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S 2276
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL PE81T N0. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V2276 BUILDING PROJEC'E IIIENrIF'ICATIIIN BUILDING ADIlRISS: SANTT IARY NO. APPLICATION SUBMITTAL DATE a© s5 6L1Lo5s y OWNBR$NAME: PHONE: CO RAC10R'SN 13: LIC NO: (�� 4 �ttC�—/ It oe r� 38 j NIC CO 'ROLM RCHITECDENGINEER: LIC NO: ADhDD�-R�ES,: _ (^� � \/�, F/i W 41 SSfoc1E '-1.A —Z- ..J JAJ pcONTncT: vxoNE: BUILDING PERMIT INFD � kd7_�crl-1 f Pel nl 14(4� ❑ Consultant Fees Paid by Applicant(Initial) BLDD ELECT PLUMB MECH C 1 LICENSED CONTRACTOR'S DECLARAT ❑ ❑ o ❑AZO ION Q'TY ELECTRIC PERMIT FEE I hemM1y atfirm'na I am Iiclicensedunder provisions of Chapter 9(commencing JOB DESCRIPTION AL with Scction](X1p ofDivisinnlnf the llnxinnaanJ Pnttessions Ctxlc,and mylicensc is in till l'omatnd affect PERMIT'ISSUANCE eg-h R. FQZV Liccn.pp��Clec.�� Lic.a a' SFUWI. ❑KITCHEN REMODEL N<a Dam 7- Counselor API'LIANCFS-RESIDENTIAL. El ADDITION ❑PLUMBINGRE-PIPE Z O > ARCHITECTS DECLARATION PANELS ❑h1ULT1-UNIT ❑STRUCTURAL. y G I undervmnd my plans shall he unM as public mand, STRUCTURALN OZ14G UP1021p AMPS F n F'W Lmcumd Professional ❑INTERIOR ❑CHIMNEY REPAIR 4l 201-R11)AMPS IMPROVEMINT SWIMMINGP00IS � a` litllnwiIharthm ( rmsbarN341m.5,BdDwvlmdPrConf^ON`sLi'lou,Lawhome OVERI000AMPS ❑PATHREMODELREPAIR ❑DEMOLITION a O incl An cit ' 4Ya F e yon county SIGNS ELECTRICAL ❑OI'IiER LL Q y which requires n permil'o mnswn,altar,improve,Jemblish,nr repair any nwcwrc yQ prier to its is'uanle.also requires the applicant for such permit as file asignd assment SPECIAL CIRCUIT/MISC. F than he is licensed pursuant no the provision of the Contravenes Locate Law(Chapter 9 aqCennmtcncing witll Secnnn]000)of Division 9ofnhe 11 ueincxe unit Protessions Code)is T'EM P.METER OR POLE INSI'. COMMERCIAL: a cC 'hal he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDG/ADDITION El DEMOLITION Section 7031.5 by anyapplicam fora permit subject spplieaorto a civil permhy of POWIeR DEVICES \ I„yp, n more than five hundred dollars($500). ❑TIiNANT ❑FOOD SERVICE GxQ ❑I,ucrwner uftha pmp_nY,nnny employees with wages ax lhc'n stilt mmtpcnm'ion, SWIMMINCIMOLRLECTRIC \ IMPROVEMENT F� will do the work,dnd meylmemrc is not Intended orotferd for sale(See.70W4,Business QOTHER a 3 m and Professions Code:The Contractor's Licence Law does not apply to an scar of OUTLHI S-SWI FCHFS-FEVE glip pmpeny who builds ar improves mann,uad who does such work himself or through his own employees,provided than.such intprovemess ore not intended or offered for NEW RESIDENTIAL U ' sole.11 hownvct the bu Itingrr i mproventrnl is sold within one year of completion.the SQ.FT.FLOOR AREA $/SQ.IT. unsuarbudder will have die h nden of proving that he did not build or Improve felt per- pnse elf sale). ❑ I,as owner of the pmpery,ren exclusively contracting with licensed contractors to coast m.I the prnjen(Sea.71144,Business sad Protmeiuna Cudo)'Ne Celmaalor'x U- cense Law does no,apply to on owner of pmpeny who builds or improves'hemon,and Y. PI M G RMI FEE who contracts for such Entice¢with a cardmc'or(s)livereal pursuant to the Contractors License Law. ' ❑ I ale exnatpt under Sec. ,13 SO 1'C for anis MIT - ANCP, Owner -D AVEST-WAI'ER(EA) Dae VALUATION WORKERS COMP17NSATION DECLARATION N K P PROTEC`F.DEVICE / ^ O J I herehy ofirm under penalty of whaq one of the following Jmlamtions: w 'I have snit will inamoslaa Cenificme"I Comeal huelf-Imam for