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S 2263 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUu.DING-ELEC'RICAL Pli n'No BUILDING DIVISION APPLICATION/1'ERMIT PLUM NC,-MECIIANICAL 2263 BU IA)INC,PROJCCIIDF.N'1'IF'ICA'I'[ON BUILDING ADDRESS, � SAKII FARY NO. APPLICATION SUHMI frA,DATE 10 1 - 1?— PI�F. S GE Itol -9-e O NFB'S NAMIi: PHONB: Ire CON'I'kAC1Uk'S NAME LICNU'. Nb b y v-STvj I EA- 5 1?22—c NIC orvlkol.x A CH ITECIENGINr;IiR: LIC NO: ADDRESS' 1� L�- 1471 G� �N/ ❑ A--I W PSR m CONTACT. PHONE: BUILDING PERMIT'INFO ❑ Cow..Itant Pecs Paid by Applicant(Initlal) BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICENSED CONTRAG'IUR.S DECLARATION QTY ELECTRIC PERMIT FEE 1 hereby affirm fill loans ran,ed under preslsh,ns or cbapmr o(enmmeneing JOB DESCRIPTION po"L 'mScaion](Xx)nf Divisinnluf the Business unJ l'mfessions Cole,and my liccnu is RESIDENTIAL' t+10p to I'IiRMIT ISSUANCB H full force and S5��eeyy11,, (� ❑SFDWI, ❑KITCHEN REMODEL Q U Mu Lic.p 591329 APPLIANC&S-RESIDENT![At, ❑ADDITION ❑PLUMBING RIiPIPF FZW Ila¢ 1�-f p.i]b TS DFCIr y Q d ---7� MULTI-UNIT ❑STkULTURAI. ABC111TECF5 DI[GLABAr10N I,,,pw � I'ANIi1.S MODIIICA'IION S p h 7^. 1 undcrsmnA my)fico nryull Be uncA its puhlic rcmnk In"1 O 11X1 AMPS p 2,.p ❑IN'1'I:RIOR ❑CI{IMNGY REPAIR W Lwe...J Pmtexsit of 201-1000AMPS IMIIROVEM17N'I' OSWIMMING PDOLS Y UWNIiR-NUILDEN DECLARATION OVER 1000AMPS ❑RAF!RI',MODEUIdITAIR DEMOLITION z W a I hereby arrno that l am exempt from the Containers,License Law for me KpaV following reason.fSction]831.5.Hu.ince and Professions CWC Any city or county SIGNS ELECTRICAL ❑(all[:R W 3 a ha which requires a permit to contract.alter,improve.dent or repair any dracome -0 Prior to Is issuance.'1.so requiresthe ppls tfor%ad%pernal to file it signedaament SPEC IAL Cl RCULUM ISC E y-, ninth I Ip It th P n III Contractors L 1� IClmpmrY W��� (u LLcagw'm Su.l 71X101+1 Omits t It Brsncs dl I ': :( ..four '1'1;M P OEIERORPOLIi INS'I'. COMMERCIAL 6 e Ibnt be n exempt thm'elrt and the basis Io mo ullepul exempt on.Any v olal on r f ❑NEW HLDGIADDITION ❑DEMOLI'I]ON n� Section 90315 by ury applicant for altermit.subjects the applicannoncivil pvnulty of POwI!k DEVICES ❑TENANT ❑FOOD SERVICE not more than Five hundred dollars(450). IMPROVEMENT ESD QSWIMMING ❑OTHER VOOLI3L[C IC (.. will Jo the work,and the.structure is not intended or uttered forsale(See.]Iw,Business u�l—w and profession,C,Jc:11C t :License Law does n t apply I ser of O11TLFIS SNIT 1'1%TUkES IY 3^ property h builds or' P thereon. I 'h J such k loosen through b semployees,provided' h t seen imp t: trotintendedoffered far NEW BESIDE nh ua,c� sQ Fr. sale.11L howe—,flu building or lmpoord"a s fold command rcuot'us npwron.me SQ.IT,FLOOR AREA SISQ,FE. builder will have me burden of promng rent he did trot bairn or i�ltprnrd for par- pofir-swdsale.). ❑1,as owner of the property.am exclusively eomnneting wild licensed contractors tu " onstma the pajco(Side.]BW.Business and Profnssiens CWe:)TM1e Conlmoor's Li- cerise Law does not apply to an owner of Property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE who contracts for such pn9ecls with a cartructm(sl licensed pursuant to the Contractors License Law. PERb1H'ISSUANCE ❑ loll exmnpl undid Sec, .B&1'C for thismason AI;I'I!B-DRn1N&VI!N'I'-WAI'IiR(EA) VALl1A'I'I(lN Owner Deli WORKER'SCOMPENSATk1N DE Ce folio ing BACK FLOW PNOTIiCI.DEVICE I M1erchy affirm under penalty of perjury one of the following Jedaralinns: ❑ Ihave andwill