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S 2582 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELEC'BICAL PERMIT NO. BUILDING DIVISION APPLICATIONA ERMIT PLUMBING.MECHANICAL. 5 o Q f� C O BUILDING PROJECT IDENTIFICATION S G BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE / 95v Hisw# x> coi,UQT C pZ�Q7;No , ctg OWNER'S NAME: /��� PHONE: CONTRACTOR'S NAME: LIC NO: 2-' Z-z- G 5TM+L� Ay✓ ) 18-1888 i2 N/C CONTROL# CI 7kE ENGINEER I66V C�?I 21)O', ADDRESS ❑ 9 / 77 17 7 CONTACT PHONE BUILDING PERMIT INFO ,1114f4'1— ��&V �/p�ZZs i��8 ❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECH /�G T'A E!/ E^� L� Lg/ LICENSED CONTRACIOR'S DECLARATION QTY. ELECTRIC PERMIT FEE 1 hereby anbm that I am licensed ander provWinds of chapter 9 temnmenemg JOB DESCRIPTION Qaz with Section 7000)of Division 3 of tire eusinessimd Profession,Case.and my license is RESIDENTIAL: �� full force and effect. PERMIT ISSUANCE �J\ K U F In aA(rWL [_1 KITCHEN REMODEL 6VU License Cama Ge.# FIzIA Dulc Conhunnr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL C524- MODIFICATION 2 y Z I understand ny plank,hull be used ax puhlic tuordx PANELS UP T02IXIAMPS D INTER MODIFICATION F�.F., R El CHIMNEY REPAIR RW1 Licensed Pmfesvional 201-1000AMPSIMPROVEMENT SWIMMING POOLS 5;-i ql OWNER-BUILDER In, he Contractor's D m Q 1 hereby ofHrm oral I am exempt from me Conlraaor',1 icelue Loss[or the OVER IOW AMPS El BATH RRMODELIRBPAIR D UEMOhITION Wd O following reason.(Section 911.31.5.Buximess and Proryaons Cade:Any ally or county SIGNS ELECTRICAL ❑D UHR y 111.11,reyaite,a Permit to construct,aIle,,improve,demolish,or repair any structure prnn its issuance,also q the applicantfor such permit t file a signed specimen, SPECIALCIRCUTDMISC. d ',>• 'lot he dpimoant thep rs 1111 C meters L L (Chun,,,9 �..OHO Qom g with Section 7IX10) fD', do 30 the Busineviand Poor, on.Cook)err TEMP M ETER OR POLE INS'1'. CC IA d W o er Ihm he Is exempuhuefram land the bmis far Ue alleged cxelnptinn.Any vinlalinn of - NBW BL TION ❑DEMOLITION !v w Senion 9031.5 by any upplicaht for a permit subjects the apdUmI In a civil penalty of POWER DEVICES IICt/lA�9FP. nota a than five hundred dollun($SW). NT ❑FOOD SERVICE Las ansa aha prnpar nr my employees with wI,c,to tharsnle congterenaion, SWIMMING POOL ELECT RIC ROVEMENT ' ZA will do the work,and the shovere is not intended oraffered forsed(Sec.9044,Business ❑OTHER [[13 m and Prafexaiom Cm1e:The Contmemrn License Law does not apply In an owner of OUTLET S-SWI TCIHIS-FIXTORES LL pmpeny who build,or improves Iherenn,and who does such work himself err thmngh his own employees,provided that such impressment,are not intended or uttered ror NEW RPSIDEN'IIAL ELECTR SQ PF. sale.If.however,the building or improvement i,sold within one yearofrompleaion,the SQ.FT.FLOOR AREA $AQ.rE owneol ailder will have the Marren of proving that he did hilt build or asphalt,for Put- Q Qeofaa'ma L owner of thevan exclusively emarmoid,with licensed ammus tem to q 6 �} slmet the project(Sea]04properly,4.Entire.had Pmfe„iah,Code.)The Contractor,li- ♦ 7 2 Cy SF sense Law does ran apply to an owner of properly who bailer or amprovm merman.and QTY. PLUMBING PERMIT FEE ie who cocoas dawchphase's IIIIaulmmmnrof licensed pursuant at the Contractors License Law. PERMIT ISSUANCE SF ❑ I van exempt under Sec. ,II a P C for this reason L (() N.TER-DRAIN cit VEN -WATER EA) VALUATION Dale rte WO F.R'S COMPENSATION DECLARATION BACK FLOW PROTE DE E 2- 3 �J J\ O I herehyothnn under penally of paqury one of the