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S2833 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING.-ELECI ICA I. PERMH NO. BUILDING DIVISION APPLICATIONIPERNUT PLUMBING-MECHANICAL S 2 8 3 3 BUILDING PROJECT IDEN'TIF'ICATION BUILDING ADDRESS: SAN'IT'ARY NO. APPLICATION SUBMlIT-I'AI.DATE 11(9x5 L-,N -VALOMh 17P-live Y J6 / 19 O\4NER'S NAME: PHONE: CONTRAS(JR'S NAME: LIC NO: 5lU 1 YINM NIC CONTROLA p ARCIIITIiCI'l1iNGI Ly I!R: IJC NOS ADDRESS: ❑ 7 y CON-1'Ac'1': ,•`^I'zV�I}0.p/ PHONE: BUILDING PGRMITINFO ���� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECCHH rJ ri L1J .�J LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE1 herem by alone, al].'it Ecen,a,l ander posm...is of Chante,9 iemmnd,g :... . JOB DESCRIPTION WZ nJhS fmw anddlko�ivisionJ Of lho Htsincss and VrnfcssiunsCWc.and mylkcnseu RESIDENTIAL' O FERMI'I ISSUANCI! 1-,2 =i�9SFDWL ❑KITCHEN REMODEL a UU 1,icen.e Class Lick APPLIANCES AL �l {�1(DDIT10:�1_'� PLUMBING kIi-PIPE NS W D m Contractor \ r ARCHITECTS DECLARATION �MIfTLUNIT ),Ir JO MODIFICATION ,=)O0 PAN,-S ZOZZ I understand my dare,hall se used a,public records �� UP"CO21X1AMPS R•myR_ ❑CHI.MNEY REPAIR F+�,I"„{y Licusul l'mfus.innal 2UI-IIllID AMPS � kOV EMI!No s7.1 ❑SWIMMINGROOLS OWNER BUILDER DECLARATION x Q1 hereby affirm that I am csanp fin-the Coommur'w License Law li,the MER 11NN1 AMPS BATH REM(1DF.IJREPAIR DEMOLITION 3 a.U following reason.Section 7031.5.Business and Pmfessionw Code:Any city o,county' SIGNS ELECTRIC IN I-y y which requires a permit m construct.alter,improve,demolish,or repair any structure MtN�J print t c 1. q d ppll tf hpermitt risigned s mnent SPECIAL CIRCUIT/MISC. I hat RTINn E to IhIp tt tit p : : fth Contractors B 1 L (Chancr9 WCIQ (cot g dSe( 70!X01D v'r.' 9 fm Bz'u dl f::' eCtde)o, 1'I:MI'MIs TER OR POLE INST. COMMERCIAL' d a e C Inas he is esc upl durefrarT and tire basis ITO it II ged ,,OmipoouAny violin' OA ❑NEW BLDG/AUDITION ❑DEMOLITION ySection]0315 by any applicant for a Permit'objects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE hat more than five hundred dollar¢(5500). IMPROVEMENT 1-?< D1.as owner of the property.or my employees with rages as their wile cnmpcnsition, SWIMMING POOL ELECTRIC a 'x will dome work.,nd mesummmre is not intended or nlicrcd forsnle(See 7(W.Business El OTHER LL13To and Profess inns Ctse:the Curarionre License Law docs not apply man owner of OUTLETS-SWITCHES-FIXTURES A' In"ny who build.m i...prow¢,mane i.Iced who Jud such work himself at Nrnugh his own employes,provided than such Improvement.are non intended or of1'emd fo NEW BESIDES IlAl,I!I.1!CT'R SQ ITT SQ, sale.ILh.Oe,,,she building orimpmwenmm is sold within one year of completion,she © SV I'I'.FLOOR AREA $TSV.17L ownce-builder will6 the burden f possingthth did notheld or-improvefor put, _ p Ys' 1 f site P PAYdu- e1yt tgm la.ds nt r Z i. imsme,Ili pmJ tF In Ru :. dRf n:C I )m C i s 1 Ik ccs a d t pptyt flrpmty n h -np ' nd QTY PLUMFSING PERMIT who t c f .A prJed tl nun mr(s)hu uul p u thee C...mantOi, - 3 `Ts Fc a g13ACK SSUANCE 1 am exempt under Sec. .B&P C f r this assn DRAIN.