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S 1837 —APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELKCfRICAL (,SIT No. BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL, `V / BUILDING.PROJF.CPIDENTIFICA'I'ION JRRLDINGADDRI,Ssu '- SANITARY NO. APPLICATION SUBMI'ITAI.DATE O ;:v ,* A ;�AV aC✓ Q OWN( 'SNAMIi'. IONG'L � � C'ONTRA"101," AMC: •J LIC NIT. P NIC CON'f1i01.# . ARCHITECf/ENGINGGN; LIC NO: ADDAESS v/S �� �// ❑ CON'I'AC'f: PHONE, 'HUILDINC PI?RMI'I'INFO ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH i 99- ❑ ❑ ❑ ❑ hIC[N}I O(ON TNACIUIt}OPCLNIAI ION QryHI LECTRICPERMIT� ,¢�� BEE,- Iaacbymtitrahtl J Is,p of Chapter 9 a,nn ' I, I' JOB DL]SCRIF11ON DMZ willhSution]gIB)nf Di i.imJn1'Iheeu sa uaJ ProfesonsCode unJ nylce.m's �r / RESIDENTIAL' WOO Q PIRMITISSUANCC W • 0 F1- n full forte and eflec O� bq ❑SFDWI. ❑KITCHEN REMODEL ZZW Licenip LlcN AI'I'LIANCLS-NIiSIDHN'fIA1. ❑ADDITION ❑PLIIMHING RIl.PIPF, N<1 Ilulc CJ Conlr:FC FOy ANCIII'I'I?CT'S DIiCLA tAT ON PANEIS ❑MGLThLNIT ❑S'TItUCNRAI, wZ Itndemahnyphers.hall beco]aspodiviscafds MOGl F[CATION OZ4� UP 10 20h AMPS El Hsi ERIE IR ❑CIHMNEYRFPAIR W Licrosal['roressi^nal 201-I000AMPS IMPROVEMENT 0SWIMMING POOLS ..1 OWNER-BUILDER UIiCCARAI'I(IN OVER 1000AMPS ❑BATH REMODBIJREPAIR ❑DEMOLITION I hereby aHna that I and exempt hour[lie Contractors License Law for the XXl3 LL F following reason.(Section 71131.5.Business and Professions Code:AnY cilY nr coo^IY SIGNS ELECI'NICAI. [IOTHER LL y whidh requires a permit rah conntruv,vl¢r,impmvr.Jefnnlish,ar repel(any smcune M•+06 prior m it osuance.also require 0enpplic:mt l ineucfi,sar nofilcaolhalsmrcmem SPECIAL CIRCUI 17MISC. pZ..LL thus he ix llecnxal puremnt mla hpnisi mnmof the Conuaclnre l.ieow nLaw y� 1+1a00� (,1 ovncingxilh Section 9101pnf Division 9 of the Hudnesund Prof oustsCo,R)or TEMP METER OR POLE INS']'. COMMERCIAL' tL 1 e W that he is eacmpt themfmm and the basis for the alleged conniption.Any vinlmion of ❑NEW BLDG/ADDITION ❑DEMOLITION m_LL Section 7031,5 by atyapp]icunt for a permit-objects the uDdi:vnt to It civil penalty of POWER DEVICES nanne'had five hundred dollars 11500). C1 TENANT El FOOD SERVICE IMPROVEMENT ��Q wi Lo(hework,the pmpeuct remyempinyceawllh wueesoa lhei(aele connpnhsatlon, SWIMMING POOL IILEC'rNIC f.0 will dnlheinrk,and lh^ a Cartr ,lanot immndave a.desforsllle(Su.d.,I Ruact of :1 OTHER 6 3 w and eddy who builds Ctor ime Comnctorn Ciccone dos suc not apply m It owner of OII1'LITS-SWITCHES-FI%TI1RF_S gy p n hit own whooyor improves cs thereon,and who d,".•such work houcled oro(through — t hit own employees,provided Ilfut wch ingvuvnnen¢^m nm intenMA nr offered for NI!W IIESIDEN'1'IAI.CLIiCP'k SQ FT. odr.11,hove,c,Ihe buildinger improvcmuniaauW within one year of enn:plclioq lhu SO EIP'L1Oj1AjZE IAI1�1�n $ISQ.FL owner will have the burden of proving that he did out build or improve for par �VL 13 /111JrD proc of wle) 1 t thep pentexclusively I' t b rah licensed t ors to IOTA(: (� n 1 , h p I 'I(S .7044 B : II f.: Cod,)1Th C 1i mrsl' --.. C1i f�/ Uf IIUrChIIN Iawdoesml:pplyt'antw rofpr hpcaywhohul(i mfr o cshcmneh:d QTY' 'PM LUBING PERMIT : FEE who contran.a for such projects with a contraclmG)licensed pursuant o the Conddich rs License Law. PERMIT ISSUANCE Ion exmnpl under Sec. .B&P C ILr this reason Owner Ilme ALI171t-DRAIN&VI!NT-WA I'17R(EA) VALUA'I ION • WORKER'S COMPENSATION DECLARATION BACK FLOW PN(ITECT.DEVICE I hereby alBmh under penalty of perjury one of the following declarstrar: ❑ IhaveandwillntaintainuCcnificateof