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S 0292 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q CITY OF CUPERTINO BUILDING-F.LEC'I'RICAL 1'Iiy 1T NO, OZ VZ BUII-DING DIVISION APPLICATIONIPERMIT PLUMBING MECHANICAL `V BUILDING PROJECT IDENTIFICATION ill BUILDING ADDRESS: SAN]ITRY NO. APPLICATION SUBMIT'IAL DAT1: © I lie O NEH'S PHONE: - p S S N MG (7 ! LItO: L fL/ NIC CONI ROLe •�ARCHILICOHA"tTRIdIF LIC NO: ADDR"S:� ^ n / .b ❑ CONTACT: PHONE: - f-f v(/(-(r'! BUILDING PIiRMIT INFO ❑ Consultant Fecs Paid by Applicant(Initial) Bl lx nIzcr. PLUMB MF-CH LICENSE:[)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE Nom{\ 1 hereby affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION W O p waZ with Secll:m]IXXpof Division Sof the IT ressmd]'mfcssione Code.und my license is RESIDENTIAL: C-F in full force onJ PERMIT ISSUANCE effect. OO SFDWL KI'ECHEN REMODEL s_U hiumsc Class Liao APPLIANCES-RESIDENTIAL [I AUDIT [IPLUMBING RE-PIPE N 6 E-ZW Doc Cnnuacmr ARCHI'1'F.C'IiS DECLARATION 0MULI'[-UNIT [ISTRUCTURAL 'Moo)Z I understand my plans shall Msed uas public records PANELS Z MODIFICATION Oz-- UPT020JAMPS [I INTERIOR O CHI,MNFY REPAIR F.~W Licensed Professional 201-1000AMPS 1 ROVEMENP OSWIMMING POOLS �C C Q I M1erehy aff rat mmN em lC elmp ER DEt fined„CR n'�IONr. License Law fm the OVLR 101X1 AMPS TH REMODEUREPAIR 0 DEMOLITION ad which LL F following reason.(Section 71315.Business and Professions Code:Any city or county SIGNS LUCfRICAL DOT ER a which requires a permit m consuact,alter,improve,demmli.h,or repair any st atione F':•O poor o its issuance,also requires the applicant for such Permit o file a signedstatement SPECIAL CIRCUIT/M ISC. the[he is l icenecd mu,m i the f the Conraao's Lleonso Law(Cha [ 9 p1 Division per a1 (cat he is(commencingwithSection7000)of DiaikfrnfineegeBusiness xempt Professions Code)or TEMP.METER OR POLE.INST. COMMERCIAL: L y e ty that he is exempt therefrom and the basis for IM1e alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLI'f10N X=y Section 7011.5 by any applicant for a pernitsubjects the applicant a civil lrenaliy of POWER DCVICES ❑TENANT ❑FOODSERVICE not more man live hundred dollars($500). F z Y IMPROVEMENT Q will Lo the work, the pmpcny,or myemployeeswith offend their sole compensation. SWIMMING M)OLIiLECTRIC will do the work,andCoo me Ia,Com is not intended m offered for sale(Sec.to an Business ❑OTHER 3 and Prnf whonsilm,o imp Cntnmcrec Licensee Law does not apply tatlf ownerof OUTLITS-SWITCHES-PI%TURES property who employees, or improves thereon,and who etas such work himself ars thrmgh his own cmployre�,provide)that e[¢M1 imprnrcn¢mx sere not intended no nlfcrcd for NEW RBSIDBN'1'IAI.I3LL'LTB I'P sale.ILhuwevcr the Ismidingorimprove...I issold wind.one year of asm....o a,lbw SQ.PT FLQQR 1AEq D $/SQ.PT. cr-builder will have[he burden of proving that he did nm held err intIF c lin per- r /� 7 Free of ale.). O I,an owner of the property,um exclusively contracting with licensed commons to TOTAL: emnxruct the projecl(Sec.TAL Endue.and Professions Cole:)The Connectors Li- JUL 14 REO ceno Law dons not apply to an owner of property who build or improves thereon.and QTY. PLUMBING PERMIT FEE who common for such pnouI%with a contractions)licensed pursuant to the Commmmrs License Law. PERMIT ISSUANCE 01.m exempt under Sec. ,B&P C for this reason Owner Dam ALTER-DRAIN&VENT-WATER EA) VV/AA�'rII\UA'IION///��� WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE I hereby affirm under Penalty of perjury one of