S 1087 NPPLICANTTO FILL IN INFORMATION WITHIK;RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING-GLF.CI'RICAL I I'IiRMIT NU
BUILDING DIVISION APPLICATIONIPERMIT l PLUMBING-MECHANICAL S 1087
BUILDING PROJECT IDENTIF'ICA'TION v
NUILDINGADIlRESS ,� ��1 SANITARY NO APPLICATION SUBMITTAL DAI'li
](0 1 l -I "&Aa-j o+ +U , /o--24 e-w 7 .
OW NAME 1'IIONIF CONTRACHIR'S NA�yF / LIC NO:
f (Let, �uAeeL_ ZSS 11 Z-� �'C $ /�Zll_ r[71 Nrc cGNrRIR,w
• ARCHITF.C'/1?NGPIVER LIC NG IaDYR1�SSr(�/ - I^I ❑
CONTACT PHONE. 'n
vLT Ate ob.1-1 BUILDING PERMITINI'O
❑ Consultant Fees Paid by Applicant(initial) HLDG ELECT PLUNIR NIECH
❑ ❑ Iz ❑
LICENSED CONTRACTOR'S DECLARATION �Qgry ":r' ' ELECTRICPERMTPah l � Fla:' I JOB DESCRIPTION
1 herchY affirm Nm I ran LcenseJ under pmnvnn,of Chapter 9(commencing
,s License and effeetlwtsmnJnfthe C:mtgrecuund Note,aam Gale.and mylsemeas PANI'I I RESIDENTIAL
IT ISSUANCE G
z G�3G 704"S/S- l �SI'DWI, El KITCHEN ItIiNlODlil.
Q V APPLIANCES-RESIDENTIAL [I AUDI'I'DON PLUMBING RE-PIPH
HtIlSDECLARA IIIN I ❑MULTI-UNIT El STRUCI'URAI.
ZOyZ I understand my plensvidl be cowl a,public records .S h10DIPICA'I'ION
_ DP TO 100 AMPS ❑INTERIOR [I CHIMNEY REPAIR
P:14 W Licensed Pnde,-mal 2101-i(MANIPS IMPROVEMENT 0SWIMMING POOLS
E5 s1 S OWNIi&BOILDER DECLARATION OVER 100 AMPS / I 0 BATH RENIODEIJRI:PAIR 0 DESdo 1'DON
C0 S��a 1 hereby about lot,I a tnpt front me Common,',L"in,c Law for as
ipyx5,�6V folluwmgrei,am (Sechon]11115,BU,mms and Ponowmn,Co it Any any or runty SIGNS ELHCfRICAL / El OTHER
xM1¢h requam a perms Ili ahngmn,elm,.ampnwe,demolish,nr repair any.ameba- -IR-
pnonous is,unnce,uham,mm,Lu.pphurm❑much man or file a valued smtement SPT:CIAL CIRCUITIMISC.
�G� Ihur rte enlmen,rd punuanuohmprovnmanol the Coutracnt's l.avan,e Law(Chaptet 1) COMMERCIAL'
�.CO
(,or n cmgwnh Scamn)f(()nfDrviaonJidda,eu,inea and l'mfesonn,Chdeht IEN11'.MITI'eR OR I'OLF.INST.
d y o C
than he is exempt therefrom and the basis for the alleged exerima n Any rol u i of ❑NEW BLDNADDITION 0 DEMOLITION
'1w Seed....111111 by au,aPphcmt lo,apnmd whlro,the apphrunl to a ca vii penalty of POWER DIiV ICRS 7 El FNANT [_1 FOOD SERVICE
_Zy nmmore than five hundred dollars 1550X) IhBIROVENIHNT
ZQ� O 1,mnxneroftheprnpenyormyentployeeswnhwage%mtheiraalerompensatinq SN'IhIM111NG P001.ELECTRIC •�
adtrill JO the woo A,and lhe,hucture as nannfunded orolfered fm rare(S,,.70b.Bminc,� OTHER
ad t.9 and Pofeslums Code:The Contractor',License Low Jars nor apply m im miner of OU'IhF.TS-SN'1l CIIliS-f1X'NI11i5
pumarly who buddy or ampm,c,thereon,and who does such work ham,elr or Ihroug.. - v
ho own employee,,provided drat wrr impro—o,ol,are net intended or ollere l dui NEW RESIDES 1'IAI.ELFC'IR SQ FI -
sale.IL ousescu the budding or improvement is word one year ofemnpleion.lh. SQ Irl'I'LUUIt AREA b/SQ FI'.
unervhudder x dl have the burden of pmvmg that he did not hurt,[.,improve for pta,
El - CEIVED
I] 1.as owner of the propenY,em exduwvely nmlmcung with licensed cnmmdon to _ 'RUAL
construct the pule"(See nuF.Bmmc,s and Professions Code.)The Commuter's Ia- r f
c ,e Law does no(apply Joan owner ol property who mdldsormmpm,c,thereom.and (QTY, .. PLUMBING PERMIT � j FEE OCT 2 91997
whoconlracn forsuch prd vcn with acommdons)licensed purman tothe Conldadnrs . " 1 . .