Cunscnttoself-inxumfor\Vorkcr's Compen- DRAINS-FLOUR,ROOF.AREA,CONO' S'IOkIES TY PE CONSTRUCI ION anion,us prOvjd,d In by Section 3](10 or the Labor Cnde,for the pedonmmec or the work lin which Wis permit is koucd. FIX1 URES-PER TRAP ❑ 1 have and wIll mmntain Workces Compensation Insurance.as required by Section 3700 ofthe LaborC,de.fortheramnnce ofthe work for which lhiV tis issued. GAS-EA.SYSTEM-1 INC.q OUTLETS ler fermi OCC.GROUP AI'N My Workers Ghmpcneauon Inn'urunce Cartier mW Policy annunciate Carrier: - PIONFRO: GAS-1'.A.SYS'I'IiM-0V9RJ(IO CEItTIPICATEOIr SATIONIINSURAN WORKERS' COMPIiNSAT10N INSURANCE GRfiASi%INDI/S'1 RL WASTE IN'I EHCT:1'J'ON BUILDING DIVISION ISIS (Ibis aectinn need not M+mmplemol if lhcpermit is fnnmc hundred Jnllura($I(p) GREASE TRAP or Inn.) I'LANCHECK IIiP. Ireton,that In the pctlormunceofihcwork lerwhlchlhiapermif is lean ed,lx hall SEWER-SANITARY-STORM HA,200 FL not cruploy any person in any mann• enol ha n M1ecOnthe Work...Conifer- ENERGY I9?i? Z onion Laws of�ghf�n' .1)✓! a l p WAILR HEATER W/VENTIELIiCTR Z O NO]ic'anl AI¢� u GRADING PEE H-f y Nf YI'ICC'1' AI'P.-CAF`. 1:after making Ibis Certo,ar of Exam tion,you should W11 HE SYSTEM/IREATING X- ? heroine afbjcO to the Worker's Compensation pmvieions of the Labor Gale,you must SOILS FEE W forthwith comply with such provisions calfik permit shall be de, d revoked. WA'i'IiH SERVICE 91. U O un CONSTRUCTION U NOING AC.ENCY NEW NESIDEN'I'I Al.PLMH. SQ,14. PAID Uc ktteiP t# Ihcrehy nl'llrm lh:rt there is lfmmlmclileadingagry enfnr lie perluu'rmanceol rr Jac work]or which this pcmthis isuied(Sce.91197,Civ.C.) 0 F n Ledm ers Nae TOTAL: U Lenders Address AYI'AL: >w 0. I erfly that I have cad II . ppl t d'I I th t th b e i tf rot f a BUILDING FEE fF".t V3 101. 1d,n fly Inhall Ity I' it,colidonar,and 1,0aw,ilatic,m QTY. I MFCHANICALIIFRMJT FEF. L) Z building Couvroafamr.and hen0nn ly.torzc nl rcaenWl s:d lelty to auupoh l he h SEISMIC 117 .Noe-mentioned'roped,IF in.a am.parswe" PGRMI'IISSUANCE IWC)agree m m save,indemnify and keep harmless the City of Culeninn against fa.l!CfRIC hili built tics,judgmvntn,costs and expenses which they in any way accrue against.said City ALI I:R OR ADD'I 0 M ECH. n in consequence al the gmnij ng u1 this pernhit. PLUMBING FEE APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,011h CPM) SOUR ER ULA YSA / CONS PRICAI.FF.E /i/(( j(J/ AIR HANDLING UNIT(OVER 10,(MCFM) CONS'fkUCTION TA% SlFnuuna nfAppllcun Canlraz nr Date EXHAUSTHOOD(WIDUCI) BOUSINGMITIGATIONFEE HAZARDOUS MAI HR]NS DISCLOSURE N51l ilmapplicanlorfutnrebni[Jing,<cupanatore ar handle hamNnm matvini HHA'UNG UNI'I(1'0100,00h BTIA u.defined by the C.peniea Municipal Code,Chapter 9.12,and the Health and Safety Cod,,Section 25532(a)P HEAPING UNIT(OVER 100INIO BTU) - 0Yes I C]No PAN V 13N'I'ILATION PAN(SINGLIi It1?,SID) Doe Receipt p Will the applicant or future building,weuputn use equipment or devices which noir h.rardom air Cor ,ar iunnrc as dettned by dm Bay Are.An Quality Manngemem BOILER-COMP OHP OR RX)J R RTU) Dowel? TOTAL: 'Yes nNo BOILER-COMP(OVER 10k.00E13TU) r I have rc:ul the lhazvdou.v arsenals nitrification,under Chuprcr 69$of Ne OJiAIR CONDI'1'IONRR- ISSUANCE DA li lnmia Health&Safety Cade,Sections 25101,21111 and 255,61 l underso d that file NEW RESIDP.N'I Al,MECH. SQ.Ff. hn0dmg I've not ainently hove n leant,thin it ja any m pn....h ity to nodry Ila enupunl of the rcquircfncnu which must he fact prior to issuance ell Cernfmam of Oocvlwncy. Owncrnrautbnrf agent Date TOTAL ISSUED BY: OFFICE