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S 2729APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING - ELECT RICA I, BUILDING DIVISION APPLICATION/PERMITPLUMBING - MECHANICAL. BUILDING PROJECT IDENTIFICATION PERMIT NO. C � �i �i J G G J BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DA OWNEN'S NAMIi! PHONE: ��„ J. 1 L` l CONTR. CIOR'S NAM ,' LIC NO: cL E 1 ^'^ N/C ❑ CONTROI,p �I ARCHI FECDENGINEER: LIC NO: ADk�RFSJTS, 5� / �(Ys �, IG CONTACT', PHONE r asS49010 ❑ Consultant Fees Paid by Applicant (Initial) BUILDING PERSIITINFO RLUG ELKT PLUMB MECH � o- ram LICENSED CONTRACTOR'S DECLARATION I hemby of Tin mat I am licensed ander pmvoimI, nT Chapter 9 (em,hi arming With Section 7004 ofDivision 3 efthe Ranine,and Profession, Coale, and my license is 'n full li,rcc vnJ o11 ` I.ianw Clans uc.n Dae Coders r ARCHI :'PS DECLA6 1'ON 1 understand my Plans shall Mused as public record, QTY ELECTRIC PFRMIT FEE JOB DESCRIPTION RESIDENTIAL: ❑SFDWI. ❑ KITCIILN REMODH[ ❑ADDITION ❑ PLUMBING RILPIPE [I MULTI -UNIT El STRUCTURAL MODIFICATION El INTERIOR El CHIMNEY kIiI'Alk IPROVEMENT E] SWIMMING POOLS I REMODELIREPAIk ❑DEMOLI'I']ON 111:R PERMIT ISSUANCE APPLIANCES - RESIDENTIAL PANELS UP'10200 AMPS Licensed Professional OWNER-exemptil on Ce Contractors I hereby .(Stat thus I tan exempt loon the Cssion, Co :Any Law co the %inch bag ream,. (Section 903LA Bm9noaa and Profession, in h Cade: Any city or county wliicb tP,rsapear,', mconstruct, miles, Mauvech Jnnolieb, oreri,ir:utyarucmra m Bense I... hapten 1) prioeehslicena(]'m'uri myaime hoviki If he Contractors that ac is licensed par and In the pm, ol'the a Rovicmr's Lkcnoe Loons Cedc) or Cale)or (commencing therefrom Iced he is andtfDivision3aftheegeinexe andon. Any Ih:n he is exempt Iherefmm and the basis for the alleged exemption. Any violate, of • Scale.7031S hy:mY.pplitentho, upermii subjects the applicant to a civil penally or t not more man five hundred dollar, lS500). ❑Laeawmrords'pmpedIts army employees with wages as their sole cmnlnvs.lion, will do the work, and the sauentre is not intended or offered for sale (Sits ANJ. Bu.i nese[IOTHER and Prolc.sions Code. TM1e Cnnuuemrs hkeme law Jws not apply to an owner of • peopi who builds or improves th nam, and who does such work him,!. or Ihmmgb his own employees, provided that such improvements are not intended or offered for sale. If, howcvan the building or inhpmvcnm I ismdd withinone yen ofcoinplcdon.lhe pWer-builder will have the burden of proving that he did not build or rainiest, for pur- e 0 site). I] 1, as owner of the pmpcny, ata exclusively contracting with licensed ennwclom m m neuct the project (Sec. 70,41. Business and Professions Cede:) The Contractors Li- nelawdtesnotapplYto:m owner of pn,pery who bolds or improves theism,, and who contracts for such projects with a commcmdg licensed pursuant o the Contracor's License I,aw. ❑ I .m exempt ander Sec. . B & P C for this re ... a 201-1000AMPSof OVER 1000AMPS SIGNS ELECTRICAL SP[CIALCIRCUI'IMISC. 