S 2293 (2) --APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..EI.EcTRIL'AI. PERMIT NO.
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING-MECHANICAL S 2293
BUILDING PROJECT IDENTIFICATION
BUILDING JIDDR S ^ I SANITARY N0. APPLICATION SUBMITTAL DATE
``uuI O O '1r^I'^' 1W /v- 5-- Y-
OWNS ....0yo5
E CON TRr T( N I C
'' n✓7 71 �J 6 NIC
CONTROLp
AmS ARCHITEC'UHNGINEER: LIC NO: /" h' 1 TM 5^ I � O ❑
CONTACT: PHONE: G II BUILDING PERMIT INFf]
7,��051(0 ❑ Consultant Fees Paid by Applicant(initial) BLDG E PLUMB r(Lc}
LICENSED CONTRACTOR'S DECLARATIONQTY. ELECTRIC PERMIT FEE ❑ ❑ k^��j
1 hereby infirm de,1 am licensed ander Provisions of chapter 9(commencing JOB DESCRIPTION
goC with Seaaun](NNll n(Davision3nf the Business and Podcssions Cale,and my license is PIHMITISSUANCE a�O RESIDENTIAL:
% in GJl fmw andsMc�
W� `315;�qV�fipb�� ❑SFDWL KITCIIIiN REMODF:1.
Mk-UU LicenseflCl��T• v Lien APPLIANCES—RIEHIMENT1AL El ADDITION C1 PLUMBING RE-PIPE
(FQuI Dao `(! Commmor
F,Dm ARCIHTECPS DECLARA O PANELS
El MULTI-UNIT ❑STRUCTURAL
zol,,Z Iundersand myPlans,,boll beused as Public recordsMODIFICATION
OZ�Q UP'T02m)AMPS [I INTERIOR El CHIMNEY REPAIR
E.y...F.W Licensed Professions[ 201-1000ANIPS IMPROVEMENT E]SWIMMING FOOTS
�Y J
OWNER-BUILDER DECLARATION OVER]but)AMPS ❑BATH REMODIi1JREPAIR ❑DEMOLITION
y C Q 1 hereby ffirm that I um e¢mpt from We Corona, is Liceme Law for the
pe3LLF following reaso.(Section 7031.5.Business and Professions Code:Any city nrmumy SIGNS F,LECI'RICA], ��
I" which regtores a Icaru m enn.uruc, It,,improve,Jnooll.vh,or acted,any structure
Q Prior ma, also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUITIMISC.
but he is licem,ed,anuvouo the provisions of the Contramorc License Las,(Charter 9
n (commencing with Section 701X11 of Division 3ofthe Businesxand Professions Code)... 'I HMP.ME9'EIt OR POLE INST COMMERCIAL;
F e
but he is exempt dismounts and the basis fm the alleged caenmtion.Any violminn ul" ❑NI?W BLDG/AUDITION ❑DEMOLITION
Section 7031.5 by any applicant faro peuiilsuhject,s the applicaono it civil penaltyaf POWER DEVICES []TENANT ❑FOODSERVICE
oat more Nan five hundred dollars(35 W).
H Z Y IMPROVEMENT
Q E31 SWIMMING I'ODI.ELECTRIC
9
{F' O will Jn tha,ark,ondl: 11,11 tea is not imm�JcA an,ffereJ lin vile(3ecJ1114,Business ❑OTT{ER
W unJ I'rnlPxvinns CnJc'ILo Contractor's Limnse Low Jocx not apply In an owner of GO 11.17,1 S—SWITCHHS.IIXTUR1i.
Nativity who studies or improves thereon,and who does such work himself or through
his own employees provided that such improvements am not intended or offered for NEW RESIDENTIAL ELEC:R
.sale.If.however,the building or improvement issoldwiihinoneyearnfcon,pletion,ihe SQ.FP.FLOOR AREA S/SQ.Ir
,ustoO.1builder will have the bnnlcn of proving than he did net haild or improve for pan
Post,of sola).
❑1,as oner ran of the property, exclusively comraoninmrs m
g with liceed coaaoTOTAL:
wr'
instruct,he Project(see.7044.nosiness and Professions Cale:)The Contractors Li-
nseLow does not atiply 1.anownerofpml'eny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
,It o.....bries for.eneb project,wilt a coamtclodv)becloud pursuant to the Contraear'.v
License Law. PERMIT ISSUANCE
E]fact ear tender Sec. .B&PC hairs reason
AIIIER—DRAIN&VENT—WATER(EA) VALUATION
Owner IAne ���
WORKER S COM of nurture
urt ION Of hefotA310N HACK PLOW PH(TfBCI'.UHVICF.