following declarations: - S 0 Lo I have and will maintain a Ceni Gne,of Consent to self-insure for Worker's Contpen- DRAINS-FLOOR,ROntr ON STORIy$ TYPE CONSTRUCTION sea..as us Provided for by Swtinn 3904 of the Labor Cade,far the perfnmtvnye of the work for which this permit is I.... . FIXTURES-PER TRAP El 1 have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Card.for the partiamvnecof the work for which this permit is issued, GAS-EA.SYSTEM-IINC.40 ' ETSii, OCC.GROUP APN My Worker's Compensation Inshmnce farrier and Policy nbmher an, IlCarrier: PolicyNo: GAS-EA.SYS TEM- 4(F.A) CERTIFICATE TIF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE GREASEJ[NDUSTRL WASTE INTF.RCF.19'OR BUILDING DIVISION FEES IThNseetion need not Be completed ifthe permit is fmone humneddallars($IW) GREASE TRAP ce#) PLAN K EE Loy any that in themin performance of as work far subjectch this ekes Compall SEWER-SANITARY-ST ORM EA.21X1 FII not employ parsoniaany manner so ere¢t bewmenubjusmlhe Workers Qtmpen- E sYFE O ,Z Alien Laws of California.Ilmc WATER HEATER W/VENVELECTR z NO][CC G UI FEE ti h NOTICE TO APPLICANT:If,alter making this Certificate,,(the E,,bar Code you should WATER SYS'1'fIM?BEATING F become subject y the Worksuch a Compeer his pcori,ul,hai of me,rad Code,you must ,S sEH forthwith comply with such provisions nr mase pertnil shall he deuned revokcQ WATER SERVICE Q U z CONSrRUCTION ome LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.PI'. PAI V work ,gUi,hvtmercivuwn(Sea3nlensingagencyf rtheperfarmnneeof Data Receipt# W the work for which this permit Ix issnee(Sec.9(19],Civ.C.) U Lenders Name T I: GU Lender,Address TOTAL: (•-t 04 1 wally that 1 lava read this application and state that the above information is BUILDING FEP. V Jut z correct I ogres Ia comply with all city and county otdinanees sad same Wws relming Io QTY. MECHANICAL PERMIT' FEE V 4 buildingaraboaam,and botchy authorize repukwhmtivesofth,,nIy nt enter,u,hi SEISMIC FEE thaws mentioned Property far ir,,cmm remakes. (We)agree to save,Indemnify and keep harmless he City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE lob1 in of the aininll oepeme.chic miry in anyway amore against wadCity gCCER OR AUDTOMECH. ' consequence of the gaining of this permit. PLUMBING PE I In c A PLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT(TO 1000OCFM) IL � IURCE REG LATIONS MECHANICAL PEE /�. AIR HANDLING UNIT(OVER 10.(100 CFM) CONSTRUCTIONT Signum eofAppliemNZARD or Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE HAZARDOUS MATE .SDISCLOSUkE Will the hythe Cofanterl Mune buildings,Cleahtstorcor handle Health nand Safety HEATING UNIT(I'O I00,000 BTU) ax def red by Ilio Cupeninn Municipal Code,Chupmr 9.12,and the I{etdth one Safety Code,Section 25532(,)? HEATING UNIT(OVER 100,000 BTU) ❑Yes ❑Nn VENTILATION FAN(SINGLE RESID) PAID Will the applicant or furore building occupant use Wuipment or devices which Data Receipt# ,nil hararlons stir eonfaminma5 as defined by the Buy Arra Air Quality Management BOILER-COMP(311P UR 1 W,IXp PTU) District' TOTAL: ❑Yes 7 N BOILER-COMP(OVER 100,0009TU1 I have read the haomimis materwls reg5Ix body,Chapter 6.95 afthe Cal- AIR CONDITIONER �T / ®SdA sell Temc Health&Safety Code,Sections 25515,Z533anA AT” 25534.1 nndeeaanJ that if the NEW RESIDENTIAL MECH. SQ.IT. !•t' building does not of ls currcndF havunenanL Ilial it i,my msponsibiliry to nmify the newptmt breyuir mems whichlana et piasunnw nfn Cenilleme nrOwupancy. 2-zz— oneraire, offitiled agent Dwe TOTAL: ISSUED BY, OFFICE