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S 2574APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECIRICA], BUILDING DIVISION ' APPLICATION/PERMIT PLUMBING - MECHANICAL 'l BUILDING - PROJECT IDENTIFICATION - ITIt MI'I'hl S 2574 ROILDINC0)RESS: / o �� A) l � SANITARY NO. AVYLICAI'ION SUBMITTAL �B OW R'Syy��AME PIIONIi: Ly ilic �r-�J 7 A :NGINEER. ��� :� C(INI'RAC'fOR :S NAME. LIC NO � uw gijDRES�S� -q �.�� - �/•/Of� N/C ❑ CONTROL4 C/1 7 /O_ CONTACT ; j��PHONE : - l� o\ 1 Prev _L_ "pV}G ❑ Consultant Fees Paid by Applicant (Initial) �, -" BUILDING :P�E/R MIT INIP BLDG I?hFCT PLUMB ' MLCH LICENSED CONTRACTORS DECLARATION 1 heachy firm dal I am believed leader P ...f Chafer, 9lenl,I ne d ig that t f 90f1(R d0 9 III 6,. dProfessions Cndc and myl'censc is ntellf d But I c Ink b I Dale- d�Cn, cm Z QTY p ELECT PERoiilT ,L ry FLFG 1 - FEE, i, '- 706 DESCRIPTION RESIDENTIAL: ❑SFDWL ❑ KI'fCHBN REMODEL ❑ADDITION El PLUMBING RE -PIPE _ ❑MULTI -UNIT [I STRUCTURAL MODIFICATION El INTERIOR El CHIMNEY REPAIR IMPROVEMENT E] SWIMMING POOLS ❑ HAI'H RP.MODEUREPAIR O DEMOLITION tmlTER PCRMIP ISSUANCEi - APPI IANGES RESIDENTIAL ARU I I I'IC'I' S D' tA'1'ION L I understand lay Qlans xhWl he its a6 o G _ L"en'sd Prof... idea Oat I am vU11.DF.I DECLARATION I herehy .(Seta That l nth exempt , le IM1e Contractors Llmtue Law for the following reaam. (Section 903 Rusinms and improve, demolish, inre or Any city or wmnY which ill. n Per e occasional, dr idler, impm e, lh,dil o < mpait any Moment III prluratilsieuanco ,ulmmyuimstheapp)nct)I fmr.ucM1drTdi nGleasia, lidne,r Thal tic ie licueaW punuanuu the pmnemns nr lee Conruda —mad P ..fi L—rd Churar 9 (cat lie , sent i thamirden and of basisnn 3th the Bminexentp Pndeny sit anon or Sur he i6 excngn Iany pit and the per for do mlceee exempdmn, Any d siltation of Sndimn 311115 by hundred licoll Ro a perm'" ,whjecn dw9tplicnnno n civl Pl,nnlry of nut more than O.v a ndoed do ar illy i t,1 ' ❑ Idothe w orofthe progeny, stricture is with wage -s aline (See 094,B sins, find dm work and me Th.aumI.haintended nrawdeforsale(Sec.,,i Walnut anJ Pmrex.ions G,Je: The Gmleadnr6 Licenxc Law does nod aptly m tin owner nl potpery who haild.. m Imprrve. There...., and who does inch work hinexdf ar Ihmtgh his own employees, provided that such Imprevemmats are not retarded or ulFecd for .wleif, hmwcvoa thehanding orinepmvemem LSnld,"tile Ime year of enmpletime, the ar- builder will have the harden of pro ing that he did not build or unpurvic lot pm� ❑ I, as owner ..(de pa y, per am exda.ively connecting with licensell contraatam m reenact [h P d , (See .7044 Business and l a .c l.)Ih no t ar. , .L reuse Lawdran, note"Ay It, anntudirof pre,cna, who hudds in inaproVee, themi aded ,le.contri mrst ch prajccN with a cant (.)lcensed pursuant to the Contractor's License Law. ❑lemexentptundmr Sec, ,H &PC fnrThis mnsnn PANELS UPTO200AMPS_ 201- 1000AMPS OVER 1010 AMPS - SIGNS ELECTRICAL SYHCIAI. CIIt /Ml C, 'fEMI', ME INST COMMBLD AL' 1-1 NEW BLDG/ADDITION ❑ DEMOLITION ❑ TfiNAN'1' ❑ FOOD SERVICI3 OTHER GMEN'1' El OTHER poWI1R D . I ' 'SWIMMING FOOL OU'rLE'IS -S WI'rCIIES FIX ES NEW RESIDENTIAL ELECTR SQ FT. SQ. FE FLOOR AREA . ' S /SQ.FP - TOTAL, - -, - f1 V .f QTY 1 `PLUMBING PERMIT (i Ir i" 'FEE,, PL'ItMI'P ISSUANCE ALTER —DRAIN .