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S 1472 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO Bull DING-ELECTRICAL Ph'yq'T"°, 1472 BUII,DING DIVISION APPLICATION/PERMIT PLUNiB N;-MECHANICAL J BUILDING PROJECT IDENTIFICATION I BUILDING AI`I/ilRE55�. SANITARY NO. APPLICATION SUBMITTAL DATE J - 1.4I OWNER'S ' ME: CJI( F.: qn COM ACTORS N f LIC NO� _ L( LlL NIC CO �ARCiII'I'ECT/IiNGIN LIC NO 1 ADDRESS: ❑ 7 e77;�t CONJAC'f PHONE: BUILDING PERMIT INFO 2.?I p,f•`ry7 ❑ Consultant Fees Paid by Applicant(Initial) SLUG f�1.EQ1' PLUMB MECH LICENSED CONTRACTOR'S DECLARATION QTY 17LECT'RIC PERMIT FEE �`tj'y T`'��[- I hereby afrrin that 1 am licensed under pnwidons of chapter 9(Cmtmrencing JOB DESCRIPTION QWz with Serum.700a.f Division 3of the Business and Rnfemiom Cals.inl my net.is RESIDENTIAL: O PERMIT ISSUANCE in full farce an(t be�fl S3 8.n!^2it ❑SFDWL [I KITCHEN REMODEL aUU License Chis{/ Lic.p C�/� APPLIANCES-RESIDENTIAL ❑ADDITION []PLUMBING R&PIPE W Dmr Commelor Fly ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑MODIFI MODIFICATION la 2 1 underntand my pram shall be used ns public mcmdr MODIFICATION -__4-oo' Up TO 200 AMPS [D INTERIOR %E1 HIMNEYRHPAIR pt,o . 7 Licenecd Professional 201-IINNIAMIN IMPROVEMENT WIMMING POOLS 9,4E-44I OWNER.BUILDER DECLARATION OVER 111(NIAMP. ❑BATH R12MODEUREPAIEMOLITION ,9z 1 hereby affirm Ilial 1 am exempt from the Contractor's C se Law for the pie,O L V folbwing maann.fSmion]011.5.Business and Pvdcssiom C :Any ci y or county SIGNS ELECBICAL ❑OTHER it ffI O ya which requires a permit Ia construct,alter.Improve,dem , r repair any smtcture 1�"' wv. prior In iLc issuance.also requires the applicant for sue rmiuofileasignedmmemenl SPECIAL CIRCUWIK ^�^�^�^�,v that her,lice Purmunna the prnvisinnn of tlm ntmcua's Li,rm,Law(Chapmr9 ��Q (commencing with Section 7000)of Division3 cloomessand Prafassi...Coli TEMP.METIiR OR POLI: COMMERCIAL 6 E a e' Ihm he is exempt Ihercfrnm xtW the basis the vllcged cxeranian.Any violalion of ❑NF.W BLDG/ADDITION ❑DEMOLITION ^m Section 703 L5 by any applicant for a it subjects lheapplicanno a civil penalty of POWER DEVICES El TENANT FOOD SERVICE Fly not more than five hundred dollars( t0. IMPROVEMENT p5p ❑Lmowaerafuapm'm,.sm is employceswilhwages as lhei...le can"mantion, SWIMMING POOI,ELECTRIC ❑OTHER F will Jo the work,end the eruct not intendedocofiremil insole(Set. Business L 3 m and Professions CMe:Thera ommemrs Licrnse Lvw tices nm apPIY w an owner of OUTLETS-SWITCHES-FIXTURES Property who builds or es theman,and who does such work himself rethought his own employees, videm that such improvamenls arc not intended or offered for NEW RBSIDIiNTIAt.ELECTUR SQ EL sale.Thvolocad uildingmimpn..mem,iv sold within'are your of completion,the SQ.FIL FLOOR AREA, $/SQ.FI'. wneoboildmov hurelhe buidenofproving that he did not build or improve for par- �I�{p W 0 pose of odr,.L ❑I.as me r of the progeny,am exclusively contracting with licensed Crustaceans m TOTAL: - �s^� mslmcl c project(Sec.]IW4,Nusinoxx and I'mfcasiom CndcO The Contrvet....1.i- A ' crime w does nm apply to an owner of properly who builds or improve,thereon.and QTY PLUMBING PERMIT FEE who jamels for such pmjeam with a coatmelor(s)licensed pursuant the Commetm's � License law. PERMIT ISSUANCE /�f ❑I our exempt under sec. ,B&PC fm thmmman Y28 , Owner Dole ALTER-DRAIN&VENT-WATER BRA) ION WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE YVf�I��'[© I hereby vtfinn under penalty el Nimy