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S 1103
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINOIIUII,D[NI:-ELECT RICA I. I'1-J\i�111'NO. BUILDING DIVISION APPLICATION/PERMIT 1'LUMIHNG.-MECHANICAL �J 11 Q 3 BUILDING PROJECP IHENT'IFICATION SAN]IARY NO. APPLICATION SHRMITDV,DATE BUILDING ADDRISS: to i4 PA L-cD V 2 `OWNER'SNAME: PHONE: ACI'OH'S LIC NII: NIC CONTROL No2rvl �N L,XI� %H .CfIIiNGINP:ER: LIC NO. ADDRESS: Q, ❑ G 1 SCEIJ(C 6(- peii a BUILDING PERMIT INFO CONTACT: PHONE ❑ Consultant Fces Paid by Applicant(Initial) HLDG _ I71ECI _ Pi UNIB MFCI I,ICENSEUCONI'RAUEORSDECLARA'HON I QTY ELECTRIC PERMIT FEE JOB©DE/SCRIPTTION I Pertly off rte that I an licensed under Provisions of Chapter 9(commencing TIA C,4 R 0 with Section 7(X 0)of UivNion 3 of the Business and Professinm C Je,and my license is B 1.-i 0O lull force xnJ dlcct. � v...- PERM]I'ISSUANCE WI ❑KITCHIEN NIiMOUEI. CC-F n �- aVgV hiccnse Clue, Lica AI'PLIANCIiS-NIiSIDEN'IIAI, At)])[PION [I PLUMBING RE PIPE S Uum Cnnaaemr ❑h1U1.T1-UNIT ❑STRIICI'URAI, ARCHITECT-S DECLARATION PANELS MODIFICAl]ON z0 Z_ I understand my plans shall he lived ax public rceords UP TO 200 AMPS INFERIOR ❑CHIMNEY REPAIR C)Zp-4F-pW Licensed ismfeesional 201-10X0AMPs IMPROVEMENT El SWIMMING I'OOIS <Yf'j OWNER-BUILDER DECLARATION OVER IINNIAMPS ❑NATII REMODEIlR1EPAIR ❑DEMGLHIGN C Q I hereby affirm that 1 an exempt from the Contractor's License Law for the ❑OTHER °' a U following.,on.(Section 7031.5,Business and Professions Coal,Any city or cony SIGNS ELEC1'RICAI. LL13 a h which mquims u Permil m compact,all,improve senudixh,nr repair any ntmmum 05 prior to its issuance also requires the applicant for such ,mal to file a signed statement SPECIA 1.CIHCU I GMISC. fly Nat he is licensed puesuanno the provisions of Ne Commtm,%License law(Chapter 9 COMMERCIAL, a1�00 (olamttencingwiNStttion 70X01 ofUiviaion3ufthc business and Professions Cei TEMPMEfPHRORPOLEINSll [I NEW BLDG/ADDITION ❑DEMOLITION a d e y that he is exempt thcmfmm and the basis for the alleged exemption.Any violation of t subjects the applicant)a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SIiNVICIE ' I—y Section 7031.5 by any applicant for a permi not mom than live hundred dollars($5aq. IMPROVEMENT f=aO 0Lus�wnernl the pmpeny.or mycnminyeeswith wugcsua theirs�le compensaiomt, SWIMMING P001.ELECTRIC El01'HER N will do the work.and the structure is not intended or offered lot nude(Sec.]RM,Haslness OUTLETS-SWITCHES-PIX'fUNES 3 dad ad Fears, Code:The Comment.License Law docs not apply set an owner of property who builds or improves Ihcrtmm,and who docs such work himself or through NEW RESIDENTIAL ELIfCfR SQ FT. his own employees,provide)that such improvements am net intended ar offered for �aN SQ.IT.FLOOR AREA $ISQ.IT. sale.IL however,the building or improvement is%old within one year of completion,Ne V� L r owner-huilder will have the burden of pmvmg that he did nal buil)nr impmvc for par V / / /� sal pct r1 ). -near,oI tire p poorly, al,excl,olel, enteringw'm1I'sNived com,ro -t P p ! D um I ,o p 1 t(S .7014 lam ndl f:.' 