@ VFN'I'- WATER (EA) BACK FLOWPROI'HC'I'. DEVICE Owner Date VACUA I ON /) zeZ 00/0 y� WORKER'S COMPENSATION DECLARATION ly I hereby alRrm ender penalty of perjury one of the following deelarmions: ❑leave nnJ will lnainmina CenifwmufConsennoself- insurermr Workers Cmnpen -, eotinn, efi provided for by Section 3700 of The IaborCode, for The Performance of The )kf h hdo pr 1 .. J. have and will maintain WorwO, 7110 (if The Labor Code. f The peg aincp ft IkforwM1 which rn its isl ed. MYW C 1 1. rr and p•In� 61 -��y�'yTq.r�� Carrdel "'�` (J Palley N� P I CERTIFICATE OF EXF.MrTION FI<O OIt CEI2S' COMPENSATION INSIJRANC17 IThi. tied for Tnceln..Ibec..mpletedifthl,pmnlais formal, hen feW dollars (5100) orleve.) Ic, ally drain the any mannneco as t become subject in the W Is rkerl Compe11 not employ any person nl any manner so as to Eeutme svnjed ,the WnrkeLV'Compem satin.. Lows orcelinom'na. hale A,dwin l DRAINS - FLOOR, ROOF, AREA, COND. crmnlc. STORES '1'y PE CONSI'RUCI'ION r, � FIXIURFS -PER TRAP GAS EA.SYSrEM - I ING 4 OUTLETS rx .caour r'] 2 GAS -EA SYS rEM -0VER4(EA) GREASEANDUSTR1. WASTE IN 'I FRCEPTOR BDILDIN-0 DIVISION FEES GREASETRAP PLANCHGCK FEE VT t - S13WER- SAN1'rARY- $T(1RM F,A. 2110 Ff. ENERGY FEE WATER HEATER WIVGNT /ELECTR , GRADING THE NOT 'ICE '10 APPLICANT: If, ellcr making this Cenificam of Exemption, you should became alffivelaidne Worker's Compensation prov'ninm of the LahorCoil you mate, fmthwiTh comply with auto provisi on, to th is permil shall be devoted revoked. CONSTRUCTION LENDING AGENCY I hereby at firm that There ism emstmeuon lending agenEy rer the performance of IM1e work fee ,Into this permit is kored (Sec. 3097, Cie CJ Lenders Name WATER SYSTEM /TREATING SOILS FEE WATER SERVICE PAT NE .. ENTI H. tip H Dom R . TN T AL: Lenders Address I certify that 1 have read This application and mate dm the above Information ix real g t Ily wnti ill cly aed ry f Ltt I'I ngm building construction, and hereb3 uallnr xc pre:mtarvunr d': lay m enmrupn Ihm chow- nientioned property for inspection purpnees. ' (We) agree m save, insecurity and keep he... tlm City of Cuperino against Iimalaiem.jndgmems . mst6lmdes,ense6 whichmny in any way accrue agam,teald City an ca mscquence of The raining or la,unmir. APPLICANT UNDERSTANDS AND WILT. COMP Y WITH ALL NON -POINT S URCC .'ULA'I'IONS 1 N 'TQfA: I 1 G FEE QTY. ME CHANICAUPBRMIT•I�' •FBF. 'M FEE. �© PERMIT LANCE .1 F,C RIC I *GE ALTF,RO AW V PIA BINGFEE AIR HANDLING UNIT(TO 10,000CFNE I'll NICALPEE , AIR HANDING UNIT (OVER IO,fN10 CPM) LY)NSTRUCI'ION TAX Siena bernApplicant/06firranter Dane HAZARDOUS MATERIALS DISCLOSURE Will the applieml be name huildingoce apmu Mom or handle heeardna. Tindent as defined by the Cupertino Municipal Code, Chapter 9.12, and the Iledlh and Safely Code, Sector, 25532(x)? Elyr, Wit Willthen lichntm future haildin tuvee ' ..met ordevice. wluuh 1((1 pP gThythe n 4mP ITmil bawNmes fir emnuminame us defined Thy the Bay Area Air Quality Management DistrictP ❑Yel (7"S.. - I leave rand the Ememlum materials requirenetLs under Chapter 6.95 of the Cali- minno Health lth & F f y Code, Seconer,25505,25533and 25514.1 unichilland der if the ,mlti b1 I 1yb ,En y p .bltyt I[y lh upant of - n.pmtn 11 met Pnl I a TN"t Len t or c EXHAUST HOOT) OVIDUCT) HOUSING Sit rFA'1'ION FEE HEATING UNIT (TO 100,000 HTIn' HEATING UNIT (OVER 100,000 BTU) PAT]) VENTILATION PAN (SINGLE RESID) Dote ecipt BOILER - COME (THE OR 100,000 BTU) a BOILRR= COMP(OVN.R IfNI,f1W B'I'U) AIRCONDITIONER ISSUANCE DATE ISSUED BY. / ✓ y (7/ NEW RESIDENTIAL MPCIT SQ. FE n card agent Date I TOTAL: OFFICE