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99100025ool Ion NTTO F!LL !N IMPOPMATICIM WITMIN REEI LINES - USE BALL POINT PEN ONLY 6 —1 l E% O0ZS O Z�0 �F-W YE, 0.' 3 IysY�. ap�0 G p.. �t,=_.o �3m CITY OF CUPE RTINO BUILDING - ELECTRICAL. BUILDING DIVISION APPLICATION/PERMIT PLUMBING -ME CIIAN'ICAL BUILDING PR(IJECT IDENTIFICATION I PERMIT NO, HULL ING ADDRE.S.' SANITARY NO, APPLICATION' SUBMITTAL HATE OWN AMW '1 NE' •J ^ /�//O (/ �j G C RACE 'S NAME,; LIC1sQ� N/C ❑ CONFROL# .RCHITECVENGINEER: LIC NO: ADDRESS: CONTACT: I'IIONE: BUILDING PERh1IT INFO ❑ Cnntiul[aut i'fCg Paid by Applicant (IBII7RI) BLOC. ! ELECT PLUMB MECII b6Y ❑ ❑ ❑ 1=Z 10p7�/ • W _ MVV • Z y7 >y y Z LICENSED CON IRACITIR'S DECLARATION I hereby anion and 1 am licensed under provisions of chapter 9 farmotcncing with Seaion7IXlB)nf Division3ol rhe Business crit PrnfessQionx Ccode. and mylicemeis in full force and e'ucel. `' Liccnw I'tx- Lic.x Dam Coin QTY ELECTRIC PERMIT' FEE JOB DESCRIPTION RESIDENTIAL: ❑ SFDWL ❑ KITCHEN REMODEL ❑ADDITION ❑PLUMBINGRE-PIPE ❑MULTI -UNI I' [I STRUCTURAL MODIFICATION ❑INTERIOR ❑CI I DIN HY REPAIR PliitMIT ISSl1ANCli APPLIANCLS—RFSIDF.N`HAL AHCHI'IIiCI"S DECLARATION 1 undeaanJ my pians shall be used oz public rcwNs PANELS UP TO 200 AMPS I.iccnscJ Prole,sionul . OWNER -BUILDER DECLARATION I herby al6nn that I um esien, from the Conttucmti License Law for rbc following reason. (Section 7031.5. Rosiness unit Pndesome, Cale: Any city or county which ¢quires a permit m construct, aloe, improve, demolish, of repair any s s t pr I t is I. 1 :aapplicanti 'hp Ito fl :'g d:I that licensedp pursuant thep 'tins of the C t t d License la (C Sidi9• P,mor urvny»iso Section 7000) of Division Sof the Business and Pops.r.n - thin he is exempt Ihcrefmm and the hasis or the alleged exemption. Any. violation of Section 7031.5 by any applicant for a permit subjects the applicant a civl penalty' nor mom mon five hundred dollars S5W), E] I. as owner of the pmpeny. or my cmpluyce with wipes as lhei,xolc compensndo will do are work. and the stmclum is not intended or offered forsale(Sec,7=. notice unit Pr f - G a: -U C t' I : I 1 d . not apply man rwine, of prolivirty who builds or improvesthereon, and who does sh work h rmsll r his pl Y e. provided th t h p c errs nm mm�Jcd nr n sal If, however, the hdd guinpnu. un :old lhn rsyvar deo np t 201-1000AMPS W Q i V 40 y Q, e C Z>• d IMPROVEMENT E] SWLvIMING POOLS ❑BN'H RFJvIODEIJRIiPA1R �UIiMOLITION ❑ OTHER - a COMMERCIAL: ❑ NEW BLDG/ADDITION ❑ DEMOLITION OTENANT ❑ FOOD SERVICE IMPItOVIiMENT - ❑OTHER OVER IINMIAMI'S SIGNS ELECTRICAL C R L S 'o IM L OUTLP.I'S-SWI fIF -FU R . TAI SQ IT. 11.0i AREA $ISQ. PC mrser-builder will have me burden of proving that he did not build rr Impros r p you of sale.), El 1, us uwmrnf ore propcny, sur esduxmely ammmetiu, wim liecnsed anummurs m consumer the project (Sec. Wlfa, Business and Professors Crde:)'rne Cmararmrs li- censerLawdresnotapplyroanownero(propcny who builds or improves thereon, and QTY. LUME NG PERMIT FEE who conwets forsuch pr jccra wim i eontmeror(s) limnxecipursuant ro the Contmcrors License taw. ❑ I am exempt ander See. .B& P C for this reason L� PE IT ISSUANCE. _ I(,jF ALTER—GRAIN & VENT —WR'I'ER (EA) L.