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S 4217
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.-ELECTRICAL Y PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4 217 BUILDING PROJEcTIDENTIFICATION BUILDING ADDRESS; N SANITARY NO. APPLICATION SUBMITTAL DATE /025Q t n� S war c a't►. 9 '-7. 2 0 -4 OWNI.,oAMD: PHONE l' NT C'fok:S NAMENi : LIC No: CONTROL �A 41tig WS Tow, AVU Iry A5,7 - U '1O NIC ARCIWfEl7r1LNGINEIiR: I LIC NO: ADDRESS: / ❑ -ONTACT. PHONE:: ' BUILDING PERMIT INFO DCICA) Z 0 wC�( 3 9 O-y4O15 ❑ Consultant Fees Paid by Applicant(Initial) BfL2Dl 'GFLEM PLUMB MECH LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE 1 hertby am th ffirat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION DMZ with Section of Division 3 ofthe Business and Professinns Code.and my license is RESIDENTIAL Yip PERMIT ISSUANCE ,�, y� g-�0 In full force ante ., � '" R QSPDWL I/fIG ICHFN REMODEL �UU Licen Clan Lic.N APPLIANCES-RESIDENTIAL Q ❑ADDITION [I PLUMBING BIE-PIPE 1-ZW Oeste '- fnntractn '�'�a CfIITIiC ❑ 1"S DECI t PION MUI:1'h ❑ CI UNIT STRU 'URAI. FvZ I understand my plans shall he spuN uscdablicrccos PANELS MODIFICATION ZOZ'%sQ UP TO 2W AMPS E3 INTERIOR E)CHIMNEY REPAIR b Tt: ] Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMINGPOOLS IY C Q I hereby Blinn that I nm ewmpt Roil the Contractors License Law for the OVER I0f0 AMPS El BATH REMODEL/kEPA1N DEMOLITION M ❑4 U follon(S wing reuxncene.7031.5.Business and Profession,Codr:Any city or county SIGNS ELECTRICAL ('YTHER 3 w y wnien regatrex a perinn nm construct,deer,improse,eemol'nn,rat repwr any smtnme Iit prior nou".auanee,aLa.regair"Ibr.ppllcant for such permit um tilcadgmcdeanement SPECIAL CIRCUITIMISC. ty that he is lice o d pursuant to the prov cions of the Contmemrx License law(Chapter 9 �IYas (commencing with Stttion9000)of Uivi,inn3of Ne Business and Professions Codc)nr TEMP.b1ElER OR POLE INSI'. COMMERCIAL' W a ca C�C that he I,exempt mcrefmm ane Ne basis mor the alleged exemption.Any violation of [I NEW BLDGIADDITION ❑DEMOLITION �mN Section 7031.5 by any applicant for at permit subjects the applicant m a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE nut macedt five hundred lot... 5500) IMPROVEMENT �ZQ E)1,as nwncnd Ne pmpcny,onny cnlployecewith-alts Pu their sole compensation. SWIMMING POOL ELEC'PRIC ac will do the wP,k.und l hedicaure is not nmndcdmolicred f(u,ele(See.91144.Bminc,x ❑OTHER tail-� and Prdcsslun,Cale:The Gmmmeaar't license Law does not apply man owner of OUTLETS-SWITCHES-FIXTURIIS © Q property who builds or improves thereon,and who docs such work himself or through his own employees,provided that such improvements art Pat intended or offered for NEW RESIDENTIAL ELECTR SQ ET. sale.If.however.the building or improvement is sold wiNinane year of compinion,the SQ.FT.FLOOR AREA LSOFT nerbuilder will have the burden of proving that he did not build or improve fur por- Q prseofsale.), - / 0 F1L m owner mf the Pnmparty,oro exclusively enmmcling wit.licensed contractors nm T 1.; ntsteacl the nation,(Sec.9044,Business and I'rofcnions CP,l I'he Commenn's I.i- nsto Law doe,urn apply m an owner m pe perry who builds m bnproves discrete,and QTY. P, TNG PERMIT FEE won contracts lot such projects with t conrracmns)licensed puruart m the Contractors License law. PERMIT ISSU CEi Q 1 am exempt under Sec. .B h P C for Nis mason ALTER- NT- IEA) VALUATION Owner Dale 'a WORKER'S COMPENSATION DECLA RA'T'ION BACK FLOW TROT: IVICIi ` I hereby l011...I under penalryol'perjuryunceffe