Worker's Cnmp INS-FLOOR,ROOF,AR UA,COND' vaioa,as provided for by Section 3700 elf rance the IaN r Cold,for the perfomof'h If STORIES TYPE CONSTRUCfI(lN work for which this peso'is issued. FIXTURES-PER TRAP L�I have and will maintain Worker's Compensation Imurance,ax mquired by Senion L)oflm Labor .ad MyCodeak, Ce,,l'nr the perfim......cnf twf he ark oJ rwhich this peonaliiss mme�d. GAS-PA.SYS'1'HM-I INC.4 DOILE'lS Trico ntCptinn 3PSVyYkrm Pitney No�I'w �[(J/72,y� OCC GROUP APN GAS-PA.SYSTEM OVER 4(EA) �J iRTIFICATTE OF EXEMPTION FROM WORKERS' /L COMPENSATION INSURANCE GREASMNDUSTRL WASTE I CEPTOR (Thi—cal on need not he complcmd if the permit is Innma hundred dollars($Ia0 BUILDING DI VISION FEES or less) GREASETRAP iilo,P RICK FEE Loy any maim me any nournro to work for which this lwrmitr ersued.I shall'Conmen- SEWER-SAN[TARY-STORM OF nm employ any person in any manner snmrobecome subject mthc Woders'Cnmpen- pSt HE QZi saelnanwx of Cnlifnrniu.IbM WATER HEATER W/VEN'DF7[E( z NOTEApplian' GRADIN IFTI. arA tev,de.TO APPLICANT.If.Cion making rsiu anis Certificate of Emulsion,herc you should WATER SYSTEM?BEATING bec'ane subjects the Wmker.c Compen,his provisions of the labor Cole,you nano W fm'hwim comply with such provisions nr his permit xhdll he dcmeJ mvnkcd, WATER SERVICE B aQ U z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.PT. PAID V kforehhi,barran ocumbit them isacot(See 3097,Co. agency fur the performance of Dec RreeiplM L4 F the work for which sir permit is isx'¢J ISac.309],Clv.C) O Ladder's Name TOTAL: F 4 L) 1<nder's Address TOTAL: I cenify that 1 have mad this application and.aae that the shove information is BUILDING FEE V1 entree.I concert comply with all city and clung ormamees and state laws retained Qjry. MECHANICAL PERMIT FEE U hnlldingconxuuction,and her Rsy nshoriec representatives oflhis city suer upoame SEISMIC FEE. abnve-men'ioned pmpeny R,inspection purposes. [s C.yN (We) PERMIT ISSUANCE ( gree m sass,indemnify and keep hannlcss'he City of CUTcnind against ELECTRIC FF.F. liabiliues,judgamno,costs and expenses which may in any way acme against said City in cnnsquenceof the go (ingof this Fcnnit ACI'IiR OR At)])TO MF.CH' PLUM BING FEE ,kAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING IJNIT(TO BI.UIO CPM) QJ1RCU REGULATIONS. o MECHANICAL FEE D —/� AIR HANDLING UNIT(OVER 10,WOC1'M) CUNSTRUCI'[ON TAX Signature ofApphcunnntmoor Date EXHAUS'IGOOD(W/DUCT) H0I151NGMITIGATION FEE MATERIALS DISCLOSURE , ^ Will the applicant or fmure building occupant store of handle hax.Won,mmeriel HEATING UNIT(TO I(Indoor ITU) as defined by the Cupeniao Municipal Cole,Chapter 9.11,and the Health unit Safety Code,Section 25532(u)^. HEATING UNIT'IOVIIR 1 1000 BTU) ❑Yen Ko VEND 11.ATION PAN(SINGLERFSID) PLA ID "1 Q 72Z Will the opted team or future baithing occupant use equipment or devices which me Receipt K ,,it hironnlous an conmminants as defiled by the[lay Arca Air Quality Management BOILER-COMP(MILOR 1111,0X0 BTU) fml)urian? TOTAL ❑Yes f 4d BOILER-COME(OVER 110,010 BTU) 1 have read the havarch as materials requ ovulanu under Chapter 6.95 of be Cali- AIR CONDITIONER ISSUANCE DATE Health A Safety Cole,Sections 25505,25533 unit 25534.I understand rent if the NEW NISIDGNTIAi.MF.CII. SQ.Ff. building does nortmrrently have a tenant,mut it is my reap risibility m.notify the tceupam of the myuiremen muu he me'prior m issuance of a Certificate of occupanry. l n Own"m Ihelrizhe age Date 'ICTAL: -0� A^17-*A� CCi 7. 7o ISSIIC:U HY: OFFICE