S3317 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.RLECI'RICAL PHR IT NO.
BUILDING DIVISION APPLICATION/PERMITPLU]1BING-MECHANICAL 3317
BUILDING Plitt IDKN'TIFICVBON
BUILDING ADDRESS'. SANITARY NO. APPLICATION SUBMIMAL DATIbi
CA SN Mli: I- PIIONE: tCONTRCFORS NAME: LIC NO: / -/_��
/ N/C CONTROL M('�
ARCIIIIECIPOINGINEUR: IUNO ADDRESS,' ❑ L-� Y
14O,p J Cl
CONTAM. PHONE. BUILDING PERMIT INFO
V ^ %. . 8-9 46� ❑
Consultant Fees Paid by Applicant(Initial) HBY— 11ECf— r1.UMB , MEel1
L[CENSEDCONTRACIOR:S DEc1ARAHON QTY ELECTRIC PERMIT FEF- LrWI /
I le y affima IMt I am lKcnwd enkr pavis rf Clapm 9lcomarcrcing JOB DF•SCRII'FION
�a0� withknlun]I11Xp of Diviaiwll of IIIc Butitxxe uaW l'nd&sionv CtWp ulW myliccn.vc is PERMITISSUANCI! RESIDENTIAL
F W. in full force"effect. C SFDWL C KITCHEN REMODEL
Q0� Licca,Class LIc.0 APPLIANCF_S-HISIDENI'I AL C1 ADDITION CPI.UMBING RE-PIPE
yQa Dutc Cnnlf.¢Iar CMUI.T[-UNIT ❑STRUCTURAL
ARCHITECTS DECLARN'1ON
1.7m PANELS MODII9CATION
ZOnZ IONrntarW my plus sMll be uaW as public rcemok Ill'TO100AMIS
OZ--� CINTIiRIGR CGHIMNBiY NIiI'AIR
GNFIaI
Licensee! 201-1000AMPS IMPROVEMI:N'f CSWUIMINGPOOLS
OWNER-BUILDER DECLARATION OVER HXXI AMPS C BATH REMODEURETAM C IIBMOLITION
C Q I hcreh,an!.tMt I am cacntpl from the Comeamev n Limn,law far he
C)a V Iidlmvmp team.,ISectast]11115.Dusima and Prnfasxbnc Cooue Any city or cwnlySIGNS LLECTRICAL C OUTER
I+1 li xhich aa9uiaes a pemdt m comb.,Wter,improve. lemoh,b,or repair any rlmcmrt
Of-
C� Priam its ocamic,also rcquiaa Etta affliction for such permit to file a signed statement SIgiC1AL CIHCUfT/MISC. 5T-PW L
I hat he is I cenwd parurm to me pmv kion;of the Gmtracofs Licemne lawChaser 9
yrQLIcmauarrcmg with Seetion]0(()nf Disisian 34lhe PudnasvW Poofell-Calle) IIJsfP Mb1"R OR POU NSTCOMMERCIAL:
d a o C that he is uemM beryfmm and tic Mxis Ra the alleged riumarim.Any ,iolat:o of C NEW BLDGIADDMON C DEMOLITION
-m
703 1.5 by any.,Ill.'far a pcmot auhjrcls t he uPPI'Icmt W-dint pcnellY of POWER DIiVICIS C1 TENANT FOOD SERVICE
FZY .Mawr dcmfircha cbPIdollan(S..Wf I,MPROVEMI:NF
Q ❑I,anwrcrof the poycny,or my employe.,with xapa nuheirmk etmtpenmion. SWIMMINGPOOI.EI.Ec-Duc
aFx+� will WoOwvrnk,wW tllnalmdme ix mol immded moRemd En wlc(.kx'.pl W,Nusinas COTiICN
W mW PrafasI..Code The Conlr ,mr's Liccme Law Jars nm apply m m wrcr d' GTLLTS-SWITCIIFS-ItA"TURF_S
Ila prpny who buiklr car impmva thcmoa,and who dies cath walk hen a f or Ehnwgh
hit awn cntplmyCes,pnivi(w thm such impnwcmcals arc not imendLal or ofle"I for RFSID Al.TI!I.IiCIR SQ IT.
xale.lf.hoverer.the building Orimpwenem is wW widdn ue yea of cmPlericn,Ihe SV FT.11COR AREA LSV I7.