I hereby mann under penalty of perjury one of We fol lowin6 Jednratians:
❑I have and will nmintain a Cenaficateof Consent u sclGinue for Workers ConaNn- DRAINS—FLOOR,ROOK,AREA,GOND. STORIES TYPE CONSTRUCTION
xmion,rax provided for by Se,lian 37M of the Labou Coda,for IN,N,fonnance of the
nk basilica Ihi.c pcnnil is issued, FIX'1'I1RF.5—I'I?H TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
00of the Labor Code,for Perfo ace of the work for which this pemtit is issued GAS—EA.SYSHM-I1NC.4OUT CO
S OCC.GROUP APN
My Wor inn be artier and Policy numpps��?(�'�
Carrier:) a Policy Na: (.JN "� GAS—EA.SVSTCM-OVER4 ) h
Clilfl'IFICAI'I:OVHXEMI'llONPROMWORKERS' GRCASFJINDl1S"fHLW 'L INTERCHVIOR
COMPENSATION INSURANCEBUILDING DIVISION FEES
(Thi.v section aced no,Mannple,eJ if,hc permit is(nr onehundml Anllars(Sllpl GREASETRAP
or Ico,A PLANCHECK HE
I cenify[hal in the terflntance of the work liruhich thispermit is is sued,I shall SHWF.R—SAN'ARY—STORM 11.20017
not cntplay any Parona in any inarner sit as to become subjecuo the Workers Camper. t ENERGY PEE
Z sa,aan Lows of California,Dam WATER H THR WNENf/ELECfR
Applicant GRADING FEE
N NO1'ICH TO APPLICANT:It,alae,making this Certificate of Earraption,you should WAII° SYS'I'HMITREAI'INC, SOILS li
pecans subjen Io the Worker's Cnmpensmiun provisions rt fire Labor Code,you arum
forthwith comply with such provisions ca, his l'enni,uhall bedeemed revoked rER SERVICE
G
� z CONSTRUCT ION LENDING AGENCY NHWRESIDHNTIALPLMIL SQ. PAID Dat Reccile#
U O l hereby cline thin there iv n co.eman
ann lending agency for eafarmance of
(~-I tnew ork h,rwhiah this,onfli is issued(Sec.3097.Cls.C.)
ll 11
'TOTAL:
C) Lender 's Name
WLender's Address TO
Rt I certify Wit I have real this application and stale thnt the above informmion is BUILDING FEE61
N cnrrcm.I again m ounNy with all city Ind anlnty oNinmmcx and stem Inwx relating m QTY. MECHANICAL PERMIT By FEE
U Z building construction,and hereby authorize representatives of this city In .1, the —
ahnve-memioned property for inspection purposes. PIiRMI'1'ISSUANCE O
(We)agree as save,indemnify and keep harmless the City o(Cupcnino against BLECI'RIC hEB
Iiahilinies,judgment,costs and expenses whidsous,many way acemeageinvtxaid City ALIT IR OR AUDIO MECI I.
sequence of the Granting of this pemtit. PLUMBING FEEAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIH HANDLING UNITIO 10.(0(il�
SOURCE REGULATIONS. MECHANICAL I eE
AIR HANDLING UNIT(OVER 10,0011 CI-M) CONSTRUCTION'I'AX
Sigmmre of Applicunl/Conlractr Ilam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ufuture buildingoccupantstoreorhandle hazallous mmeriul 111?ATING UNIT(TO 100,000BTU)
as defined by the Cupertino Municipal Come,Chapter 9.12,and the Health and Safety
Cola Scdlon 25532(a)1 \/ IIIMTING UNIT OVER 1 f 0.000 B U)
❑Yes Lx Nn VENTILATION PAN(SINGLE RMID) PAID
I\ Dac Rmelpt
will the applicant or lawns building occupant use cyuipmem m Jevitts which
1 emit haza Yoss air eo Mbrome�Nsn defined by the Bay Area Air Quality Mmmtgement BOILER—COMP(3HPOH IIN),(X10 BTU) TOTALTTffi
:
Ulsast t Bol[.F.R—COM P f OVER 10.000 BTU)
AIR RESIDICONDU IOHA
I have rand the LamNous n,mentils requirements under Chirpier 495 of the CA ISSUANCE DATE
fond.Inn h&Solely Code,Sedans 2551L5,25539and255)4.11.norsamd oatif the NIiW HBSIUIiN'fIAL MfiCH. SQ.FL
bar a snallarmalyhavea¢nu thin itI is es at ace"i to notify the accupan
of arc cs which mu f he n :ior,o i uarlcc of x Cenifica b
V! 'ro TAL. ,.gam - O �s..tJCU
uthorired Ibcm Ulm 5 •(.7,J ISSUED IIY: e
OFFICE