S 2470 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ISLE TRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL _ (� /I 4 O
BUILDING Phroi IDJ EITPIFICATION
BUILDING ADDRESS: - - SANITARY NU. APPLICATIONSUBMITTALDA'1'E
-��Bubb Road, LOT "A"
OWNER'S NAME: PHONE: CON I'RAC'L'OR'S NAME: LIC NO:
Deblin I a CA Lim Part. 255-4300 Debcor Cor oration 385712B N/c coNIBGI.#
, \RCHITECT/ENGINEER: LIC NO, ADDRESS' ❑
Environmental Innovations 12280 Sarato a-S'vale Rd,#101 '
CONTACT: PHONE: I:'BUILDING PERMIT IN fO
Shannon D. Paboojian 255-4300 ❑ Consultant Fees Paid by Applicant(initial) HI.DG ELECT PLUMB MECH
Project Manager - Debcor Cor [� [�-
LICENSED CONTRACTOR S DECLARATION
ARATION QTYELECTRIC PERMIT FEE
I hereby affrm Int 1 lid a p f Chapter 9¢nmme ll g ', JOB DESCRIPTION
❑aZ with Secdnn 7(H)B)oLD .cion Sof the Bt.c isamd Professans Cotte and mylw . L
0o In full f�ie.nJ effetl. PERMIT ISSUANCE
MIT W'-' WI. El KITCHEN REMODEL
CZHU Data Chas Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
I IT
m¢W Data—Ceatraeor
FPy A—fialb man DECLARATION PANELS ❑MN:1'1-UNIT ❑MODIFI ORAL
MODIFICATION zoianz
IundersmnJ my sloop shell be usml.c public rmoNa MODIFLOATION
U I'T0200AMPS 11 INTERIOR ❑CHIMNHY RF,1'AIR
F r�F"{ij Licensed Prfoo,ional 201-I0)(BAMPS IMPROVEMENT (]SWIMMING POOLS
OWNER-BUILDER DECLARATION. pypR IOU)AMPS El BATH REMODEL/REPAIR DEMOLITION
C¢a� 1 hereby affirm Not 1 are exompt from Ibe Contractors License].me for the
o F O following reason.(Seared 7031.5,Business and Professions Coda Any city or county SIGNS ELECTRICAL ❑OTHER
which requires aPermit t t I,this,improve,dicieselia,or repair }a euro _
ymJ p,i its k,mmuv,m,o4 s 11TITTlic,amI lt poren,tot1 .Onedia.brourn SPECIAL.CIRCUI'UMISC.
mr,be is I' IT pou,niont...the powimoroofth C Taal License L (Chapter9
W (commencing with Section 7000)ofDivision 3 of the Business and Prefcssmnc Code)or TEMP.MET ER OR POLE INS'P. COMMERCIAL-:
6t p, qv list he is exempt met I and the basis fur We alleged exemplioa Any'olmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
W-'mwSaundra 7031.5 uny bapdi,rm forapemtit.dhjcct,thpliwn e apto penally of POWB�D ICES
ti ❑TENANT ❑FOOD SERVICE
not more than five insured
..paty, ,myempl. ROVEMENT
� nLothework,andTrepeny, remyempleyap wilhwages
red foralei(Sea 704,Busiidn, SWIM GPOOL ELECTRIC
p.,
mwill delhn work,Cars, he Connenot,tended License I.. dos.,,I apply t1oI,. ❑won,
and PretensionssCode:The..ammeter's Licence taw door not apply s if owner of OUT EO ITCHES',FIXTURP.S _
property whooyin,c rn Improves thereon,aper who does such work himself orthmngh
his own employees,molding rim such mens is a da me um intended nr d ion.for NEW RESIDENT AL EL SQ PI•.
Of
owns ll lowered The have the lander of improvement is that
lhe did nope build
or improve for the SQ.FT.FLOOR AREA 5/SQ.FT,
cr-builder will have the bunlm of proving Ihm he did not build nr improve for pur-
pmedsowne
❑I,a owner of the Sce,E94,Business
exclusively contracting with I)IdeeCcnmmonn n, TOl'A L: r/ (�
,rmtma the project(Sm.7fW4,Nucinesx.nJ Professions Cadcp'Ihe Contrnmor's Li- -
cerise Law does not apply td an owner of property who builds or improves thereon,and QTY PLUMBIN rPERMIT - PEE.
who contracts forsrch projects with a contractors)licensed parmare to the contractors -
License L.w. PHk MI'I'ISSUANCHitts
E I.m exempt dander Sed. ,B&P C for thlsrmvan
Owner Dale
ALTER-DRAIN&VEIN-WATER(EA) VALUATION WORKER'S COMPENSATION DECI.ARA'I'ION BACK FLOW PROTECT.DEVICE.
