941697` APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
f CITY OF CU PF.RTINO BUILDING�ELECTRICAL PERMIT NO.
' BUILDING DIVISION APPLICATIONIPFRMIT I'L1ID1131N1:-M1tl!CIIANICAL x, S 0605
BUILDING PROJECT IDENTIF'ICATIONJ,
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT F.
OWNER S N E: P ONFi: CONTR CfOR'S MEi: `IC NO' Ay yy
p � _ �,- � � I'-� cohrruDl.a
•A RCHI'IECF/ENGINEER; LIC NO: ADIjR'S5: t
CONTnCI': PUONI;; _ 'BUILDING PERMIT INFO
�r
❑ CnRSWtRDt Pecs Paid by Applicant(IIul18H I11,DOEl.li"' PLUMB MECH 14A EJ
LICE NSEDCONTRACTORS UEC(ARAHONQTY s ELIiCTRIC PER .''FEE
ntercny affirm that l licensed i provision,of Chapter 9c out ' g . - IOB ASCRIPTION
❑4'2. with SacimY(OXI)'fD'9.bn3ofthe Bumemand Pmfasson:Csde J yhrnmis RESIDENTIAL:
W O PERIOD ISSUANCE.
F,UO^ in fill form.ul cB'a,. ❑SFUWI, ❑KITCHEN REMODIiI.
C U F Class ass Lic.M
Q U APPLIANCES-RF:MUIiN3'Inl. [--]ADDITION ❑i'LUMITURAI PiI'li
N� Dme _ CSDECr
R' AHCHITELTS DECLARATION
❑MULTh UNIT' ❑SFRUCIUHAI.
I'nNF,hS NODI(EY R10N
mZ iand udmnJ my dice—landl be uncd ase public rcavnl
UP"F02(I(1AMP5
pZ=p � ❑N''FF,RIOR ❑GIIIAINEY NIiI'NN
r,4tfy Llcxmed Prufessinnul 201-1000AMPS IMPROVETTIE?N9C]SWIMMUGI'OOLS
OWNER-BUILDERDECLARATION OVER I(NIn AMPS ❑BA'I'HRI?MODEI t;l'A ❑UIiMOLI'I'ION
I hereby affirmIh',I pt f theC ,act 'L Law for the
it. al toll ng : .IS i n"I031511 m JRf:.'msCd An, lyor county SIGN}LLFCIRICAN ❑OFIIER
If1�Oy which reqPermit1 construct. In p J permit
p Y_Wemre
pp � poi I .. co. q the.offapplicantf hpmsh 31signed.fraccum SI LCIAI.CII<CIII'f/MISC. 64t Vill;1or
wwN that he licensedlar tt nth p sans of the Contractor',I : 1' IChapier9 COMMERCIA'
��p0hourannel ng with Seen T 70( )nfD'vision 3ufthe 5m teas,nd lmfmfrns Codd nn IRM R MET ER OR POLE,I NST.
W i1:0^p� that he no ,nua t thereto n.,[the two,for theaincl d!eve.np.inn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
YXP g
u' Smt Y Y PP P 1 pl m t I p why of Iv)WI:R DhVICES ❑TENANT ❑FOOD SERVICE
^Zy antro to f hundred d Ilan 1$5(X)1 IMPROVEMENT
0I,es nwaarnf sic pmpany.fir mYan ployunw lbwa6`-s avtb�renRcompanx.ton. SWIMMINC.I.LELEC'1'I11C
F• voillde the wnrkanJ Theewanre is net intended nrnffemJ for safe(See 9(hla.Bminus El 011 .
^w
a3^ a'dP ,Cd.T C o q nl' 1 J I pdy, Aar of OUHEIS-Solid C }_pl%'I URI'.S
ismandY h it ld: p ,h 1 ai,ths, rich work h If through
his ese employees,provided that such unprovemants are not intended or mored Inn NEW RESIDENT FIAT,11 EC'1'R SQ t1'.
sale.If.howco,the building or improvement is sold withinora year of completion.the SQ.IT I'L(RIR AREA $/SQ.IT.