m.buildcr will here the buNcn o(pmving taw he JW mor haiu or impnvc for pm-
E]1,a.,met MIFEE
6ob
❑ 1,it tnvrcr of IM pmycrty,em nelusivdy evnmetioe with liancd arlrcEors m construe,Else Miler(Sce."IDLs,Busrrss a l Profs"".Corle:)M Cmmacto/s Li-
QTY PLUMBING wM10contrae,for such pmjeees watt a eontmcEox(s)Ilecnw.l pu—I to theComr aOr"
Lareraa", PERMIT ISSUANCI!lam cramp aid Sm. ,If&PCRx Nit mi«on
AUDIR-DRAIN&VIM- VALUATION
Orxxr Ihw WORKER'S COMPFNSAHON DECLARATION BACK ItLOW PHrI'fI3CT.DI herebyalum muterpenalty Of perjury oneofIhavcv willmain[vnaCmircteofCm mtuselfinsumfaWMersCml - DRAINS-ELIXIR.ROOK. S7ORIIES TYPE CONSTRUCTION
as povit ed for By Section 371X1 of the Labor Coble.for tM perftmnsna of the
work far wNch mi,pcmdl is foiled, fIX'ILR]S-PER FRAP
Fl I have and will maintain Warl Compercat Inrwwne,n raNniral by Seaton
391X)MIM:fal Coda for the perRmnaruc of the wmk for wbkb Ehir pnmutlivxuM. GAS-EA.SYSTTM-I INC.4 OUTLISFS (ICC.GROUP APN
My Worker' mu nnmtinn .,non cunicr uaW Polley amnber
Comirr Rolky No.: ; GAS-IEA.SYSTEM-OVIII4(EA)
1 ATEO- aFA 1 Nbe FROM WORKERS GNI:ASIONDUSFRI,WAKE 1:INTIiRCI!PE.IR
COMPENSATION INSURANCH HUIIDING DIVISION FEYS
1lhk veEinn n¢d notbecuntpluN ifthe lcnniE kfor mehuaWral dallve(1100 GRFASETRAP �•a
m lm.) YIANCDECK FIiIi f o
Toy any
in p'nomewcOf lhewmcoma hichObje thin thmmlxismedlshall SIiWEH-SAN1'1'ARY-SIDRM I!A.2df1Ff.
not employ any pecan any mnnnermns In hccnrrc wbjmtmJw Wnhers'Conapen- I!NERGY hL'E Z
OZ avian laws M Califoama.Date W'ATIN IIIATER WNENTHJF.CIT( GRADING FE
O Ap icwn
Ii
NOTICE!TOAPPLICANI:If,.,fair askingthk Ccnifcem ofl!.um,mum,you should WAIER SYFUBAVBEAI'ING
N 1(1115 6
narcma mann mthe Nuch t kion,or this
-it halons of thelabor Code,you m.,v NJ
W lonhwilhcoinply, with ouch prvisnnsamis pcmnit small ba Jeemnl revoked. WA'll?R S1iRV1Cli
a0
CONSTRUCTION LENDING AGENCY NIiN'RESII31IlTh\1.PLA1B, SQ.FT. PND
UO 1Noebyotram,that mere i s a cmnslmction leading agency for the pctfoomence Of m RecdpI
- 'he wok for B.It Nu permit is issued(.Sue.NH].Co.C.) v TOTAL
UIsmder's N. s
Iwmdrr's Adthcas TOTAL:
I ccom y that 1 have read this uPPI'tolkm awl store IME the nMrve iofommtion is ❑UI ICBG (j
Fy caarcct.I vgaa Eo mmplywith dl cityaraJ caumyaJivuz3 slut start laic rclwioK to QTY MECHANICAL PERMIT FEE
U Z huadingeammrran,wnetenr amnonae¢paaenmdra annis city mento span me sE15Mlc O C
ON.vcowntimed'0",fur Insp Minn pm v- PI!RA11T ISSUANCI?
We)al to rave,indemnify arW keep harrnlas the City of Cupertino againn E1.[ C FFF
liabilitinitWg"'entc cents vad cxlews which may in any way accmc agvimt uiJ Cid ACD!R OR ADDOOMECH.
111CyUCKCOIOf lhegnmlingotlhis fenail, I'hI1MNIN I! Z
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO 10,00ICFAI)
MECHANICAL cH
SOURCE REGULMIONS.
liz-
1�fj AIR IIANDLIN ,UNIT(OVI?R IO,IXXI CFM1I) CONS-FRUCFION'I'AX 0
Si A omtrrE«^ Data I' HAU.SFHOOLOWMUC) HOUSING MMGAfION Fl]!
HAZARDOUS MATENIAI S DISCLOSURE
Will ma applicant to tmurchuiling oCupant.stmeor u
hand hamNt ,amanol I[BATING UNIT 1111 100.00()BTU)
to dclimnl by dac Cupenirso Municim Cade.CTlaptcr 9.12 and me Health aril Safety
Cork,Section 25532(a)? IIIATING UNIT(OVER 1(1(.000 BTU[
❑Yes L]No VI!NHIATION FAN[SINGLE RE910) PAID
Dem Rmcip X
• Will the applicant m future building occupmt um quTmem Or du iecs which
unit hvaNws air contwan
nirl,as, and by aha re
Hoy Arca Air Quality MagancnE 11f11LER-COMI'OIIP(3N IIXI,IXO BTU) ��}
Dinnm? TOTAL: 7
❑Yes E]NO BOILER-COA1P(OVER IdD.(I(ID HIL)
I have read dee wardoso mvniWa nNaienlenut ureter CMPlerM195 M Jae Cali- ISSUANCE CONI]I'TIONEIt ISSUANCE DoATE
funis Ilealm&Satety Coale,Ssvimo 255(15,25533 and 25534,1 utdentvd aha lithe NF:W RP_SIDHNfIA1.MSCH. SV.FT / �y-4 O
building Mas nx emre'ndy have u rasa BIW t it iz my relryxtsihility to Iexily dm iasupant
of Ile rtquimrcms whkh must h non pint m issuance of•Cmilimtc of(kcuryrey.
(hrnnaw
nvhaoredugent - Ilam '1(ll'AL Z X ISSUE[)By T�
OFFICE