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S 1131 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPE RTINO BUT LDING-ELEC"I'RICA L I'pJ`�N11'I'NO. BUILDING DIVISION, APPLICATION/PERMIT PLUMBING-MECHANICAL XJ 1131 BUILDING PROJECT IDENTIFICATION BYILDINIIIIkESs: Q SANI I'ARY NU. APPLICAI K N SUBMI'PIP 'AL DAI. © o�-h 'S a�� � f NERS NAME: PIONS CDNTRALTQ NIC CONHN La rrto�Y�-►� �Os-t�-�fi3 - ARCH[ ECDENGINL°R: LIC NO: ADDRESS: ❑ CONTACT. PHONE: BUILDING PERMIT TNI C] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMII MECH LICENSED CONTRACT'OR'S DECLARATION Q'T'Y.2F,2LECTRICPERMFprFEEELECTRICPERMFI' FEEI hareby:minathat 1am Reensed ander mviona,of chapter 9(counn.....n JOR DESCRIFa"I'ION WOO '1n Section llNHl�lljyJ�ion:1_nfthc Business and ndounnx cn�Jc,XnJ lnYlifvnvaix � RFSIUFNTIALFOOw [I(�J-C.�i UANCE. ❑91 DWI. ❑KI'I CIIIiN RIiM0111?h GUU Licc1 vc :h1: Lic.w YIJi Dmc lie it r S-RESIDENI'IAI, ❑AUDITION 'L11MItING ItIi-I'll'li 'Dan CHITELCi IIF,CLAkAT10N ❑MULTI-UNIT ❑SfKUCIURN. ZZ� Iundero,minyplamennll hcumdns public record. MVS MODIICKI'ION ❑INTERIOR 0 CHIMNIEY REPAIR W Liccmed Pn resdonal PS IMPROVEMENT SWIMMING IK)f 11,S OWNER-BUILDER DECLARATION MP5 ❑BATH REMODELIREPAIR ❑DIEM01.1'I RON 6 I hereby afrmt 11ta 1 am exempt from the Contain, License law for the ❑OTHER Xy C) following reason.]section 7031.5.Business and Professions Codl Any city or county SIGNS ELECTRICAL al�+IaN which requires a permt m ror.Wam i , her,improve.demolish,or repair any anmc F u'OQ pAnrmita issuance,also rcyuimsthe applicant for such permit m file a signed%mtcment SPF.CIALCIRCUIT/MISC. fes} that he is licensed panuamm the provisions.fine Contractors License Law(Chapter v COIAMERCIAI.; I+1�00 10Omtrrcncin6 x'ith Section NXXB ofDi,man 3ofine Business a^d Pmfico,ion,CoJanr TIiM ROR POLE INST. 6 6 e tY thnt he is exempt dundmm and the Misis for me allege)exemMion.Any violation of ❑NEW BLDG/ADDITION 11IN101.IT1UN W=m Section 1031.5 by any applicant for a permit%xitpOs the applicant to a civil penalty of PO ' ICES ❑TENANT ❑FOOD SERVICI: n mom than five hundred dollars(5510). IMPROVEMENT =Q �1,as owner of lM1C Pmpeny.ormycmployecswith sages as theirsole u'mpcnmtinn, 5 MIN LELECfRIC ❑OTHER F will Jo the work,and the sweture is not intended or offered forsale(oar1 1 ..1ness L'3m read Professions Coca.To,ColnmctoA License Law does not apply to an owner of OUTLETS-sW .s-FIX'IRES property who build.,or improve,thereon,and who does scan won,hmrsclf or throngs S Ir11 his own nttploycas,provided mut inch improvements am not intended or ollumd for NEW RESIDENTIAL Q saIt.IL however.the builJin•urim Idwithianne ywrofenmplction.the SQ.FL FLOOR AREA SISQ.Irl'. b Pnrvcmant l,m, owne r-huilAcr will hove the hurJcn nl proving thm he Jid not huild or Ilnpnrvc Ibr Pur- Mtsem ewe.). 'rcrrnL'. ❑ I,as owner,d the property,um csdnxivcly contracting wuh tient+sod mnm"Inal to / con,aue't the r oina(See 7(94,Koonce,and Pmfexxion,love.I i na Clouree disco ,Cn RTi �Ej� ccn,h Lax'd ,uni apply loan owacngen d progeny who mu ldx or i++;prove,thamon.unit QTY. PLUMBING PERMIT 17EE sem✓ who varnmcls lir mch projecl,with a c.mmumrt,Q licensed Ptomma to the Contractor's License law. PERM IT ISSUANCE JAN 0 8 O 1 am exempt under Sea .B k P C lin This maum ALTER-DRAIN&VENT-WATER(EA) VALUATION Owner Date WORKER'S CfIMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE BY: — I hereby alum under Penalty of perjury one of the fallowing declarations: Fl I have and will maintain a Certificate of Consent to self-insure for Worker's Compete DRAINS-FLOOR,ROOF.AREA,CONI. STORIES UC'TION satin,as pum did for by Senior AW of the Labor Cale,for the performance of the work Ln which this pcnnit is:.weds FIhTUkIS-PER TRAP I have end will muinuin al Or,Compensation Insurance,as required by Section 3110 of the WMv Csde,for the performance of the work for is a� m+it isj..ucJ. GAS OCC.INC.40UTLEI'S fICC.GROUY AI'N my W of c m suruncc mer and P.lic r �J1 GAS-EA.SYSTEM-OVER 4(EA)) Cmnc Policy Na: CHR'OMCATEOFEK+MPIION FROM WORKERS' GRFASP/INDUSTRL WASTE INTERCEPTOR COMPENSA ION INSURANCE BUILDING DIVISION FRES IT his section need not tlevnmplemd ifmc permit..furore hundred Jolla,1511X11 GREASETRAP IFF IECK FIT or In,,.) Iwnn,thin in the Perfousince ofthe work for which this permit is lsxucd,I shall S12WITR-SANITARY-STORM I?A.201 FI'. FEE nnl cntph,any per.mn in nny]nun w,so as m beam,.subjcm:no the W..kcrx Can+p:;t- Z natio^Lows of Ciliniu^in.]lulu WATER HEA1'BR WIVENOE AlCTR G FEE zO npphe:mt ti NOI'ICE'r(I APPLICANI..U.after making this CcniGcacof 17.- dna,You xI aid WATER.SYSTEM/TREATING EE ti [' bemmm�compluthe Worker's psam,Orthis provisionsofthe LabraCode,keyou onto fti1 ti lonhwiln comply wile such pmvisinm nr this pcnnil,hull M1c Jeonud revoke]. WATER SERVICE a Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI', Z Date c pl q U O Ihemby wr^mmm mem is acorswcoms leading agency for me lwdommuccof D. the work for which this permit is issued(Sec.3091.Civ.C.) 'I'OTAI,: C) l•" lender's Name 'TOTAL: r Lenders Address G FEE 1 1 comfy that I have mad this application and state that the above information is F" h u+rreculugmemromPly with all city and county ordinances and sum tax's relating to QTY. MECHANICAL PERMIT FEF FEEU Z building construction.and hereby authorise reprcse^utives of this city to enter upon the nerve-mentioned propcny for inspectio^purposes. I PERM1IIT ISSUANCfi / O IC FEE(We)agree m save,indemify rend keep hanmexs Ne Cityof Cupertino againstliabilities,judgments.costs and expnses which may in any way acme against sail City ALTER OR ADD TO MECH. ING FEEin onsequence of the granting ofthis permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IU.IXXI CPM) NICAL FFE gSOURCE REGU[.AlPONS X AIR HANDLING UNIT(OVER IONX)CFM) COUCr10N TAX Signuorcof ApplicamlContract I EXHAUST HOOD(WMUCT) HOUSING MITIGATION FTIE HAZARDOUS MATERIALS DISCLOSURE: Will theapplict I or lamina building^...pant domor n Be haea don,oencrial IH:AFING UNIT TO 00.000 BTU) as defined by the Cupertino Municipal Cede,Chapter 9.12,and the Ilcalth unit Salcey HEATING UNIT(OVER 100,00010 U) Code.Scai.n 25.532110'1 0 YO, E]No PIQ NS INGLE RESIDE PAID Dj Will the applicant or mturc huildingocc.pnt use equipment ordevias which (,3HP OR 100.100!1 B'I U)air aorimminent,as Jcfined by the Bay Area Air Quality Management (OVER 100.000 BID)❑Yes ❑NnER I hath mad me b ar,Se tion, is lcqui 533 ad 25534,nder 1 unr A 95 of da Cuh moria licallhkRa@ty Codc.Stein^s 23505.255]3 vr02 than'tndcnundtheiflncIAL MECH. SQ.ITL huildi snrn cunca', camnant.m jt is mYrezprm,ibility to notiry me weupmnt I ru hie etpno anteofa Cenife e f /� m TOT / ISSUEU BY: Ownc or amM1on a agent OFFICE - _