ff �,��7 /00(o xn O
I hereby arm under penalty of perjury one of the following dalmaimus: G—! Ul
❑ I have and will maintain a Campeau,of Consent to self-insure for Worker's Cmnpea, DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
emion,as provided for by Section 3700 of the Labor Cede,for the performance of the
work for which this permil is,op, . FIXTURES-PER TRAP -
❑ I have and will Injuries Worker's Compensation Insurance as required by Section
3700 Of he Labor Code,for theperfmmanceof the work for which this permit isissuad, GAS-HA.SYSTEM-I INC 4 OUTLETS OCCG P APN
My Worker's Compensation Insurance carrier and Policy number are
Carrier: Policy No - GAS-HA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASHANDUSI'RI,WAS]E UoLE CPPIOR .. .
(Thissearednerd notbc amplcladd llmdaurtsfeeors,hundmddollaiNryd - UI II TVISIOMPP.&S
nrl,eaJ
GREASE'I RAP PLANC 'C P t rV
.Z
I tori fy the in the performance of the work for which Inns panmliaiaducd,I hall SEWER-SANITARY-STORM EA.200 FT.
'I nut employ any rem nt in uny manner so ns to haeme object the Wmkers'Conran- F. 3 N cation Laws of Caldrome.Date WATERHEATERW/VEALUELFCTR •7910,
��jj AppEmrl ' OkA G PE'
r'a f% NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS]rDF%RHA'I'ING
H become snbjcn to the Worker's Compatrmion provisimw o[IM10 Luber Codc,you mus mSOIL PEE
W Fri comply with such pmuame,or this panni)nhall he dm
aeedoevoked. WATER SERVICE
Q
-CONSTRICTION LENDING AGENCY NEW k1iSIDfiN'I'IAh PhMH. SQ.FI'. PAID
U0 I hereby affirm that there is a construction lending agency forthe performance at Date Receipt#
V. — the work for which this permit is issued(See 3097,Civ,C.)
0 Lenders Name T
FU Lender'sAddress TOTAL:.
1 partly thot Ihave re'd his in"Inestold and ,are thin the b f Ian s BUILDINGF
(10) Corneal lagree Wply withall city and county norinernateand start 1 Idlgto QTY. MECHANICAL PERMIT,, FEE
U 7, buildingcarrognation,andhereby authorize representatives ofthislyt I ponlbeSEISMIC 3
shove-anceritured prepatly for inspection parposer, PERMITISSUANCE
1 We)agree to save indemnify and keep harmless the City of Cupertino against ELECT 'F E d
hodultfea,judgments,costs and corers,4 which entry In any way...me terminalsaidCity ALTER OR ADD'TO MECH. �7-
meyuencenfthegrdmingof this portent. PL' I IFEE Z
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,003 CFM) MBCA [CAL FEE SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.001 CFM) CO RUCTION TAX ";
dawns of Applicantl tactor - Dole EXHAUSTHOOD(W/DUC13 HOOPI rMI'1'ICATION FEE �`
HA"LA ROU S MATERIALS DISCLOSURE
Wilma applicant or fawns hums,electrical mom Or handle hazardous sa i.l HEATING UNIT(10 1110008 BTU)
as defied by the Cupertino Municipal Code.Chapter 9.12.and the Ileum and Safety
Core.Section 25532(.)? HEATING UNIT(OVER 100,000 BTU)
❑Pas []No VENTILATION FAN(SI NOTE RESID) PAID
Date Racist#
Will app contaminants
aaut or building occupby
Bt Area emporiumQuality
Managecas eatich BOILER-COM LHIP OR 100,0X1 BTU)
mit hazardous air uonmminunu m dented by the Bay Arca Air Qmlity Menagemem TOPA L:
District - HOILER-COMP(OV OR 100,000 BTU)
❑Yes ❑No
I have used the hazardous memlots rc reals under Chapter 6.95 of the Coli AIR CONDITIONER
quiet p ISSUANCE;IJATIi
fbmiv &S fide Sections 25505.25533 end 25534.1 urdem.nJ the Blue NEW kBSIDEN'IAL MECH. SQ.FT
building does not currently have
almnn,dnGtic
my responsibility to notify the occupant � — L4-(r--�L7�tV
V,
dr direments which muss be met prime issuance of a Cenifmte of Gacupanay. _ill
Owner or authorized agent Data NOTAL: ISSUED BY.
OFFICE