�'✓2I__� woe r Date L I VALUAHON BACK ROW Play] ECL DEVICE W(IRKER'S COMPENSA'T'ION DECLARATION I hereby affirm under penally of Perjury one of the following declarations: 1qqq 10 © , ❑ I havered will maintain aCenifcmeof Cnnwat toxlf-inmrc for Workers Compel 'anon, ax Provided fie by Section 9700 of the Labor Code.lhnhc per[mnancC ofthc k for which Nix permit Missouri Klase and will maintain Workers Compensation Insurance. as required by Section oflbc Labor Cala, for Lc p,it bnnanmof the work for which rhH hermhieQie�wcd, My WnrkcLbfmxEs. tjkp•hrsur,Hy,•canicrand PolicyPoliy Nr: ��—t1 Canicr: j�%'8�/A i-1•'•cL/ DRAINS —PLOOH OOF, AREA. GOND. STORE_ EPARTM6NT RTINO)cc. GROUP TYPE CONSTRUCTION' APN[j I 3 FiX"rUR P TRAPf)rI T r OAS—BA Y. 1-I INC. q OUTLETS C V c GAS' EA. SYST`HM ' (EA) GREASE/ 'A. ' iRCEI'TOR C17KFIFICAI 17 OFEXBMPDON PROM WORKERS' COMPENSATION INSURANCE G BUILDING DIVISION FEES (TTi-ce, urecd not hecampvical lfthe,cnnit ixforonehondrWdolla,61(l) nr loss.) GHEASHIRAP LANCIiI� Icenify the in the pertonnance of me work liuwlich rhixpennit ...ed, (shall nm enrployuny penoninanymannersousmbecmnc subject rrthe Workerd Camper. SEWER-SANI'rAR -) 3A.2WFT NERiEE WATER HEATER WIVESILVE -C WA'rCR SYS'll?M/fRHA'IING p SOILS FEE V RAID K°cnplK TOTAL: z Z = F --r , Wforthwith i3r U pI i3. F" (] L) salion lawn of California. (late Applicant )'RE NOT ]CE APPLICANT: il', after making lin, Ccnmerne of Exciepoon, you should become suhjecl nr IM1e Worker's Compensaliun pmvixions of the lalnrt Colo. you sora ilh ... It provisions urrhis permit shall he devoted revoked. CONSTRUCTION LENDING AGENCY hereby ot, incfimuhanhcrc isseed(So,.30 len ding agency for the perfonnrncc n( ma week for wbieM1 this permit is issued (Sas 3119]. Civ. C) Lender's Name Lenders Addles WADER SERVICE NEW RESIDENTIAL PLM1iB. SQ. FT. TOTAL: IIUILIIING FEE T� >+ 137 Fy I agree That 1 have read solsty and coon and store that the stall w, niton is b k1m Iogrecmcomply »iso all city and courtly ordinances and stale lawsrelaringm baildinpcotumrnlon,'unitbarebyiumorire rcpmscntatives of thiscitymemoupon the QTY MECHANICAL PERMIT FEE SEISMICPBL PERMIT ISSUANCE ELECTRIC FEE starve -mentioned property for inspection purryaes. (We) ogres m sore, indemnify and keep hamdess the City of Cupertino against ALTER OR ALI) I'OMECI I. PLUMBING FEE linbilifrs, judgmemr, c(axand e....... iehmnyir any try aceme ogainq said City in cnnuyuence of dwgmrtingnfthrs t AIR HANDLING UNIT UO 10,000 CFM)- MECHANICAL 193E APPLICANT'vDF.RST DS O WI .L COMPLY WITH ALL NON -POINT BOUNCE,� C 10'IL /`c to %7 AIR HANDLING UNIT (OVER IB(IWCPM) CONSTRUCTION TAX Sign urcofAppllcan/ tucmr Data ARDOUS MATERIALS DISCLOSURE EXHAUS'I'HOOD(W/DUCT) HOUSING MIT ]CATION FEE Willmem,di or future building escaped smrtour handle hnrallous material RUN] IN'G UNIT ('10100,0(X1 BTU) _ us defined by rbc perinn merclpal Codc. Chapter 9.12, and the Health and Safety Csde.Sevtion' 321x)7 HEATING UNIT (OVER I00,000BTU) El Yes 0 N VEN'IILAIIONFAN(SINGLERL'SID) PAID — Dam Receipt# BOILER—GDMP(311PQR IW.O(XIBTU) Will the applicant or future building receptor use eyuipmem or devices which :nal hr,anlousuircuromen:muaJefinedhythc ltuY Arca An Quality M:m:rgenenr TOTAL 7r) eO BOILER -COMP (OVER 1(10.000 BTU) District? ❑Ych ❑Nn AIR CONDITIONER I have real the luzvdous materials recimoenrs mole, Chapter 6.95 of the Cali- ISSUANCE DATE NEW RESIDENTIAL MECH. SO FL folia Hcahb is SuEty Code. Sections 25505, 25533 and 255341 understand mar Hthe builA ng exe nal atmnlly have n mnrnr, ora It is my ropomn,iray m umlfy me acupmn of the mquhements which most be mer prior to issuance of a Crrtificme of Occupancy. TOTAL: ISSUED BY: Owner or amhonxed agent Ilene OFFICE