S 2471 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O&D
CITY OF CUPERTINO BUILDING-ELECTRIC.AC PERMIT NO,
BUILDING DIV ISR)N APPLICATION/PERMIT PLUMBING-MECHANICAL S 2471
_ BUILDING PROJECT IDE.NOIFICAT'ION
BUILDING ADDRESS: O SANITARY NO. APPLICATION SUEIMITTAI,DAII?
..,Bubb Road, LOT "B" Z
OW'NER'S NAME: PHONE: COMI'RACIUR:S NAME LIC NO:
AM Deblin I, a' CA Lim Part 255-4300 Debcor Corporation 385712B NC CONTR(B,x
ARCHI DICUENGINEER: LIC NO: ADDRESS: ❑ O / 'J
Environmental Innovatio 12280 Sarato a-S'vale Rd 11101 l/ l/ JS 09
CONTACT: - e]h fZ 610 ONE: BUILDING PERMIT INFO
Shannon D. Paboojian 255-4300 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SB:cE
Project Manager — Debcor Cor I� Q- [:I— �
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE '
1 hcreny of irm hat 1 nm lieenwd undm pmdisinns of CM1aprcr 9(ennnncneom, _ ]OB DESCRIPTION
O�Z with section 710000 of ivision 3 of he Business and Pmfesslon,nwe,a.d my license is R ENTIAL:
O O PERMIT ISSUANCE
is full fareemid effect. DWL D KITCHEN REMODEL
CUF License Class Lic.x
y ZQa Dam Corirader APPLIANCES-RI!Sun!N'nAl. ❑ADDITION D PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT ElSTRUM URAL
PANELS
Zpr/sZ Iundemand my plans shall be used as Public recoNs MODIFICATION
p Z�2`0 UI'TU 2(NInMPS El INTERIOR El CHIMNEY REPAIR
a�F'; Licenwd Profz,,ional 2111-IOR)AMES IMPROVEMENT []SWIMMING TOOLS
C Q I hereby alfimn h 1 ameaanpt from he C ntraclar's License law for he OVER land AMPS
ARAI[ON L1 BATH RF.MODF.IIRF.PAIR UEMOLI'I'ION
K36 U following mason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS Ii1.ECfRICA1. D OTHER
LL LL H which acquires a permit to construct,alter,improve,demulish,or repair any nmcmrc
F_—OQ pEorto itsissuance,also requires the applicant for such permit file a signed statement SPECIAL CIRCUIT/MISC.
that he is licensed Pursuant to the provisions of the Commerce's License Law(Chapter 0
W1'p0 (commencing with Section 70IX)of Division]of the Business and Professions Cade)or THN1P.MEIT!R OR POLE)NST COMMERCIAL:
a a c C hat he.,k exempt hemhtm and the races for he allege)exemption.Any violation or NEW BL ❑DEMOLITION
XroLL
Section 7031.5 by any.pplicam forapermit subjcrruhc applicanun.civil Penalty POWER DEVICES
D FOOD LITIO SERVICE
not mom than five hundred dollars($500).
,, DG/ADDITION
FD1,as owner of rhe Employ.or my employees with wages as their sale comperoainn, SWIMMING POO�.lil-1?CIRICwill Jn he work,and he suuctore is nor intended or offered for sale Ore.laid,Bsiness fn
Wit:m and Pmfessiuv Cale:Tne Comnenrtx Liceme law Jtex nor apply m i m owner of OU'ILEI.S-SWITCIIIS-FIXTURES
and Prw who builds or improves hemnn,aha who sews such work hinudl nr Ihnrugh
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL,FLECT R SQ FT.
sale.If.howeveethc building or imprmnmcnr is sold wiflia use yearof compleliou'doe SQ.FT.FLOOR AREA LSQ.PT.
er-builder will have the burden of proving that he did not build or improve far pur-
poso of sale).
D 1,as owner of the p,,),aY,am exclusively couluxiii,wish beenced common,In TOTAL: �✓- a '�f
construct the project(Sec.7044,Business and Professions Codc)Me Contncmr's Li- •J `�'
cense Law does at appl,tomiewnerof prupcny who bulldsm improv e,domain.and QTY. PLUMBING PER FEEr
who contracts for such projects with a con scions)licensed pursuant o he Conimmor's (�O/
License Law. o
D l am exempt undef Sec. ,B&PC burr this reason I'ERMI'f ISSUANCE?