'Gd '1 Ir C t l :I - ca La J tapply t Ip pent h h ld ml :t rc d QTY. PI-UMBING PERMIT PEE who for such p Projects.with a contractorh)Icensedpursuant to the C t e I.e la PERMIT ISSUANCE �N1 q7 PAID I]1 am exempt under Sm. .B Bo P C for this mean 0L Puts ALTER-I) IN VENT-WATER ILA) VALUATH)N Owner Hale /y1 �' l .r � WONKER'$COMI'IiNSATION DLCLAHAIate BACK I'LO ROfECT.UNICIi I J VV I 1 herby mdfina under penNly of pc jury anent the following dealaral 11 `/ J l have and will maintain a Cenilicam of Consemmvelhitnutelor Workers Compen- DRAINS-FLOOR. OI'.A : COND. STORIRS I'YPF CONS"I'RUC'f[ON Sation,as pmviokJ for by Section 37(X1 of the labor Gale,for the pe forrommos of the FIXTURES-PER TRA work for wm vi tats permit i.i...ml. T❑I have and will-ainmin Worker's Compensation Insmm�¢,as rtquircl by SMion OCC.GIII I 70"One'aho G.le.for Ne perlimnanmof the work for which this permit is issued. GAS-IiA.SYSTF-M-I G.qQ PLT$ AI'N My Workers Campconation Insurance carrier and Pol icy number am: GAS-IiA.SYSTEMOVER ' 1 Cameo: policy NalIV CIERTIFICATE OF EX EMI'TION FROM WOR KE RN GRLASFANDUSTRLWASIE INTLRCF.I'fOR COMP12NSATION INSURANCE. N(1 DIVISION FEESMisseelionncNnotbdmmnpleteJif thepcmmitisformahuaJmlJWlmx($100) GREASE'I RAP 1'Id NCHECK FI ' �( or lees.) I certify that in the performance of the work for which this permit is issucd.I shall SLWER-SANITARY-STONM LA.2(XI FT. LNIiRGYF Ii not employ any persn.in any"tanner u a Ime6 t to the Workers Cnntpen- �Z r'GO�`�' GNADING FF. Q z nasion Laws til Calif.. li WATIiR IIIiAI'IiH W/VENT/TiLliCl'R rN-i NOTICE TOctto the Worker Compensation this Certificate of of I Labor n.you should WATER SYS'lEM/rRGAI'ING SOILS I'lili > become suhlect m the Wader's Coons in tis previsions of the Imed i vCode.You mnu.w W ,� foMwall comply with such provisions nr this permit shall RJecmcl invoked WATER SERVICE Q PAID nm CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fll ate Hacipt a U0 I hereby a ren thatthere is a construction lending agency for the perfomtance of �o {L the work far which this permit it Issued(Sec 91197,Cls.C.) 'I'A a O I'y Lender'.,Nunn 71T ULenders AJdre, I UILDING ITEI nify Nat I have read Nis application and stem mat the aMv,inflammation is FEEcromect.l agreem comply with all city and county ordinances and Stam laws minting nm QTY. MECHANICAL PIERMSEISMIC FEE 1„) iZ building construction.and hereby allnaim rtpteconsivcs of this city to enter upon the above-mention)property for inspection purpose.. P17RMIT ISSUANCE ELECTRIC FEE I (We)agree to a'avq indemnify and keep handless the City of Cupertino against liabilities,judgnems.costsand.spcmcx which maymany woyattme against said City ALTER OR ADD TO MECH. PLUMBING IFP in consequence tilthe granting of this permit. l APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT' AIR HANDLING UNIT 00 BI.INNI CFM) MECHANICAL PER SOURCE REGULATIONS / -^CATIONS CTAT— �jt//;v ] AIR HANDLING UNIT(OVER 10.(NO CFM) CONS'IAUCf10N TAX Signor of pplicloWCommuseer DT EXHAUST HOOD(W/DULTI HOUSING MITIGATION FEE HAZARDOUS MATERIALS DISCLOSURE Will thellimhcanlas fimne haiidingmwcrox-ram In cor handle nazardou-nexedul HEATING UNIT(TO Fill.NXI OTU( as defirad by Ne Coperma l Municl)nl Come.Chapter 9.12,and Nc Health and Safely HPA0)'I'ING UNIT(OVER 1141,0 11 I'UI Croda Section 255321x)? 811E ❑Yeses VIiNT1IAT10N FAN(SINGLE RESIU) - Dam Reccipla W ill the applicant or future building occupant use equipment or divines which BOILER-COMP OFF OR 10.100 BTU) ail hazardous air contaminants as Jefioed by the Bay Arta Air Quality Mamtgement J TOTAL: oivtrin? BOILER_COMP(OVER IINIJX)I BTU) �Poa AIH CONDI'1'IONIiH ISSUANCE DATE 1 haveHealth mud the hazardous mor2.55 5.25533 ran under Chapter 695la1 the Cmi- fmnia Hralth Res Safety Gde,Sections 2.$5(15.25533 ammJ 25534.I understand th:ml if the NEW RI3IDLNDAL MliCll. SQ.Pll Mmili ing docs not currently have a tenant,that it is my msp rrobiloy to notify the oecupam / dents which mus ten poor m n,annce of n Certificate of v .nt r age I O l'1"'''_g/ ISSUEDBY: OFFICE