PCfarthismnmml PERMIT ISSIIANCI! S Jy c ALTER-DRAIN&VENT-WATER(IA) VALUATION caner Date Q L) WORKERS COMPENSATION DECLARATION BACK FLOW PROTIECI'.DEVICE I hereby affirm under penalty of perjury one of the following decimations: fit v ❑ Ihuve mW willnmimeinmCeniliate ofCnnscm to salt-in sure far Worker's Cotnpcm DRAINS-FLOOR,RODE AREA,COND, ,mina,as Provided Car by Section 3]00 of the Labor Gate,for Ute performance of the S76RIES TYPE CONSTRUCTION work for which his permit is issued. FIXTURES-PER TRAP ❑I have and will nom u s Warkers Confirmation Instance,m required by Secti m 37Mof the"hot Code,fonhmperformanccolthe work ou which this Pruni,is word. GAS-HA.SYsrrJdd NC.40U'H.HTS I OCC.GROUP APN My Workers Cnmpensatinn Inmaoce sanctum!Policy number arc: Cartier. Policy No.: GAS-EA.SYSTEM OVER 4 DIA) ` I-I^_at CERTIFICATEOFEXEMPTIONFROMWORKERS' ..JP at" COMPENSATION INSURANCE GREASEJINDUS'IRL WASTE IN']HICEPTOR BUILDING DIVISION 1285 fThls.cdion nudnot hu aampleaA if hapermit fur ane hundred Jollurs(511X)) GR[:ASit'1'kAP or lcssJ I'1. HK�T� Icenify thatimhe performance of the work 6rwM1ichthis Permit isissued.Ishull SENEIi-SANITARY-STORM P.A.2D)Irl'. mol employ any period in any o saner o 1 bacgplr�h,lecuo the Warkers'Compen- ENERGY ITH z stniun Lnws of C: 1 7d-u WATER WATER WN 1,117ELECI'R zt PWD � APPliam � GP N NOTICI!'T'APPLICANT.if.ager making this Ccrtifa.of Exemption,you should WATER SYSTEM/TREATING I••' bernme mbjecl m the Worker s Cmancesmion provision of the Labor Code.you must SOILS ITS fmhwilh a>mPly with such provisions or Ibis p.:.it shall he deemed rcvokuL WATER SURVICE CI VOr Cinthe iso c ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PC I'AIU Q (hereby affirm thin ismronswction coding a6c^cY for the perlDrmancc or Date RueiPIM Clsthe work for which this humin is issued(Sec.3197,Civ.C.) p Isodcr's Name I I TOTAL: {ULl Lvndcrs Address TOTAL: Q, 1 certify that 1 have read this application and sum that the above information is BUILDING FEE 37z•O o IA correct.)agree.comply with all city and county eminences and.state laws relating to QTY. MECHANICAL PERMIT FEE L) z building comm�tcliun,and herehy euthorizerrpres,amtivr,nfthis city m enter upon are SEISMIC 17I717. j• above-ria^tinned propcny for inspection purpns. PERMITISSUANCE // (We)agree to save,indemnify and keep hamllcss the City of Cupertino against 5:Sv ELECTRIC blip 3 bob / liubilitics,judgmcnts,cnsm and expenses which may in any way mctue against mail Ciry ACTERORADUTOMIiCH. in asequence of thegmmins of this permit. PLUMBING 1Tk! 3 s y APPLICANT UNDFINI'ANDS ANDALL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO Io.hPa CFM) MECHANICAL FEE SOURCE UI IONS Q y T 72 AIR HANDLING UNIT(OVER I0.000CFM) CONSTRUCTION TAX goamraofApplic^nVCnntmclar Dma HXHAUS'1'IIOOD(W/DUCT) HOUSING MITIGATION PEE HAZARDOUS MAI'MIALS DISCLOSURE WRI the applicant or future building wassail store or handle JoUrcmrx material HEATING UNIT(TO I W."BTU) as defined by the C.,mirn Municipal Code,Chapter 9.12,and the Health and Safety Code,Section 25532(a)P HCATING UNIT(MUR Ioo,N)o It I'I)) �e��e El Yes ❑No VINTILAf[ON FAN(NJ NGLERI?SID) PAID '9-4F� 0511hi�cr( • Will the applican or fate.building occupied use equipment or devices which Date Receipt x emir hazardousairoamamiaim,as defrad by the Be,Are.Air Qmildy Management BOILER-COMP CHP OR I M.01)BTU) TOTAL. / Dintricr'I -la7 ❑Yes No HO(LER-COMP(OVER H10,00011'TO) ❑ I have resit da bazamnus materials requirements ander Chapter CONDITIONERr 6!15 of the Cult- ISSUANCE,DATE fomin I ladlh&Sa1'dy Code,Secliems 25511,25573 and 25534.1 underxumd that if the NEW RESIDENTIAL MECH SQ.Fir building does not unready have a tenant,that it is my responsibility to miry the acupant of the equiremat which must he met prior to issuance of a Cmificate of Occupancy. -y Owmcra uslari,edttgent Dane To'rAI.:L/7, 7Z ISSUED BY. �T2 /�Iv7k7A.�G OFFICE