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S 2197 —APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CCI TV OF CUPERTINO BUILDING-ELECTRICAI, PE IT NO. " APPLICATIONIPERMIT PLUMBING-MECHANICAL 2197 UJILj11NG DIVISION IIIIILDING PH(1J Y:CI'IDHN'1'IF'll'ATION BUIL DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE o i10 y/moo OWNCif$,AIAM HONF.: COF�tA R'S ME: LIC NO: ` tt//._••..MMAA `✓ NIC CO HOLp AltClll'I'IiCT/IiNGINEE CA LIC NU: ADD :S ❑ LON'I'AC'F. C1 1'UU Ii (�'Vv�sl� BIIILDINC PERMIT INI°O ❑ Consultant Fees Paid by Applicant(initial) BLIIG ELLS/ E-CTPLUMB ME(I'll E 1fr— I_1 LICF.NSEDCONTRAMOR:S DECI.ARAHON QTY. ELECTRIC PERMIT FEE I frothy.11ion,that 1 um licensed unJer,provisions of Chapter 9(commencing JOB DESCRIPTION Zp with Section]OXBof Dlvismn3afthe Businessand Professions Catle.andn,y license is `` mi uir.NTIAI: ulOPERMIT ISSUANCE �tyF in full fume and eR ❑SFDWL ),KITCHENRFMODEI. UU Lmenzc Cross Lica APPLIANCES-RESIDENTIAL. KADDITION ❑PLUMBING RH-PIPE ad Dmc 1 m11`a n _ ti RCHITECTS DECLARATION PANELS ❑MUCI'1-UNIT El STRUCTURAL Z z I un�pyyy shall a Ise cords s MODIFICATION Oz�- [' I) © ar c I UP 10200 AMPS iC`ZQ ❑INT1iRIOR ]CHIMNEY REPAIR I:a V,E. Licensed l'ndex mal 201.10MAMPS IMPROVEMENT SWIMMING POLLS qv s�OJ OWNER-BUILDER OIiC1.AItA1'ION OVER Has)AMPSIIA'rl I REMODEUREPAIR FM0 Q 1.1'I'ION yy R: I herehy aRimt that I am exempt trial,othe Counicare I.Icense Law far the W /�s{F _ J<�0.U following,anon.(Section 7031.5,Business and Prole,,i m,Codc:Any city or county SIGNS ELECTRICAL Ll OT'f11iR kY�X� E�� tR177 3 W y which requires a permit to contract,ular,improve,demolish,or repair any structure I �L prior to its issuance,also requires the.pp.icunt fur.such permino fire a signed statement S PECIAL CIRCUIT/MISC. �y2 that he is licensed pursuant to the provisions ofthe Counselor's License Law(Chapter 9 WE500 (commencing with Section 7000)of Division 3 ofthe Business and Pafasiena Cei TEMP.MITER OR POLF.INST COMMERCIAL: dl cy tbut he is exempt therefrom and the basis for the alleged exemption.Any violation of C1 NEW BLDOADDITION ❑DEMOLITION XmN Section 7031.5 by any applicant for a permit subjects the applicant a civil penalty of POWER DEVICES ❑TENAM' [I FOOD SERVICE I- not moot(Iran five hundred dollars(55W). IMPROVEMENT ¢ I]Las nwnrroftheprogeny.or my employees with wages as heir sale compensation. SWIMMING POOL ELECTRIC C will Jo the wmk.aad lhestmcmre isnot intended,,,offered bursae(See7034,Business ❑OTHER ❑a1and Profes.sion.s Code:The Con(metors License law does not apply to as owner of 011'I'LLTS-SWITCHES-FI R -72 property who builds or improves(hereon,and who Jots such work himself or through It,own employees,provided,hal such improvements are not intended cr offered for NEW RESIDENTIAL EL' SQ Fr. safe,st,mwev«,the building or tmprovenwnt is.old witl....one you ofcontple.ion,the SQ.IT VL00R AREA $/SQ.IW. o,arr will have the burden of paving that m,dad nal huild lir irapmvt lin,pur- I a of sale.). �j I] 1...ownc„f the propert,am esel rii,cly enmaracI ng with licensed cnntmc,arr,w TD L: OX 62 construct the project(Sec.7044,Business and Professions Cade)The Contractors Li. cense Law does nal apply to an owner of progeny whit builds no improves thereon,and QTY. PLUMBING PERMIT FEE who contracts for such Projects with a cnmmetons'l licensed pursuant to the Contmetars L"'em PERMIT ISSUANCE c. �pIr� Sec. B&P C for this reason w tlr�Cb Dare AUIER-DRAIN&VENT-WATER IIIA) VALUATION WORKER'S COMPENSATION DECIARATION BACK FLOW PROTECT,DEVICE �0 1 hereby affirm under penally of perjury line oldie following declarations: 01have attd wil.maintrin a Cenificaeof Comem aulf-insare for Worker's Compen- DRAINS-FLOOR,ROOF AREA,COND' STORIES TYPE CONS'TNUCTION smion,as provided for by Section 370()of the Lehor Calc,for the perfnnuom,of the work for which 11r,per it is tamed. 