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S 2825 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECPRICSL PERMIT NO. BUILDING DIVISION APPLICATION/PERMIT PLUMBING,-MECHANICAL (� �oO BUILDING PROIISCT IBENTIF'ICATION J J BUILDING ADDRESS' SANI'IARYNO. APPLICATION SUBMITTAL DA'Z'E / © / 52 DEE��o-56 OWNER'S NAIvi. ^ PHONE: CONTRACTOR'S AME � �f� AC� l SIC CON]ROL# a ARCHITECT/ENGINIiF.R: /+I lI LIC NO: ADDItES`l l•$:�(-r /ON- /T^�L� `ver L, ❑ CONTACT _py�I�, ��//,.��,_,�/� PHONE, Q r� N'N1 1V✓F/ /t BUIL.elyIJINC PERMIT INP BVI%/ '�'ro h+Qr "�"^'7 q�y•�T/UQ ❑ Consullanl Fees Paid by Applicant(Initial) RLW ELECT PLUMB NlECH Awl VOL Pgd8 ©� Z_ LICENSED CONTRACTORS DECLARATION QTY. ELECTRICPERMIP FEE 1 hereby affirm Thal lain licensed under provi,i m,nT Chapmr 9 ocontmcnviag JOB DESCRIPTION M=z with Sceian](XM))Of Divisinn3ol the Business and Prnfcssians Gdc,find myliccnsc is RESIDENTIAL: F OOH in full force all cR PHRMITISSUANCE ai—E. 0 ❑SFDWL ❑KTI CHEN REMODEL. QUU Liccnsr Lica APPLIANCES-RESIDENTIAL h¢i 'ac Contraamr DUITION ❑PLUMBING Rif l'IPii F.DN ARCH]'i'L7CT'S DECLARATION PANES ❑MUI:I'I-UNIT ❑STRUCTURAL. Ol Z O m G I umdentand my Plun,shall he used as Public records MODIFICATION Ozr3� UP'10200 AM I'S El INTERIOR ❑CHIMNEY REPAIR F 4t'W Licensed probate.nal 201-IBfIIlAMPS IMPROVEMENT SWIMMING POOLS �=�,,.I OWNERBUILDERDECLnItA'UON OVER 1000AMPS BATH REMODEI/REPAIR ❑DEiMOLITION C C Q I hereby of ino that I am cacmpt from the Comiani License Law far the a06U following reason,(Section 70313.Business and Profess%Ions GWR:Any city aumm, SIGNS ELECTRICAL ❑ITHIiR '3 W y which requires a permit to construct,alter.improve,def udish.or repair any%occturs, ; prior to its issuance,also requires the applicant for such penniun rile a signed statement SPECIAL CIRCU ITAI ISC. E y1Y tbm Inco.liccnnal punt not lu the pn:v n(tnR CnntnmtO!%Liecnse Law lCnaptcr9 "aux Waap0 (cnmmcncing x ith Stains WXp)of Division ofthe Businen,and Profession,Cndc)or TEMP.MLI'ER OR POLE INST. M PR I Ia.{y o a IM1ut he is exempt thRref nm and Tho basis Gsr the alleged RxemPtinn.Any viulmimi of NEW BLOOMED,HON 0 DEMOLITION n Section 7031.5 by any applicant for a permit sahjet%the applicant)a civil Penalty of POWER DEVICES V:..y I ANT El FOOD SERVICE mm marc than rift hundred dollars y($50b) employees S� will Las othe work. ndPmPerty,ontry RmPloyee.with wages astheinnle W4.B sines, SWIMMING POOL F.LIiCTRIC I ROVEMENT Fes' willdothtwork.and the ntmaureisnot rs License Law does till apliec9oan.Business Lee LLQ] m air Colo:improvefire s thereon, License Inwssucnmapply s an owner of OUTLETS-$WI'ICfIES-PI%TURES 1 his own who builds or improves thereon,and who docs such twork c ded...or through III lir awn ovesti he provided,improvement such mens ovoid w tan not intended Or pliantforced fur NEW RESIIIP.N'hIAI.I?LIiC'!'R SQ FI'. owns Lhowevehtbe vette bur improvement it athwithinoneyeandcomPletfor the ^ O g SO.IT.FLOOR AREA SJSQ.Pf n��n-builder will have the burden of Proving Ih;n he did nal build m improve for par- L O anam.>.- ❑1,as owner orthe property,am exclusively contracting with]accused commenm m na...I Incpr Jve IS,,.7044,Bun arta 1'mIca s mCOA.J'IhtCnn.