tower-builder will no,the h Aden of proving that he grant build fir improve for par-
pescofsure). IfYfAL_ P A ' r1
E]1,m owner of the pnlpeny,nm exclusively contracting with licensed contractors to
construct thproject(S90,14 Ruvirm,,v andPref.. C k)I bit C t n I' s
wnLa does not eply, fp pony h n'Id. p :tit and QTY. Y •1 PLUA1BING PERMIT FEE
contracts for sten proicat%witntennl d (xnaeread pursuant In Be Coaraamra '' SES' 16 RE CU
License Inw. PERMIT ISSUANCE
0 I mo rwoof,radon Sm. ,B&P C for this reason -
ALTER-DRAIN&VIiNI'-WAI'IiR IIiA1 ALHAI'1(IN •• -
Owner Dam
IO -
Wmunder SCOMPENSATION DECLARATION BACK FLOW PROIBCT.UIiVICIi
I hereby affirm under Penalty of perjury one nf,no following r Wdaasoac
❑(have and will lJimaintainbSection 37umof the L,duo self-in sure for Worker's Canpcn- pRAINS-NL(R)B,ROUE AREA.CUND. $'TORIES TYPE CONS'PRUCHON
.,,inn,as pmviJed Iii by Section 3900 nl the Luhnr Crxln,for,he pelormnnce of the
work for which thin patmit is orker it X'ff1RES-PEIi"rRAI'
❑ I have L will maintain Worker's mna,of he w Imumnce,as o,Ise by Section
19(Nl of the Labor Cools,tiro the pelnrmanee of the work rix which ohls pcnnit i.isxuan GAS-IiA.SYS'I'IiM-1 INCA OIFfLIT'IS OCC.GRf1UP APN
My Workds Compensation Insurance carrier sad Policy narrow,arc:
Cartier: Policy Nn.: CAS-IiA.SYSTIiM-OV13R J(EA)CI RHFICA'i'li OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRHASHANDIIS'I'RL WAST IT IN'I HRCIiP'll)R
BUILDING DIVISION PERS_
(ndswedist fusion,becnmplard ifthe pcnnit is fnrnne hundred Jellfa($11d) GREASIi'FRAI'
or lc,,,) PLANCIII:CK NIi13
I cenify that in the performance ofthew'ork for which this permit is issue,(shall SEWER-SANITARY-STOI1M HA. FI'.
not employ any person in any manner so as to become sabjcet to the Workers'Cempen- ENERGY Yl?I?
Z moron Lfwsof Celifnmin.Date WATER IHATFR W/VFNT/ELECI'R
` GRADING FEEpplicam
NOTICE TOAPPIACANT:If,odua making this Certificate of I?stanption,you should WRIER SYS'I'EMII'REAL ING
W5became subject to the Workers Compensation provisions of the Labor Cale,you mm, SOILS PEE
fnnhwith comply with mach prnvision.a or Ihis pemtiI shall he decmeJ rcsated WRIER SERVICE
U Thai he,-is.c ON NIiW RIiSIUIiN'I'IAI.i'LMH. SQ.19L PAID
D Z Dam Reccip,X
L) p (hereby M.Thai isaams,mninn leading agency for perfannancc of '
Fthe work In,which(his permit is issued(Sec.31199,Civ.C.1
lenders Nam, )lAl.:
CUS1 Lender's Addmss TOTAL:
yI connify that have madnths application and state that the above information' BUILDING THE
rH.t lc, co ct.l gree, ply tit all city and county ordinances nLtate la li gt QTY.,a ',.MECHANICALPERIcHT' ' 'l, PEE
UZ building construction, 11, by rthari fie. fit esrfo.s city To anter rpon the SEISMIC IEI:
above mentioned pmpeny far inspection p ryoses. PERMIT ISSUANCE
(We)age.m save,iinknmify and keep hanalcN,the City ofpenio
Cuu almost
ELECTRIC THE
Iiabildies,jud,froma mvimad expenses whch,nay many way accmcaga leasuid City' ALTER OR ADD TO MECH,
in asequence nf,he granting of this patPLUMBING PEE
APPLICANT UODEy$TANDS AND WILL COMPLY IT A N '- All'HANDLING UNIT(TO 10,000 CFM) MECHANICAL Fi3E
OU R' 1, ' NS,
' AIN HANDLING UNIT(OVIil21f1,(IIX)CFM( CONSTRUCTION/AX
.Tier fApplicanVComractor ()a" EXHAUST HOOD(WIDUC) HOUSINO MITI ATION FEE
HAZARDOUS MATfiRIAlS DISCLOS E
Wllthcapplicvm fir fumrehuildine"oeupom store fir handle nm.urdousniancial HEATING UNIT TO 101.000 BTO)
as deposit by the Cupertino Mimicipol Cee,Chapter 9.12,and the[health ofd Safety -
Code,Section 2553200? HEATING,UNIT(OVER 100.000 ITT U) '
❑Yes ON. VENTILATION FAN(SINGLE RESID) PAID
a¢ 'kcceiptM
Will the Ar cicmt m Faure building occupant use co Air
or Mann which
emit hamnlous Ar wmmminanty as oleOnoA by site Buy Area Air Qnfli,y Management BOLLEN-COMP(3HP OR IIH1,3111113TIT) O 1
District?
❑Ycs ❑No - BOILER-COME(OVER 100.0011 BTU)
I base madohe hamnlous matemok requiremems under Chapter 6,95 ofthe Call- AIRCONDIHONHR ISSU C DATE
formes Health&Safety Calc,Sations 25505,25533 and 25534,1 unbuttoned that if the NEW RES ID17NTIALM I TCE I. SQ.T-1
building Jsns not correctly have a tenant,that i,is my resrymsibili,y to notify the scut em
of the requirements which oma,he mot prior In itirnanc,of a Cenficale of Oecorymoy.
Owner or amnnrired agent Dae TOPAL: ISSUED BY.
OFFICE