171X'IURES-PERI'RAP 3R, 1 hnvo lona will nmintain Workers Conmensminn Inxu,unre,ru required by Set i / 1 S �.. 37N)of the Labor Care,for(be performance of lhcwork forwhich(his permit is issued. GAS-HA.SYSTEM-1 INC.40UlLHTS r OCC.GROUP AI'N M it„,,, I'll ation Insurance currier lona Pit icy numher are: GAS-EA.SYSTEM-OVER 4(EAI orris PION 7RO C IFIC O OP COMPENSATION INSURANCE FROM WORKERS' GRIiASI%INDUNI'RL WASTB IN'fERCEVI'OR t COMPF:NSATIONINSURANCI! BUILDING DIVISION FIiIis ('this section need not be completed ift c,smot isforone hundreddo.lars(E1(0) GREASETRAP ar less.) PLANCItfiCK FEE Iredly that in theperfamenctofthe work for which this Permit isismed,l shall not emplpentonnn oy any in any maer sit as ur be«see sahjeO n rhe Workers'Counter. -SANITARY-STORh1 FA.21XIIl'.pen- ENERGY FEE 1 s ZV 17 z satin,,t.nwa of C.lif ahia,slate WATER HEATER WNENTMLECfRPi GRADING 1911' �j Applicant NOFICB'IY)APPLICANT:IL aper making this CeniOcam of Exemption,you should WATER SYSTEM/TREATING h Is femme aai,rct m the Worker's Com (inn Inn,ni'the Lula,,Gude,you as, 500,5 PEE j pens. sam�a mtmwBh eritnp.y with such proviamaa ri�esti.�:rtlat smell Ise Jcemed revoked. wnreR selv.ce 672.9 A UO CONSTRUCTION IANUING AGIiNCY NEW RESIDEN I AL PLMII. SQ.FI'. i'AID • '” y I herehy ani, mar iso mn5uuction lending agency for the perfrnmwlce of we Receiptq rk for whi this (Sec.7fNl],Civ.C.I k. Lender's Name TOTAL: 57 Q I.1 Leader's Address TOTAL: 7.?,i CI certify act 1 have read this application.nd state that the above information is BUILDING F17F FVi Correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT U Z building construction,and hereby amhorize representatives clans city to enter upon the above-mentioned property for inspection pmrryi PERMIT ISSUANCE 11n) (We)agree m save,indemnify and keep harmless IMe City of Cupeninn against I L CTRL go- 62 liuhili(iev,juJgmens,resisant espenses whielthar,in any way scram,again..said City MAKE OR ADD TO MECH. an narquence of the granting panni LUMBI }motto of t. 0 t AI'I'hICAN" INDCRSTANDS AN .GDMpLY WITH ALL NON-POINT AIR HANDLING UNIT!TTI III,(NNI CF SDIIRC' Et I S. A C ITE Cs�T rcrry� AlI2 HANDLING UNI'I'(OVIiR I0JNI) :PMI —5 -- ax— CONST -' IN TAX 76 Sig Item ontmemr z / Dote 1 13%IIAUS'f IIOOD(WIDUCI9 Y O ' HOUSINGM 'IOATIONPEE o HAZARDOUS MAT'ERIAIS DISCLOSURE Will the applicant or future building occupant striae,handle hazardous material HEATING UNIT(TO 101,00X)BIG) s as define)by the Cupertino Municipal Code.Chapter 9.12,and,be Health and Safety Coat,Section 25532(a)l' HENT[NO UNIT(OVER 1(00.0!X1 HTU) �p Yes El No VENTILATION FAN(SINGLE RE51D) Gr PAID `' 9 fly ReceiptX Will the applicant or future building occupant use equipment or devices which �/ emit haaarmms air contaminants as defined b the Ba Arca Air Quality Management BOI LFR-COMP UHP OR IW.0X1 BTT) /6 s-7 Y Y Y g TOTAL: V Z District'! IiOILEIi-COMP(OVER I(X),(XX)IITU) ^� ❑Ye, ❑N AIRCOND.TIONER �� I I n I the ha. J ,m I iuly I t Inc tt'unJer Ch4.,r fi.95 f the Cal- X ISSUANCE.DATE hm s l l latit&Safety Colic,Scei n,25505 25599 star 25534 1understand O a d d e NEW RESIDENTIAL MECH. SQ.FP. hu' 6 t mmnllyb ate taut y :p ,h'1'tyt ify,h Icctpml IhL or a net chin n rime ss cofaCt wte ofOuup y. U Ihnrized.gear Date TOTAL:? s -(� ISSUF.0 IIY:�y` f-)A,7"n'S"CG OFFICE