9910012 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-CLECPRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUNIRING-MECHANICAL
BUILDING PROJECT IDENTIFICATION+
RLALDING ADDRESS SANITARY NO APPLICATION SUBM1'ITAI.DATE
./ 4vT- ' 0-4-
PHNF E �9
_ NIC (:ONTROI,p ,
ARCALFCT/ENGINIHER LIC NO 125A 4IMw!'c ❑
CGNTnCONTPHONE PuGN )BUILDING PERMIT INF0
❑ Consultant Fees Paid by Applicant(Initial) BLDO Lf:C PI UMB M/
I.ICI?NSEDCONTRACTOR'SUT:CI,ARA'I'ION ' QTY. ELECTRICPERNIIT�.r FEE,' ❑ ❑ J
I hereby affrtm that i am licensed under Pont anns of Chapter 9(n+mmennng I f JOB DESCRIPTION
"Z with Secuo 7")of Drviaan 3offhe BUabewand Professions Ede.end my beam,i. RESIDENTIAL
�cc I PERMIT ISSUANCE
�W F, a^f^Il i"'"r ❑SFDWI. ❑PLUMBING RE-PI EL
U - Ilcen I.I,.'# APPLIANCIJ-RESIUIiNT1Al. ❑ADDI'T'ION ❑PLUMBING RIi-PIPE
vFiQ1 Dam Con DELL /y��{
ARCHITECTS DECLARATION ,;• t / PANELS ❑MUEI7UNI'f C1 STRUCTURAL
ZO'73 1anknmdmy plar-h,dl ben.ed a.publlc records --] MODIFICATION
OZDD Ul"I'02UItnNIPS ❑INTERIOR ❑CHIMs iV REPAIR
F�fW [accused Probe sanne] 201-1000AMPS I IMP VHMEN'f []SWIMMINGPOOIS
9l) OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑B HREh10DE1JRIiPA1R DEMOLITION
"• 1 hereby altun,that I am cae.P,Item the CCnI,.tor'I hiccnse Lnw for ih
°O L U tollnwmg re mon.(Section]031.5,Busanet,send Przde..ions Cale AnY ca1Y or cnuntY SIGNS ELECTRICAL (TER
ty 3O which requires a parnat to comwct,der,unpmve,dcmnb.h.nr mpmr ony.uvnm /
F"� J pnvrmn.tsmanee.nlvoregmrealhe applicant fur-wch permm^fleaag^eJ•tateme^t SPECIAL CIRCUIT/MISC. V
C$L tvy�p' I hathea.heeo...I, III tIn the prnu+.aom nl the Cnntraclor'x Lneme Law'(Chilial"
^p0 (cnmmvnemg with Seem,. Dtvmm�3oflle Rmmev.nnJ Nalevsmm Cade)nr '1 EMP M HI ER OR TOILE INS'1. M .
C. e Y that bar,cum a therefrnce and the bop for the alleged csemluu.I Any vmi.omp t. ❑NEW BLDG/ADDITION ❑DEMOLITION
•'ny Section 7031.5 hy.^ty applicant far a paradl ublecn the applicant to a cavil pcnahyof POWER DEVICES []TENANT 0 17001)SERVICE.
olmare man rive hundred dollars($5001 -1Pnlavr:mm�n�
G=
It p Las owner of the prupeny,nr my empinyces xtlh x'ages as lhc:r sole um+pcnsaunn, SWIMMING POOL Iz LECTRIC /
�..0 wdl do the wnrA.anA thr.wnure isna mamdcd nruRereJfor sale lSer](W Benne., �O° t �
W 9 and Professions Cale The Commences Luense Law does not apply m an owner of f OUTLEIS-SWITCIIGS-,FIXTURES
pes property wM1n bu11JV ur+mpnaeex thereon,nnJ x'17^down mcd w...A notch ar Ihmngb k j
has own employees provided that such impmvemem,am not:mended or ollcretl Inr I NEW RIiSIDENT1AL ELECTR
vale If,hnweve%the building or impmsement is sold within one year ofran+pletion,the ti - irMT i RARER 199 IT
ouner,hualder%all have the hnnlm of proving that he dal not hwld or improve far pur- / ll l
❑1.s owner of the pmpenY•um eula.Ndy ronvaceng xnh hcensetl a+mracmn m I 'fOTAI,C
verse Lo the es min (Sec.vats,wnerof.and ny who iane Cadra The Contractors and .) • „
c se Low does rim apply tomnwnend properly hmlJ.nnmprovesthercon,and lQTY• !}, ': j, PLUMBING PF.RhI1T' '(;' I •>�. By
who contracts for such prejeas with a contractors)licensed purmanf m the Contractor, '
Laenm lsw PERMI'1'ISSUANCE
❑ Iamexcmpt order See ,H&PCfor lh+s reason
MITER-DEAN&VENT-WAFER RA) /pALOAI'ION
nor Darn I S
WORKER'S COMPENSATION DECLARATION HACK PI-OW PROTECT'.DEVICE
P Ihetaby affirm under penalty of perjury one of the h+llnx'ang declarations.