@ EWATER(EA) VALUATIOL-a DateN O WONKP,k:S COMPENSATION DECI.ARA'I']ON OW PRO Ii !VICE /Z / O11 by fl t d pc Ip fP J rY flit fdl gd I. f (IM1 d 11 tt C t t 1G : u ll t f W k 'C nen FLOOR.ROOF, D. STORIES TYPE CONS'I'RUCHON anti p o l n by S i 9]IIU f nit L bor Ud.., ce p rfnrmnnev d he TO. CIXI'l1RES PCR TRAP �7 i 0 1 have and will maintain Worker s Campensatimi Insurance.as recuiredbyti tion FO. Al INC.J U'LETS C� J7(NI fm I M C I ( thepar T fm workfwhichsh:M1 itis:wed. {s k.. \ OCC.GROUP �bPN My Workers Compensation Insurance currier and Policy number am Carr:¢: Policy No.: ASS; 1!A.SYSTEM-OVER 4(, ) INL CI!IiCI171CATG OPI3XICMPTION PROM WORKERS" '(IiIwSNINDUSTRL WA$'TEI Td' CI! '< COMPI3NSAfIDN INSURANCE BUILDING DIVISION FEES (Thi,se,lioa need nm be complumd if me permit i.Toms,medmildellun($100) orlcss.) i HASETRAP- PLANCH'CK IEP. 7 IcenifY that in the pertommncwdthe work for which this pcnNt is iszu0A,lwhall '1sWCR-SANITARY-STORM EA.201 IT. not employ any person in any manner w as to become sahjed to the Wmkcrs'Compen- NNERGQ OZ anion L'awsnf C.bfomia Date IWAIERITMA F"YTI-EC�R—z Applicant ZNOTICE TO APPLICANT:It.Ilio making mise Cenilicam of Lxemmian,you s10Id WAYI7R SYSTEMOR I EA'II NG becme sobjectto the W^,lau'.C...ipensation pro sin O of the Lubar Code,you must fomhwim comply with such pmt.' user this permit wmll be deemN revoked WATER SERVICE Z) CONSTRU(JTION LENDING AGIiNCV N1!W'RE$1DENTIAI.1'Ib113. SV.PT.UO aU C) 'he work for which this ponnin Is t oust(Sec.3097.Civ.C.) 2O Lender,N^...v 7OW Lendvr`'Add �'(Y /aIcertify that 1 have read this upplicntiun and s,am tout the atxwe inhummaon s y cooccs.l agreem comply with all city and county ordinances and state hiss relatingm QTy.. MECHANICAL PERMIT FEEUZ building consuucsion,and hereby authorize resmsenmuives ofthic city m enter upon the iorn,,mentioned pmpemyfee inspection proposes. 1117RMITISSUANCI: 2 (WO)ngme m save,indemnify and Wep harmless tiro City of Cupenine agoitst EEC IC PEG O babiliec...uAgmmme,uo,n,mdexponseswhich mnyu,any wayac—aguinsl said City AM ER OR ADDIO MECH. DLII BIND IEEE in maCANT a Ufnengranting SThisp WIL SOURCE REGULATIONS, AND WILLCOMPLY WITH ALL NON POINT AIN f1ANDLING UNII'1'10IO.WUCPM1H EHANICAI.PEE SOURCE R[GULATIONS. ��� �� � / . C • � �/C�� AIR HANDLING ON['1'(OVER IBM)CFM) CC.STRUCTION TAX ignamm of ApplicuHAZARDOUS I rte E%IIAUST HOOD(WIDUCT) HO SING MITIGATION FTSE ImmeMATERIALS DISCLOSURE Will ma upplie'.ml or future building nccupunt dam ur handle M1emrclmues Inulunul I IL'AI'ING UNIT'(I'U 11 ling)BU) as defined by the Cupertino Municipal Code.Chapter 9.12,and the Hnanh and Safety Cada,Section 25533(x)? I IHAI'ING UNIT(OVE K 100,000 BTU) ❑Ycs I h^ RNE.WRESIDEMIALMECH. - W(S INGLE RFSID) PAID ])are Receipt e Will the applicant or future building uecupam use equipment or Am'ice.which ir '(JI{I'OR 1[NI,UfNI BTU) min haaamluus air mntammxnta as dofncd by the Buy Arca Am Quality Munugemem Z A - DismmP OVER 101.B(N113'1 U) Cl Yes Pj No I have read the hazardous materials requirements under Chapter 6.95 of the Cali- ER ISSUANCE DATE, fomia Realm N SafetyCMe.Sections 25505,25533 and 353J.1 undenmrvJ that if the 'IAI.MIiCH. SQ.FEI J _ 7 _ g 9 building does not ounce ly have a Imam,that it is my mwrymeibilior ,,notify ds,ov upam nide, i nwhchmnd b/e mm pri:rmizsuane Ufa Ceniti" (kr. UED Owner,r-ad.uris.ed a gent OFFICE