AEON-DRAIN&VENT-WATER(17A) VALUATION
Owner 110
Date
.WORKER'S COMI'IiN$A'IION UI3CLARATION HACK FLOW PNOTECT.DI!VICE �� O O
I hereby affirm under penalty of perjury one of line following declam ionu a
D l haveaml will maintain a Ce"diente of Conxenttoselr-innve for Wnzker's Compen- DRAINS-FLOOR,ROOF,ARHA,CONU' STORIES TYPE CONSTRUCTION
satin.,a,provided for by Section 371X)of the lahnr Cale,for rhe perfornuome of the
work far which this permit is issued FIXI LIKES-PER TRAP
I] 1 have and will maintain Worker's Cumpvnwtiun tolermme,ux required by Section
3700 cfhe Labor Code,for theifuriumi rhe wod rnr which thin stet is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS Pe F OCC.GR($UP APN
Can
a Warkm's Cnmpcnsvtion Invurvnee mrtiaaand Policy numheroro: l
Carrion Policy No.: MS-I?A.SYS'rl!Mi)VER 4IEN
CERTIFICATE OF EXEMPTION PROM W ORKI?RS'
COMPENSA'T'ION INSURANCE GREASI IINUUS'1'RL WASTE IN HRCE19'012 ;
LD DIVISION ME 7S
('This section recd oat neemnplemd it the tanner is fnnmebundrcd dollar($11X1) GRI?ASIi'I'ItAI' �• O
nr
le".) PLAN E IEE
Toy any hatinrhe perliounn,tons to Nee lreclo,stuchdtisl,seW ie 0,C', famlood o_ SEWER-SANITARY-S'IORM F.A.200 17E
not employ any peen.m any mannose tons m neennleatlbien m rte workers'ennlPen- H a >
Z sateen Lows nl C.lil'orniv.Dm° WAI'IlE Nl!AI'13N W/VENTII?LI3CTIt
y�O ll
Applicant - l G DINTBF
q p NOTICE TOAPPLICAN'I:If,vfmz narking his Ceniliutm nl'IkonynlOn,you should WA'Ilit SYSTEMIIAIiAI'ING vv
beams ob ce,to he Worker',Gtmpcnwlion pmvi i,ol'Ihe LahnrCode you nn, OIL4 F
G>a forthwith comply with such provisions or this permit shall he deemed mvoketL WA'fElt SERVICE! -
Q
CONSTRUCTION LENDINGAGENCY NEW Itf:MlJliN'I'IAl.PI,MII. SQ.PL PA
U O Inemny arartn tn:n hem lsaonnnmotinn senders nec.er rat me pe nr Date Rreniptx
,� Lawn's rat sensor roma parlor i,'r,aaed(see 3na].ay.e.l
OLender's Banc
U
W Ixnder' Address TOTAL:
I certify that 1 have read no,application vnA sane that the nhnvc information i, BUILDIN
Tai) correct.l agree to comply with all city and county ordinances and state law,relating to QTY. MECIIANICALPERMIT FEF.
L)Z building construction,and hereby authorize representatives or this city m enter upon the SEIS 1 3 "� 2-
above-mentioned property for inspection purposes.
(We)agree m save,indemni If and keep ha-tale,, he City of Cupertino agi imt PERMIT ISSUANCE? B FF.F. s'
Iiabilitie.s,judgmcnts.costs and expenses which may in anyway acme against sued City ALI ER OR ADD TO MECH.
in consequence of the granting of this permit. PL GFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI"rfr011.(00CFM) MEC ANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.(NN)CPM) CONST UCTION TAX U �7
S,nauueofApplirarmCoetmcmr Date I!XHAUS'I HOOD(W/DUCT) HOUSING MITIGATION FEE
HAO
ZARDOUS MATFRIAI S DISCLOSURE:
WilTtne applicant orfutum buiko.,oi cupanm...co,handle h...ad materid HHATINC,ON['I'(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and he Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 10.000 BTU)
L]Yrs I]N. VENTILATION PAN(SINGLE RFSID) PAID -
Dam Res iptx
Will the applicantornds a iffireg ty theB useco AirQuofdManawhich NOILIiH-COh11'(3HNOR IW.(XIO BTU)
emit htmNous air contaminants as defined by the Bay Arca Air Quality Management
District' TOTAL: i
El Yes Disler BOILER-COME(OVER 100.000 B'RH 73 (9
I have mad the bm:adouxmammal,requirements undef Chapter 6950(the Cali AIR CONDIT ION17R ISSUANCE DATE
form.Health&Safety C d,Sections 255115,25533 it 25534.1 n shush mhif the NEW RESIDENTIAL.MECH. SQ.FE 12
building does net currently have a tenant.that it is my responsibility to notify the occupant K
of he"tort ems which must Jaime,pnor to Izw.ncc of a Cenifierw of(Acuponcy.
Owner or authorized agent Dam TOTAL: I ISSUED BY: _
OFFICE