the following declarations: v ❑Ihavcandwillmai.lain.CenificamofConscnttoulf-insumfor Workers Compen- DRAINS-FLOOR,ROOF,ARF-A.CONDSTORIES 'TYPE CONST RUCTION station,xs provided or by SiNdo n 3700 of the Labor Cole,for the Performance not the work for which this permit is issued. FIXTURES-PE,R TRAP E3]have and will o,ondon Workers Compensation[as umact,as reyuired by Section 3700 of the Labor Code.for the Performance ofthe work To which this Permit is issued GAS-HA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP ANN My Worker s Compensation Insurance carrier and Policy number aa: Caron: Policy No.: GAS-F.A.SYSTEM OVER 4(FA) CERTIFICATE OF EXEMPTION FROM WORKERS' COMP12NSATION INSURANCE GREASrANDUSTR]-WASTE IMLRCEMOR (Thissaceionnaed not becompletedifthepernit isfuro.ehundred Jo11ars1111p) BUILDING DIVISI( 5 GREASETRAP or less) PLANCHfiCK II ?I? cern fnthe pc kfnr which this permit is issueJ,Iahall SEWER-SANITARY-STORM EA.21X11'1'. not employ y a 'it R o ( ocnnm subject to'heWorkui Co.,. ENERGY Flip. O z ardor ld - yrryia WATER HEATER WNEN'TIELECTR z O Ap,hve G GRADING PEE h NOTICE TO APPLICANT:IL oirle,makin,this Ccrnfcme of Exemption,you should WATER SYS'fEMG BEATING ? hecmme mnixl to he Workers Cnmpenation provisions of the Labor Code,you must SOILS TGE fnnbwim comply win such provisions or this permit shall he deemed revoked. WATER SERVICIi a0 UO CONSTRUCf10NLENDING AGENCY NEW RESIDENT IAL PLMB. SQ.II'. ]'AID I hors hicfinn permit i isamnsweti3097.Cin.agency for the Performance of 1 ns. RccviptM W. F the work for whicM1 this permit is iswN IScc.309].Civ.CI C) lenders Name TOTAL: WLender's Address 'I MAL: F6. I certify that 1 have read this application and some that the above mfimmioa b BUILDING IEE Uto comer.I agree no comply with all city and county ordinances and slate laws relating to QTY MECHANICAL PERMIT FEE Z building construction,and hereby authon a mpresemmivesofthin city[center upon the SLISMIC Fort 4. above-mentioned property for inspection purposes. PERMIT ISSUANCE. (WO agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC PGB Iiubihties,judgmems,costs and expeny. hichmayinanywayaccam.g.m.,aid Cay gDIER OR ADD TO M1iCIl. oneequenceafnegtnmin•afl f(pe tit, PLUMBING IzElli APP NT UNDERS" D ANE 'tL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,fXN)CPM) S , �GULAII 1 MECHANIC .FEE 7/✓(- ' �/TiL 9T AIR HANDLING UNIT(OVER 10,000CFM1 CONSTRUC ON'TAX Signnture ofApplicxnVC cr ( Dane LXIW HAUST HOOD IDUCfI HOUSING All ATION F[I! HA R )US MAI TRIALS DISCLOSURE Will the upplieem urs fuwrc building rneury'tm swrernhnndk hx'exrJo..material HEATING UNIT CIO 100,000 BTU) as deinal by he Cupertino Municipal Cala Chapter 9.12,and the Health and Safe,,Code.Section 25532(x)? HEATING UNIT(OVER 100jora ETU) El Yes ❑No VENTILATION PAN(SINGLE RIiSID) PAID Will the applicantor future building occupant uequipment or devices which mit hanus air n [s vfuturese Dam E it mNtmminanno Avf ncJ by the Buy Arca Air Quality ManagementBOILER-COMP OHP OR IOFFRXI BTU) Uisrder? T.TNN. -1 Yoe, 0 N HOTTER-COMP(OVER IIXI,IXIU IiT'U) 1 base read the hmmdous nmmriak myuinmems under Chapter 6.95 of me Cali- AIR CONDITIONER ISSUANCE DATF mads Health&Safety Cole.Sections 255115,25533 and 25534.1 understand thin ifthe NEW BESIDE building MLCH. SQ.]l'. building does not currently have a ranent,that it is my responsibility to notify the occupant of the r.quiremems which must he met prior m i..move of a Cenificme of Occupancy. Owner or authorized.gen[ Dam TOTAL: ISSUED BY: OFFICE