'TEMP. MIiTEIt OR POLE INST B_FRL IA : [_1 NEW BhDO/ADDITION ❑ DLMOLII'[ON �TCNAN'I' C1 FOOD SERVICE IMPROVEMENT POWER DEVICES SWIMMING POOL ELECTRIC UTLETS-SWITCHES-FIXTURES O NEW RESIDENTIAL ELECTR SQ ET. SQ FT, FLOOR AREA S/SQ, FT. TOT L: O QTY. PLUMBING PERMIT FEE PERMIT ISSUANCE ALTER - DRAIN & VENT- WA'I'17R IRA) Owner ❑:vc I WOR KER'S COM PENSATION DECLARATION 1 hereby afro, anderpenaltyof perjury Iof nc the following docked is O lhove had will maintain a CeniGcac of Consent tox Ifoinvum forWarkera Compen- ,alta., as provided for by Scctit 3700 of tIm Lah nr Code, for the lv,formarma of the wak for which this permit is issued.el I have and will ami main Worker's Compensation Insurance, as required by Section 3700ofihe lather Ced,Bribe perarrommodithe work fnrwhich lbi, permit is isnacJ, My Worke , ''ompensa'on Insurance harrier and Put numhcr re' Camara: ��� I'1 Policy Na: CERTIFICATE OF EXEMPTION FROM WORKERS' COM 1117NS A PION INSURANCE (This rwelion need not Inc completed tribe permit is for Inc hundred dollars IS 100) nr las.) of work this thenal is ins'Comi,ull the any manner Ie, any Person not cmployanypennninanymanncreoazmMa,tae mbjecnothc Workeri G,mpeo- ,it, Laws of California. D:nc Applicant NOI'ICE'10 AI'PLICANL II; slier ,taking his Ccnilicum of li¢ntplion, Ycu ceased) Mu,me subject meas Waelcr', Cnmpcn,miun provisions of the lobar Code. gnu nom torhwah comply with such provisions orchis permit shallMdecmeJ revoked. CONSTRUCTION LENDING AGENCY'Mew I hcreby;,flirmlhw deem:.aemnwction lending agency far lhel,edilan sand the work for which this Permit is issued (Sec. 3W7. Civ. C.) Lenders Name Lenders Address I rent I that 1 have feud this application and state that the above inf rmmion is meat. I agree to comply with all city and aunty maditetnces and state hews relating to huilJing mmlmdiun. and herby authorise representatives, of this city memerurym the .have-mcntimud property for inspection pum,ows, (We).gme to re.re. indemnify mad keep harmless the City of Cupenino against cora and expenses which may in any way seethe againa seat)Ciry in'ililicsamme of ' onxquvnce of the graining of this pemtit. APPLICANT' UNDIR.S'I'ANDS AND WILL COMPLY WITH ALL NON -POINT SOTJRCFk JI TIONS /�\ ��/ l VAI. WYIION ��YY''''�� L.Y HACK FLOW FIRM ECT. DEVICE DRAINS-FLC0R,R00F,AREA,COND. O'dua;" (k]C.GROUP `3 TYPECONS'TRUCTI( / / /V/AJ APN / �� Z i-IXTURES-PI7R TRAP GAS - EA, SYSTEM -I INC. 4 OUTLETS GAS - EA. SYS "TEM-OVIiR4(EA) CRF.AS E/[NDUSTR I. WAS] H IN ERCEPTOR BUILDING DIVISION EF.I!.S' - - - _ CREASE TRAP PLANCHECK IIIE - ^--- SEWER -SA RY - STOFlf EA, 2SALP1 ENERGY [;[IF, ER IT - "P,N'1' CTR ER SYSTIiM! RP.ATING Ira h 'ATE C M R U GRADING P[ FEE SOILS PF,E PAID Da Receipt Or RF.SIUENTIAI. PL MB. S I FI'. TOTAL: TOT - Bl11LD C FJi /© QTY. MECHANICAL PERMIT FEE SIiI5h1 'hili PERMIT ISSUANCE, O ELECT IC LLE ALTER OR ADD TO MF,CI I. PLO, INC FEE AIR HANDLING UNIT (TO I0,00a CFM) MECHA ICALFEF. AIR 11Nl'I (OVER IB.IXHICPM) CONSTRU.]ON TAX Signature of Applic.ninCommmor 111 Data I IA%ARDOUS MAI'F.RIALS DISCLOSURE Will the applicant or future building occupant stem or handle hnr.vrdom material as defined by the Cupenlno Municipal Code, Chapter 9.12, and the Ilcalth and Safety Code, Section 2.5532(a)? ❑ Yes Will the applicant or future building occupant use a pan a Air Qua or dMana which untie LuearJan, via wnlaminatn s defined by the Buy Area Air Quality Management Dome, I C] Yes 1 have read the harardaos nederix re. 15533 55 3 an under Chuptte h to of ed Cali. ILmiagdoes&tcome Gdu.ea tinas 255115,25533and25591.1andetn.ttd fled tithe holdingdoes have amnum.thato inuanenal aeCsidi amhnifythe,ems,°t Ill ts whic h nr m issuance of . Cenilicae of Oscupanty. EXHAUST HOOD OVIDUCT) HOUSING MITIGATION PEE HEATING UNHT 0 I(Xid(M B 1' U) HEATING USI' (OVER 100,000 BTU) PAID Date Rece1111 W VENTILATION FAN SINGLE kES1)) HOLLER -cUMP CHP OR I00,000 BTU) O BOILER-COMP(OVER IIp,(NIR B'I'UI AIR CONDIJ'ION'DR ISSUANCE DATE <� J< -�-Is -7 /vjl ISSUED BY: NEW RISIUHNTIAL MECIL SQ. iT h nus tan aM `estD.tc TSI' L: OFFICE