following doiamIt.... / V have and will maintain a Cenificmcol'Convert ,,aelf-inure fur Worker's Compen- DRAINS-FLOOR.ROOF, .A. D. STORKS TYPECONSTRUCION cio sn,is provided for by Section 39 W of the labor Code,for thpe e rfom rance of the work for which this permit is issued. FIXTURES-PER TRAP 1 have and will maintain Worker's Compensation Insurace,as required by Section 3900.fthe lame and norPmncc ofthe work forwrhich this Permit is issued, GAS-EA.SYSTENPi INC.4 OUTLETS OCC,GROUP N My Werke' Iraw urunccca ' lPetry ymtT�`-5f).��0' GAS-I TA.SYSTEM OVER 41 IA) Z� Curricctx rrmerPolicy No: .,x111 LL J CENT II'ICATE OF I:XIEMP'1'[ON FROM WO HS GREASI%INUUSTRL WASTE IN'TERCF,I'TOR COMPENSAI'IONINSURANCIi ( BUILDING DIVISION FETES (This secdnn nese not bt,compincJ if tnc pcnniGsfa Dothan red dollars 15100) GREASETRAP or IcsaJ PLANCHECK FEE I certify that in the performance of the work for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. not employ any pein in any manner so as to become subject Ps the Workers'Compen- LNF.RGY FEE n Z scours Lawr of CaVe n e,Duro WATER HEATER WNENTRILEC R Z Applicant I GRADING FF.E NOHCE'B)APPLICANT:If,after making tons CeniOcmc of 121uption,you rh...Id WAl'ER SYSTUMTREAIIN(i (•" become subject um the Worker's Compernmion provisions of the labor Code,you must SOILS FEE forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE 0 d CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL.PLMB. SQ.FT. PAID L)Ql hereby allinn that there is a comwnion lending agency far the performance of Receipts the work for which Nis permit Ix issued Ile'.7(19),Civ.Cd lender',Nlnnc TOTAL, W bender',AdJrc,a I"'it 1 I erro y them 1 bast read this applicminn and state that the most,infimm:nian is tlU11.DINE F h roncn.l agree mmmply won all city tnJ county ordinances ane sms laws slating to QTY. MECHANICAL PERMIT FEE SEISMIC FE (• Z- V Z building comwction,and hereby uutnorizerepreseiddivexofthis city to enter upon the `` /^� above-mentioned pro,ey for inspection purposes. PERMIT ISSUANCE -5 nits (We)agree to save,indemnify and keep harmless the City of Cuceno.against ELHCfRIC FEE iahiliflr,.jud,nmP..cuax and egrenxes which mayin any way acmeinomm"raid City ALTI7R OR ADD TO MECIT PLUMBING FEEY to in cunscqucn ui't..grunting Prim,'enuit,spIP . s LICANJNDERTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO I0,0k)CPM) MECHANIC ALP'E 0 O ,RCE R [ULATH NS. 7-21v _G C{ AIR HANDLING UNIT(OVER BLOOD CFM) CONSTRUCTION TAX it, m lsof Ap I I moncmc Dail 1 EXHAUST HOOD(W/DUC) I IOUSINGMITIGATION FEE IAZARDOUS MATERIALS DISCLOSURE Willme, Ilcamnrfumrebaldl.gnccupantslnrcnrhandlcharamourmmcrial HEGGNGUNITGo I0P0(X)BTU) m defined Ne nn Mwiuipnl Ccxle,Chnptcr Y,12,mtA the Hoven and SnlJty Crile,Section 25532(.)l HEATING UNIT(OVER IINI IXxI 11 FU) ❑Yes E]No VENTILA TION FAN IS)KOLE RESID) PAID Date Rtteipta Will the applicant of future Wilding occupant use equipment or devices which ROLLER-COMP DNP OR 100.000 PTU) emit hazardous air comaminen s as defined by the Bay Arca Air Quality Management qL: DisaictP BOILER-COMP(OVER 100,0X)BTU) E]Yes No I have awl the Imrardens marml,rectimments under Chnptcr 6.95 of the CA AIR CON DI'I'ION BR ISSUANCE DA98 !omit Heallb Safety Code.Sections 25505.25513 and 25534.I understand that if the NEW RESIDENTIAL MECH, SQ.ET. at iogdoe I Acutrently a e Present.that it ismy reapnnsibilitymnscadvilwasaopeor �j ,- cAy to requ - ten,wnien est be met print arae of a CrrPfi.a of Occupaay / rl u rte renthc r rnt D'ute TAL' ISSl1ED 11 V: OFFICE