License Law I / PERMIT ISSUANCE
] I'miu—p(uMr,a S" ,B,ik PC forth..mn,nn
Owner Ole ALTER-DRAIN K VENT-WATER LEA) � In'I/ VAWAI ION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 8701E
1 hereby affirm under penalty of penury one of the follow tog di,uWatums
]I have and is all maintain a Certificate ofCon,ent to s0butpre for World,Compen- I DRAINS-MOOR,ROOK AREA.COND TYPE CONSTR UCI'[ON
,ahun,m provided In1 by Soren 370o of the Labor Cnde,for the penorneace of it_ ^ STORIES
wed for wu,h has pemoO,owned. S- FIXTURES-PERT RAI' �� 3
0 1 have and will maintain Waked,Cumporacdton Insurance,vs required by Seaton = _
3001 of the labor CuJn,for thepaboarmen of law work ter x a,li the lemma,issued ) GAS-EA SYSTIiM-I INC 90UThGIS r OCCGROUP AI'N
lily Worker',Compensation Inundator,tamer mail Policy number arc -
Cartier Policy Nn GAS-F.A.SYSTEM-OVER J(EA)
CER I'IFICAI'E OF EXEMPTION FROM WORKERS' GItEASIIINDUS'I It],WAS'I'EIM'111tCEPTIIR -
COMPENSATION INSURANCE I BUILDING DIVISION FEES_ _
(Thu unarm need not be eomplrmd dlM1e permn i,forntchrucreddollars($101) GREASP TRAP
or less) PLANCHECK TEE
Icemfythatmtm anyournmr, of the wed for hicbthnpcamnnnwed,I,haI1 SEWER-SANITARY-'STORM P.A.2W In'.
net employ vny person an any mavner to Moo ecnn de N'- ken'Compen- ENERGY FEIi
Z .bran Lax,ol aurora Da ��� v# WATER DEAL ER WNENTIELEC'IR
Z Applicant GRADING THE
NOTICE TO APPLICANT IL after making this Cmahcam of lixempmn,you should WgTF.R SYSTEM/IRF.ATING SOILS TEE
Ri M1aan.e,object to the Warker'r Compensation p,ov..nn,of the]..No Co l4 yun must
fnnhwaNCnanply with such pr9n,um,or this lemon atoll be JCenurd rcvnACtl WA'T'ER SERVICE
z CONSTRUCT ION LENDING AGENCY NEW RESIDENT IAT,PLNHL SQ,FT PAID
U I hereby affirm that lhcrcn a esn,tmmum tundras agency terthe pe,fondmme of
D.ne ReretPlp
the work far which the permit ,,,wred(Sea 3097.Co,C)
ULender's Nam'
9L. I rediry arm I have results.,apphcmmn and late that the above nt(nnnaum _ i BUILDING PBE
tin correct.I agree to comply with Andy and county mahadueas unit slnelaw,rclmmg u' Q'fY' , MECHANICAL PERMIT PCE
L) Z hnJJmgcon,wconn,and hereby authorize repre,enmhve,of thnwymcmernrymdte .- SEISMIC FTiIi
aline-mentioned pmpeny for mspecumn purnows PERMIT ISSUANCE /
0We)agree to see,mdemmfy and keep harmk„the Cary of Cupemno agmmt 1 121-ECI'RIC FFE O )
Itahirties,ludgmenl,.costs and expemes which may in any way accrue agmT,t said City AL'1'SR OR ADDI O MECI I (PLUMBING IglE
at seq...ceoflhe gramm, ifthi,perms. _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ( AIR HANDLING UNIT TO ITAX CFNU I MECI IANICAI,FEE
SOURCE REGULATIONS I _
AIR HANDLING UNIT 10YIiR 1011((9 CPAD I GONS'TRUCI'IDN TAX t, '
Signmurenf Applicant/Coductor Date C%HAUS'I'1{OODIWIWCI} (HOUSING MI'I'TGA'I'ION IEi
HAZARDOUS MATERIALS DISCLOSURE '
Will theapl,hemtor timme hudrng,coupaln boner handle huaardnu,mammal HEATING UNIT OD 100,0(X)BTU)
.r,defined by the Cupertino Municipal G,Je.Chapter 9 12,and the I Icalm and Snlety 1 _
Code,Section 25532(ml HEATING UNIT(OVER 101,01011 LU)
Yes No
E]Ye, VIiN'f11.Af[ON PAN ISINGLF:RIiSIU) PAID an Receipts
Will the applicant nr future bmldmg nocmpanl use egmptrtenl or des ace,which BOILER-COMP'0HP OR 100,000 BTU) U
etnn herardau,minor mmnmaO as defined by the Bay Area Air Quality Managers eat I TOTAL / S
0 Dishor) BOILER-COMP(OVER 101,001 BI'U) -
0 Ye, ❑N. lI
I have real the hwnnlnc,mulmd,nrtgmrcmenl,under Ch"hur 6.95 of a he Cuh- At R CONOITIONFR ISSUANCE DATE To
foram Health&Safety CNCSauon,25505,2553I mm25534.l understand 111.1 ifthe NEW RESIDENT IAL MECH SQ.FT,
hluldmg dies urn cutremly have a tenanh the n is my re,rymubalaq m onufy the aeupam l ll
if 11h9 admucmeni,which malt he nett pnor to a„uanra nfa Cerotio nc of Ocerpancy
Owner or nmhenred agent Dale TOTAL ISSUED BY
OFFICE