—as r,— ru Law does not apply in an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE whnmmmcts lO.euchp j,,,with a cmtmldono)Itccnacdpncanurt I,,Commumr's License law. PERMIT ISSUANCE [D I for eaemPt under Sec. ,B&VC fimthis reason Owner Uma - ALTER DRAIN X T-VENWATER IEA) VALUATION 2�r p WOR KdiR'SCOM PENSATION UE Ce folio ing BACK PLOW PROTECT.DEVICE Thereby a0imr ander Penalty of Perjury one ohne Pol4nvingdecimations: '� ❑Inoue and will nmintuinaCmillcutenl Concent tO xdf-Inmremi-Worker's Contpen- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPIi CONSTRUCTION uric.as Provided for by Section 3]1X1 Of the LoMr Code.lot the performance of the ark far which this permit is issued. PONT GRES-PER TRAP I] I have and will maintain Worker's Compensation Insurance,as require)by Section 3700oflls Lal r twpvliamanec of the work for which thinZPe��QTiro.c isox,errr, GAS-EA,SYSI'HM-I INC.4 OUTLETS OCC GROUT' N My Workcr's m n Iio L ranee carrier and I'nlicy nn, JO O / Carrier- Policy Na: O GAS-P,A.SYSTIlNf-OVI3R 41EA) �� G,IiRTIIICAOi OF EXEMPTION XF,MPflONFRWORKERS' COM PENGREASEANDUSIRL WASTE INTERCEPTOR AN Illus section need not he annplaeJ ifthe permit is for hundred dollen($11X)) BUILDING DIVISION P141S ^ ser less.) GREASE TRAP PLAN'CHI'.K FEE C% 1certify that in the any mantes of the work for which his permitisers'Co[,hall nal entpluy any Pcram is any manner so as to heroine mbjact In the Workers'Camlvo- $EWI?It-SANITARY-S'I'OKM BA.21X(PI'. ENER F kE Oz satimn laws Of California.DateNATIJt HIiATF,R W/VIiN I'?LliCflt Q Applicant GRAVI FEE: z y NOTICE 10 APPLICANT:IL after making this Ccrtificma of Exemption,you shwld WATER SYSTEM?REATINC, a7 become%object to the Waders Cnntpensntion pr ck on%of the Lab...Codes You nmst S 811 S !li forthwith comply with such provisions to tus permit shall be retired revoked. WATER SERVICE Q U'Z CONS ufluarRUC PION LENDING AGENCY NEW RFSNENTIAL PLh1R. SG.FC PALS V O I lo,vsh li his thenbem is a<ansvu<tionlemdis,agency Tonne Pednnnana Of D:nc ReceiPta W U the work Iia which this Pemtit is ix.,uRA(Sce.3DJ],Cis,CJ F' Lendcr's Name ] L. lender'sddv Anifyt I ccifY 'I' A y that 1 have rear This application and stare the the above information izBUILDI.G FEE O tq correct.1 agree in comply with all city and county Ordinances and state laws relaing to QTY. MECIIANICAL PERM I FEEr L)z building construction,and hereby authorize representatives of this city...enter upon the SEISMIC FE OQ atmve-memioned property for inspersion purti (We) olein save,indcmml,and keep hanmlcr.I nv Cu,of gains FERMI'I'ISSUANCE 6 > p yn Pertinna I ELECT .I'F, til liahilitiee.judgmema,costs and expenses which may in any way acetas against said City Aun: OR ADD T(IMC;CII. an comscyuc of thegr;mting afthislwnnit. TO, I FEE AI'i'LIC �T 'NI)ERS'TANDS AND WILL COMPLY WI'rll AL1.NON POINT AIR HANDLING UNIT(TO 10.0g)(PM) SOU .:RI .UI IONS, MF:CII [CAL F.. AIR HANDLING UNIT(OVER 10.000 CFN) CON. RUCTION TAX Sib ' vol AppllcunVCm nctnr hale EXHAUST HOOD(WMUCD HOUSI,C,MITIGATION IEP. HAZARDOUS MATERIALS DISCLOSURE Will the applicant or(intim building occupant store or handle hatwous umner'll I]EATING UNIT(I o IOO.gID B IT as defined by the Cupertino Municipal Cade.Chapter 9.12,and the health and Safety Calc,Section 25532(m l .�A 1IEAINC,'I'INUNIT(OVER 100.000 BTU ]Yes L/^ VENT LATION FAN(SING I.I.RES IDI PAID part RccciptM Will Inv n 1,11.1 m nr fmum building occti, use OtImpmem n.devices which emit havari air cumurairmat,as defined by the Bay Arca Air Quality Management BOILER-COMP(dTTP OR 100,000 BOLD UinvinEJ Yc, / BOILER-COMP(OVER 100.0X '1 BTU) 11 I havered the hwarduus mxteria6ngWremgnn under Chupter495Ofthe Cd, AIR CONDITIONER ISSUANCE DATE fomia Health&Safety fide.Sections 25505.25533 and 25534.1 unrerstand that if the NEW RESIDENTIAL MECIL SQ6F7. boiWingrt' tat onenly have vvnmuthat'n is my respnuibility rn notifthe rccuantraftherq o cwhic t decal agent Dare o LSSI1EiU BY, OFFICE