1 have end will nmmlmn a Ccrokalc of Conwnuo wl1-lnanm Inr WarArr's Cnm
❑ fwro (]RAINS-FLOOR.ROLE,AREA,COND 'pi SIORIIiS I'\'I'IiCONSTRl1CTION
worn,av isch provided for by Se ... ?]0(1 nl the Labor Codc,fur the performance of Ili. I
[have lhn pcmuna orke PIXNRES-PER TRAP .
work❑ 1 have and xall mumum n, ,ros mintpmrcaonn Insurance,m regmrnJ by Seuasl 1 ppFF/T
3]t1W it f.uMa Cod.,fnrlhc prrfccmuncc nl the I Inr whmh Wls purmn an asincJ GAS-IiA SYSIIiM-I INC 4(rUTLE IS ULC GROUP
My WnrAeT.T Compenaeonn lnwmnce came'anup al ey?9p her 'Lnjilp r
Canter ' ZL�� yo No:{Q Z (Y GAS-EA.SYSTEM OVERiIIiAI
CERTIFICATE OFEXEMPFION FROM WORKERS' GRF,ASPIINDUSTRI.WASTIi INI'F.RCEI'IOR
COMPIINSAFIONINSUI(ANCE
RUILUINO )I VISIU ,
('Thrs sechnn neW rim ha enmpleleJ of the Iwmnl n farnnc hunolrctl Jull,us($11X)1
ar lessl OR PSI:TRAP 1'LANCHIiCK FF.F.
[scary thmnnthe perfrnm:mcenl the work for x huh ihi.perms+......J,I dial SIiWF.R-SANI'I'ANV-STORM HA 2(x11T
not employ any penon in any number so tom become whaled o,the WnrkcrJ Comryn- ENERGY Itlili
OZ ,storm Ciphlormil.Data WATER IIIiATER W/VF.NT/ELIiCfR
Q Applicant ) (GRADING PEE
VT NGTICH'10 APPLICANT 11,alter maAmg this Cerulicam al lixcmponn,you should WATER SYSTEM/I'RHATING'
a ; hecamc wb)em to the Worker'.Compen.aitmn pnw.auns of the labne Gdq you most
tiU11.5 PIIIi -
QBartwlthcomply wish such pnrv.arms or his permnvhall lc dermal recalled. WATER SERVICE
Z CONSIRUCT10N LENDER!AGENCY NEW RESIDENTIAL PLMR. SO FI' (PAID
V z I hereby affirm that the.I.aromuumion lending agency for the psrhnararn,al 1 Date Il"a"IIs
wF the work for which(has permun issued(See 309],C1v C)
Lenders Nam- TOTAL:
Wlender.Addrea TOTAL: -
pr.,•Po I comfy that 1 base reptilian,applicehon and aim thanhe above anlorm3 on i. 1 Ii1111AING PI?li
h concert.Lngreemd+mplyxmh died,andcounrynrdmanees and slam 1pxsrdaong I QTY MECHANICAL PFIRAIT FEE. '
building construction,and hereby aathodre reprcsenlames of this city n+enter upon the t - - smstpuC FEC
utwvc-mentumeJ pmpeny for m.pecoon purpwes. 1'F.RMI'I'ISSIJANCIi
(We)agree to sane,mdcmmfy and keep halonvo the City of Cupertmn against HLECTRIC PER
hahalitms)udgaren.,casts and expenses which may In my way.wcme against said City ALTER OR ADD10 MECH.
mgr¢nce of the granluty or this a rn o PLUMBING FEE
APPLICANT UNUERS'fANDS AND WILL COMPLY WITH ALL NON-POI NI' AIR HANDLING UNIT('IY)10,IXXI CFMI MECHA N[CAL FEE
SOI CF.RF.GULAI'IONS _
•�,_�/[pi}- _ rr/T1 AIR HANDL]NG UNIT(OVER 10,M)CFM I CONSTRUCTION TAX
Sgneare of Appl....t]Conlmemr bate !XHA US]'HOOD fW/DUCT) I IOUSING M I'I'IGA'FION FEE
HAZARDOUS MATERIALS DISCLOSURE _
Will theapplicant in fumrebuldmgaceupmntnre or handiehreardots material HEATING UNITOO RIB000 BTU)
as defined by the Cnpcmnu Monle+pai Code,Chapter 9.12,and the Health unI Sadcly
Cale,Section 25532(^)^ []CIA]INC.UNIT(OVER 100k0010 BTU)
❑Yes "No I (PAID
VENT[hATION PAN SINGLE RISIU) -
W111 the applicant or Intone IvOdlng twcupaal n®equipment or devices wlndt Dele Rem I a
earn hmeNnw aircontaariitanl.a,defined by the 11.1 Arca Air Guabry Mnnagenum BOILER-COMPI7HP OR IIXI,IYq B'i'UI
Dr.dtr.
❑Yes a No BOILER-COM P(OVER 100,000 BTU)
I harallous mamnels regmrenxms mnMr Chapern95 of the Cui- AIR CONU'IIONI R ISSUANCE DA� ?—
Inscoedme
lomm Health&Safety Cale,Secuams 25N15,25573 and 25534 1 under.und that tithe NEW RESIDENTIAL.NIECE. SO IT
of me g dabs ion oarzcntly...I a tenant,that n a..my re of li C ably 10 r u fy the owcapanl
of me{mrcmenN xlnch must he met pnonn nsmncc of a Cenlficam of(ACUpancy.
Ownenn autbonmd agent Dale TOTAL (ISSUED us' -
OFFICE'