S 0184 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IUILDING-ELI+,CTRICAL I I'E MIT NO
BUILDING DIVISION APPLICATIONIPERNUT PLUMBING-MECHANICAL. 0184
,♦ I t. BUILDING PROJEc"r willSI'IFICATION ' . _
HUILDINGADDRIESS: SANITARY NO API'hICAI'111N SIJIiN1i'fl'Ah UAII
.1p1�„� APRIIA�NA�}yJ��]
O/�E�S 2 IJC noel qw�r mow/2•//o! CDNI'µ^LTpR�',S'N�11�'. i2 W V.�v ' V`
✓cK_,CTORS `C N/C CON'I'ROLp
MNRIUJIT�f&INF,LW ' LIC NO ADDRESS ���
CONTACT. �/•/']"xT PHONE BU ILDING�PEElRMIT INFO
61eNh G�tkoo►t/�f /7.lwr EJ Consultant Fees Paid by Applicant(Initial) UC ELECT PLII In NIECH
LICENSED CONTRACTOR'S DECLARATION it I I ' f
IQTY ELECTRIC PkiRM1llT' 1 TEE
1 hereby affirm that 1 am heemeJ under provmmm of Chapter 9(commencing :' .t•r:. . . t '. I JOB DESCRIPTION
Q P•Z
FOwdsn+Cale,aJ my lmenm L.
O
fail force and edem PERMIT ISSUANCE h SFDWL ❑KITCHEN REMODEL
r Ub- IALensc Class loo
6 U I AI'I'LIANCES-RESIUENI'IAl, I A DITION E]PLUMBING RIiPIPIE
NZwj Cn'S Ze.r '
Don RC F.CI'S Dr:CLwRAT10N PANELS ❑MULTI-UNIT ❑MODIF'ICATIO
IZO Z IunderswnJmyplau+ha l bemeda+publrercanrds MODIFICATION
IpZ-q UI'T021X1AMI,S ❑INTERIOR ❑CHININ17Y REPAIR
F+�F-LLl I"emed Probe...nnal„ 201-100DAMPS IMPROVEENIENT El SWIMMING POOLS
OWNI?N-BUILDER DECLARAi'ION OVER 1000AWS\ \ ❑RAT II REMODI7IJR1EPAIR ❑UFNIGIATLON
C C�Q 1 hereby affirm thm I em exempt from the Contractor'+License Law for th_ — \`
04 V reason
halowful ,ISeuum]1111.5,Bioiial,nn I Prnlcona,Code Any coy sir clmmY SIGNS Id,ECI RIC 11 I D OTHER
t+l y which requires a perms to enmwn,ide,improve,Jemohsh,antenna any someone -- - ` P A ' D
pnormsSce...ce,alsnrequarcatheapphcam for CoM1remnnmMeo sgned+mteaneatl SI'F.CIALCIRCUITIM ' i
that ncing wait pSnuuna toahe provnisionf(he eBusinessandProf Law Is Code"'
W4'g0 (commencing with Secaon]IX")of Division of the Business wit Professions CalO or TEMP.MLTER OR W)LE IN.
4yx e eG Ihut he in exempt therctrnm and the h.nn for the alleged exemption Any viofit,of ❑bH W 1215.' QWWt;f1.LTiON
Wpm Section 7011.5 by any applicant for it Perms scums the applicant)a civil pcnulty of POWER DEVICES El TENANT •x LJI DSIeRVICE
.F. Y ntmarcaban rive hundred doll",($500I
QQLasawnerol the pro"it",my employees with wages as(heir soic conapensa,, SWIMMING I'OOLIiLfECTRIC, LNI�'f�(+�V'' 'r"TGUrtHIIN(I
will do the work.and fi a awaure n not ltnended or offered for sale(See 7 W,Resins^ �OTIIIiN
I L °m
and Professions Code.The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIX'OURES
progeny who builds or Improves thereon,and who dues such work ham(elf nr thmugl
his own employees,pmvide!that such atop...emems are not more ed or oRemJ for NEW RESIDENTIAL E LECTR .AFL
sale.If,however.the banking al Improvement is sold xnhm sine yearofeamplennn,the SQ IT PLOORARIEA S/SQ FT.
owner-budderwill have thelumen ofrrovmgthathedadrat IwJdorimpmec for par- {T y" � "{►—�/s���,
pose of"
Fl 1. Aal
owner nl the property,am exdusrvdy aamrashng with Ilcawed nmuactory in ,•,Iw +1 i�7_
construct the Project(Sec.]DW,Business and Professions Code)The Contractors Li-
Se Law doe,not apply to anowner ntpoTpeny who hudds or improve. hersomamd IQTy.' :, . . •.i PLUMBING PERMIT '` .V •',I FEE f
whneontrets for such pmlecn with acnntractorls)licensed Punuanunthe Qmuactors
t Llcensc law.