maintainstion 37M of the Labor Code,for for Worker's Comp em DRAINS-FLOOR.NWIIAREA,COND. STORIES TYI'F.CUNS'tkUCT10N scion,as hick this for by Section 3]011 of the Whin Code,for the derailment the �$k[•�kI for which IM1is permit is issued Irlh-fURI3-PER TRAP F have and will nsalnuln Worker.Compensation Insurance,as m,doad by Section ]1 fol Lim),Coda lin the performancrot'0m work for which this peril is i...W. GAS-PA.SYSTEM-1 INC,J OUTLET'S OCC GROUP ANN My Wm1, ' CnnnPr,s Insurunre rnricr and Policy nunnbpr u'c: Card(a ir�ON policy Nn.:a-sJ nfladelQ GAS-EA.SYS'IF:M.OVER J OEM CER I'I IICN'E OF EXEMI'1'ION FROM WORKERS' GREASIVINDIMI-RI,WAS 112 INTERCEPIOR COMPENSADON INSURANCE BUILDING DIVISION FEES (Tho,woumaddema M:cmnpleacd if lbepemnit isfu...chundreddolao Dl Wl GREASE TRAP _ or le".) FEE Ie I certify that in the pertormance ofthework for which this proof is issued.I shall SEWER-SANITARY-S'IO22M doily Any)conn in any manner m us m hccnme suhjcct to IM Workers'CnmPcn- I?NI?kGY FEE Z 9alinn Wwsol'Cahfnmia.Dula WA'1'F.R HF,ATER WINES I'r © GRADING PEEZO ATd1antNOIICE'IOA1'PIUCAMI:Il:altermakingthisCcnilicaaofExennpli'I you should WATER SYSTI!AIl1'RIiAI'INSOILS Igilibecome subject ,, beWorkers Compcnvtinn previsions ofthe WhnrCsxle,you mowforthwith comply with such previsionso thi.slnnnitdoill be demned revoked. W'A'rER SERVICE:DCONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIl I'nIU Dam Receipt at C.1 I hereby union that there is.conwmetion lending agency for the performance of Da — theworkhad which this pernm is issuW(See 31x91,Civ.C.) TOTAL: O ULeade's Nome ITa I,undcr's Address L5t 1 certify Ilett I hue rwd this applieniun and nmac Ibut the whoa.information is BUILD canea.I agree to comply with all city and county onlindril and.state laws relating in QTY. MECHANICAL PERMIT FEE V Z building construction.and hereby authorize representatives of this city m enter upon the SIi1S, ohm-mentioncd Property lin inspection purrynes. ITRMI'T ISSUANCB CIA (we)agree to save.indemnify and keep barless the City of Cupertino against Iiahilaies.jW1rood loon penses which may in any way vecruc ugaimt void Cir ALIIiR OR ADD*10 MI!CH. I'I. Ei1NG `insIN in nICAN1CCt b This pS� it. AI'1'LICAN'I' . DE A b II COMELY WITH ALL NON-POINT AIR IIANIJLING UNI'1'Cf0111•IIfNICFMIEcl .ALFEE 1 r SOURC '. Pill. ) 996 r r AIR HANDLING UNITOVER Ip.f(ln ClsM) '( ITRUI ION'IAX S' lure of App icanif nmmor Ume l EXHAUST BUDD(WR)UC) UOUE IN+ TIQN FEE EIAZARDOUS MATHR AIS DISCLOSURE Will the applicant or future building occupant wore or handle hazardous material PEATING UNIT(TO 10.000 BTU) m defined by the Cupertino Municipal Code.Chzptcr 9.12,and the Ilealth and Safety Code,Section 25532(;)'! II BAII NG UNIT(OVER IIX4(XX)BTU) Yes No VI!N'1'I I,ATIUN I'AN ISI NGLI?RESID) I'All) Dull kcccipl p Will the appl'nvnl or future budding motpunt use equipment ur devices which [loll ER 13HP OR 100,050 BTU) mit hvallous air conmminan6 a,defined by the Ray Area Air Gorday Management '101AU. Diwria' BOILER-COhIP(OVI?R In)JXX)BID) ❑Yes ON. 1 have recd the hamrdo-materials mquircilicars under Ch,rarr 6.95 of the Cali- In CONDITIONER ISSUANCE DATE himiaIcahn&Sdiny Code,See,feet 25505.2553.1 roy...J 255)4.1 understand a o"u'relflad NEW BCSIDEN'r1AL MI:C11. SQ.1*E / hnddmg Joc.v Ant anrently M1avca mount,thin it is my iesPuusihilltytonnlity the oeaipam l � �� � of the requirements which muni he mrt prior ns issuance of Cunid'aac o1'Or Owvcr mauthowed agent Dote IfYIAl ISSUED BY: OFFICE