onc of the following dcvlunrro r: L/U ❑I have and will maintain a Certificate of Consent ea srlf-insom for Worker's Compen- DRAINS-FLOOR,ROOF.AREA.CON D. STORIES TYI-ECONSI'RUCI'ION emion,as provided for by Section Tina or the Lahor Cafe,for The performance of the yy9rk for which this permit is issued. FIXTURES-PER TRAP ISI I have and will maintain Wmka,x Com,nsalion Insurance,as required by Section IDOofthe labor Cade,lathe prdiormanct,ofthe amdforwhich this Permit is issued GAS-EA.SYS'E'EM-IINCAOUFLIi TS OCC.GROUT' APN My Wnr 'e moria rt dllgicy pgmbp�rpjtp_a�.$�, GAS-BA.SYSTEM-OVER 4(EA) Cartier. Policy RO -O_ ZJI CERI'IFICATF. F.XI:MPTIONIBOM WOIiKF.RS' COMPENSATION INSURANCE GRIiASFJINDUS'BL WAS'T'E INTERCIiPTOR 1 I 1 tDIVISiONFEES (Thissec0..... not he emnpivmdif the permit is litronc hundred Jnllnrs Ol W7 GREASE IRAP unless) I'LANCI11iCKl I certifythmintheperlbrmm�cenflhe war fon hi ch Otispennamisawd.111all SEWER-SANITARY-STORM EA.200 IT not employ any person in any mannas it ale rghj W.the Woders'Compen- ENERGY TEEQ Oz saline Lawn nfCal �i6 WATER f11iATRR W/VENT/ELIiCTR z Applicum GRAVING y NOTICE'TO A�CANT: -oder nuking ix Certificate of Exenlplinn,you should WATER SYSTEM/IR1iATI NO SOILS ITH7 abecome wbjmt It,the Workw's Compensation provisions of the lahor Cale,you su al {47 forthwith comply wifirmahprwisionsur this psmut,loll bedeemed revoked. WAI'I7R SERVICE. 0 U2 CONSTRUCTION LIiNDINGAGENCY NEW RESIDENTIAL PLMII. SQ.Ff. LAID para Neccipla LLQ IMr which thi that issued(Sec.30 len ding agency for the perfnnnance of 0 F' the work for which this permit is issue)(Sec.109],Cie Cd Lenders Name TOTAL O Lender's Address TOTAL: , I certify that 1 have read this applicmian and atom slim the aMve infrmtation is BUILDING FEIi U h buten.l acne m Comply wRb all city mod manly nrdinarmes end tomo lows r n e QTY. MECHANICAL PERMIT PEE construction. representativesrepresentativenterupot -a building annslctirn,and hereby authorize representatives of this city to enter upon the SEISMIC IEE above-mentioned property for Inaiwation purl osen. PERMIT ISSUANCE (W.).g..to save,indemnify and keep harmless the Cil,rf Cupertino against ELECTRIC FEE liuhllilies,judgmSS��,coss:vnd expeves which may in any way aame.,moo said City AL'f1iR OR ADD TO MF.C11. PLUMBING FF.L os.ineonsCANJ DHI gS rmit. API' CAN 1NUIiRS' NDS AN WILL COMPLY WITH ALL !O POINT AIR HANDLING UNIT LTO III,(Np CFM) MECHANICAL FEF. SOUN IF :GUL TIO ISf� AIR HANDLING UNIT(OVER 10,000 CIN) CONSTRUCTION TAX Sqn.tV of Applicm we EXIIAUS'f HOOD OVIDUCT) HOUSING MITIGATION FEE HAZARDOUS MATERI S DISCLOSURE Will theapplicanl orfmutchuilding occupant smreor handle bazallous material HEATING UNI'f(T0100,000 BTU) it,defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety Code,Section 25532(a)? \ HEATING UNIT(OVER 100,000 BTU) ❑Yes No VEiirrTLATION FAN(SINGLE RESIU) PAID Dam Rcceiplp Will the applicant or future building occupant use equipment or devices which ROVER-COMPUHPOR 1(1(k000BTU) mit hazallous air cnnmminanm as dcfinud by the Bay Area Air Quality Managemmat TOTAL: District? BOILER-COMP(OVER Indiana BTID ❑Yes &No I have mad We It at �serials requimmenly under Chapter fi 95 0l me Coll- AIR CONDITIONER ISSUANCE DATE fomia Haalth&Safety Cale, 2 (15.255JJ anJ 25514.1 undcmaal lhtl if the NEW RESIDENTIAL MECH, SQ.fT. buildingdcesnol entlyha section tis my respmsibilirymnnlil Ne ecnpam of the osm L thasen Ibe enfa Certificate panty. Owner or s age me f� TOTAL: ISSUED BY: OFFICE