I am exempt under Sec ,651'C far th is asvvan l I'IiRMII'ISSUANCF:
Owner Date ALTER-DRAIN S VENT-WATER LEA) ��UATIONI''�
WORKER'S COMPENSATION UIECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under Penalty of Penury one of the following declamunn+:
[have and will roanlaan a CefllfiC.LIC of Currant to Self-manrc liar WnderS Cnmpen- DRAINS-FLOOR,ROOF,AREA, )� STORIES TYPE CONS'fRDCI'IOP
cation,as provided for by Section 3]118 of the labor Cale,tar the perfnnnance of Ili. a t
work Ear w"Lh this permit is issued. ITXTURES-E'ER TRAP
have and will muma5m Workers Compenamann Insuruncc,w required by Sadao
J]OOafthe WMr Cad[,Forum Eafamemeofthe work for whnh Chas pennnnnsucd, GAS-HA SYSTEM-I INC.d OUTLE';ir > / n I OCC.GROUP APN
My Worker s Compensaima lnsumnc[camer i na Policy number are
C
Carner Pn icy No GAS-LEA SYSTENt-OVER41FAI
CERTIFICATE?OF EXEMI4I IBOM WORKERS' 14q I
GONIPE 'ATION 't1RANC1? ❑REASP./INIIUSTRI.WASTE INTERCEPTOR ` E DIVISION FEEL'S
(Thos SCcaon nee amp wilifthe nmtnfnrune hundmaddall.($1(NH l�
rl Sa a GREASE?TRAP PLANCHEC "By that pi, or .ne o theworkl r Ixht non is issued,I shall SEWER-SANITARY-STORM P.A.20017. �j
tea I y ism n sty a . ob cu a Workers'Can,,. PN[Rf1 �
ton n G i m WAIFR HEAIIER W/VFNT/IiI.F.C'I'R GRADING ITE/
w phca t a s t
'Z' h N ICE a aIN t Cenl cat f E,o mpoon,you should WATER SYSTIENITNIEATING
a ; became t t One Worker'+ ' cation the Luber Code,you must SOILS FEE
s Jm a sip rmvasaanu
0.1 ra forthwith ply nh such pmva ms or thus perms shall moil revoked WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDIENTIALi'LMe, SQ FI', II'A 10
U 0 I hereby affirm that there is a construction lending agency for the Performance of I Dale
r Ihewodforwhlchthnperm U,i..ued(Sec 3097,Cis.C.) (V\
D.I Lender's Nam-
Lender's Ail^•^ , �/'— V1 /'
a. O BUILDING IgiLV /
a i cemlly that 1 have mad this application and vale th t the above mfnrmmaon u ,• r ,( I _
h comet.I agree to comply with all city and county ordinance end sate laws rclatingto QTY MECHANICAL PERMIT ,FEE.
U hmlJmg amawctmn,and hereby nuilaonze repreandmc>nt W+nty in aterary it the '1,', ! I �I' I. •' SIi1$N1IG FEE
ahnvomenooncd pmpeny for Inspection Ou T es. 1�
We)agree rT sore,inA std Aa charmless the C y of Cupemm�eguma I'ERNfI'1'1551JANCIE I IELECIRiC
1 In a u dgmenlS,costa m whlab say in any way "me oat smA Clty ALTEER OR AIID TU MECII. PLDNIRIN qBi ^� It
c1 d'm'the an of n rmaL
OUR E I'OUNAT�('TSAN S. f%ILL .IMPLY sLl NON-POINT AIRIIANDIANGUNH(TII MAX)CFMI NIECHANICALFEIi
AIR HANDLING ONITHIVER UMMCFM) CONSTRUCT ION TAX
SI�lfatureofA IaatnUCmunwao Date EXHAUSTHOODUKIDUCT) HOUSING Ad I'IGA'I'ION FE
HAZARDOUS ATE I SDISCL(ISURE
Will the Iicant or once buildmgt ea am st co r h,He ezomous mammal REAI ING UNIT fIO l 0000"BT1L
as defined by the upertmo Municipal Cale, after 9 12,and th Health and Safes, 1
Code,Sea x255. 1114 BEAT NO IJ NIT(OVER I(NI,IXN111*1'D
E]Y. 0 N
VENI'ILATIUN FAN SINGLE RP PAID_SiDI I Dent Recemt
\ Will the applicant or future building occupeni use equipma t or devices which
it hmardom air contammants a defined by the Bay Area Aar Quality Management BOILIER-COMP(3HP OR 100,000 BTU)
Y Y I '1'OI'AL:I
a Igrict'
' I ;OILik-COMPIOVPR III,(RI if rut
]Yes No, _
I have lead the hazenl......temd.m is under Chu ter 695 of he Ceti- AIR CONDII'IONIiR ISSUANCE DATE
.25533n
fnmu Health n Safety
ntr centrally ha e.tend 25505,25531 and 2553) i to mfitand that tithe I NEW RESIDENTIAL MF.CIi SQ.PT.
t of the os Jnesnends which hurt be met of toisuaceofit ihdnytoeo fOccupirO..lavoltaliparl
of the r�mmmentx which moat M met pnnnn issuance of n Certificate nl fkcupancy. I
r
Owner oro finumeA agent Dam IIy, J UPS)BY:
OFFICE