S 1682 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
'rl'OF CUPEwrINO BUILDING-HLF,CTRICAL � 111,1811''NO.
BUILDING DIVISION APPLICATION/1"ERMIT PIUMBUR:-MECHANICAL 1 6 8 2
BUIIAING i`ROJRC'1'ID4:NTIFICAI'lDN
�'l1.DINC�� �' /i � SANITARY NO.�PPLICAUON SUItNI'I"1'AI.LAI
n R'S ANTE: _ I(LN ll/JII�COONN`'TRACI ORS NA- LIC NO: ���
In`/I{/nl/ NAL COON}TRROLL 1X�
,n I FFEC1'/ENGINEER: LICNO'. AU ESS: ❑ �% —
CONTACT. PHONE: BUII-DING PERMIT INFO (��
_ � ` ^1 ❑ Corgallanl Fccs Paid by Applicant(Initial) LD �LECf P� MECH
LICENSED CONTRACrI15:9 DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby%than thin 1 am licensed and,.pravi.am,of chapter v%.massing JOB DESCRIPTION
O with Seclhm 71Xg1of D.,Won3 of the ursine%,and Pntrmdnm Cuda and my limosis is VIiRMI'I'ISSUANCIi RESIDENTIAL:
Fly,- in full torrential ekem. ❑ 'DWI. ❑KITCHEN REMODEL
aUV I,imnsC Class Lick APPLIANCES-RESIDEDUAL DITION ❑PLUMBING RE-PIPE
NZ W Dan Commaor
F7N ARCHI'I ITC1"S DECLARATION PANELS MULTI-UNIT ❑STRUCTURAL
ZOyZ I undervand my plon,%hall be used a.public(%cords MODIFICATION
UPT02(m AMPS
OZ^O ❑INTEk10R ❑CHIMNEY RIiPA1R
F�Fu1 LieensCJ l'rnfessionnl III-I(X MPS _ IMPROVEMENT ❑SWIMMINGPOOLS
6 1 hemby vffrm Ito Nlamtlxnupf 3frun't he C mm�or's License Low 11h, VE IM)AMPS ( ❑BATH REMODEI/REPAIR ❑DEMOLITION
X3LLFfolloing re m_Nectlon]0315.Bi sines and Ptafic ns C,wle:Any citym ELI: ICAL -` _- ❑OTHER
whish requites a permit In rnnnmet,aIle,im,m,r.den relish,e,Icpair any 11 F Wionoiu issuuncc.also reyuims Nc aPPlicanl lonuchN miuolile%signed stn ALCWaf ,3 IndhC is Revised pfsoanrto the provisions of The Cenuacmr'a License law(ChasW�00 (commencing with Section 71100)ofDlvlslon 3 ofthe Benin,and l'mfessionsC iM Iii OR IY)1S' COMMERCIAL:a C that he Is exempt Ihcrefmnl and the basis fr the ullegcJ exemption.Any al% I m sow ❑NEW BLDG/ADDITION ❑DEMOLITION
X^u Session 7131.5 by any applicant for a permit subjects the applicant m a civil lered,of LOWER DEllrrS-
W ❑TENANT ❑FOUR)SERVICE
F,zy nnlnmre than live hundred dollars($500), IMPROVEMENT
Q ❑1.¢c owner nfthe propvny,or my employcexwith wngcs:u their rode tttmpcnsminn, SWIMMING POOL ELECT RIC
Sys 4=.m will Jo the work.and thextracmm is not intended or offered for sale(Sec."/LIN.Business ❑OTHER
L3^ and Profession%Cade:Tic Contractors License Law does not apply to an owner of OUTLETS-SW I Cl lits-FIX'I UR,
Too who builds or Improves thereon,and who doe such wmk himself nr da gh
his own employers,provided that such improvements arc not imm�dcA nr offered fie NEW RESIDENTIAL ELECT R SQ FI'.
sale.IL lmwever,the building or improvement is sold within one year ofcompletion.theSQ.FI'.FLOOR AREA Il F1'.
rnhuilde,will have the burden of proving(hal le,did an bald or improve for pur- Cock-11% 001 ^ Yy 1
of tale). l(-J11
I,nc owner nr the property,am CoC1a%ivuly contracting with licensed contractors to
a the project(Sec.70,14,Business and Professions CMCJ The Contractors Ii-
"IenivoLawdoesnmapplyntanawaarot'pnaf any who hailm or improves thereon.and QTY. FLU BI ERMIT FEE
who contracts for such projects with v conTmc(oa,)licensed pursuant to the Contractors
I-m nue Lau'. PERMIT ISSUANCE
\ ❑ Ism exempt under Sao. ,B&PC for this mason
-1
tarer AITER-DRAIN&Vii (ISA) VALUATION
� Dara
CRS COMPENSATION DEC RATION RACK FLOW PROTECT DEVICE 6"7 -78
1 hereby affirm under penalty of perjury one of the following declwouo, LLL
❑ I hastened will maintain.Csmficmeof Cmmrmmsnlf-insure for Workers Camper- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'IYPG CONSTRUCTIC
nation,as prnvidud for by Section 37(X1 of the labor Code,for the NK ranee of the
work for which this mm,is i...ink FIXTURES-PER TRAP
❑ 1 have and will nminmin Workers Cuntpeasumn Insurance,as required by Station
3700nOhC WtmrCMe,for the Nlformance of the work for which this Noah is issued GAS-IiA.SYSTEM-]INC.4 OUTLETS OCC.GROUI'�J ANY
MYWorker'%Compensation Insurance carrier and Policy number an: � �
Carrion Policy No.: HAS-IiA SYSTEM OVER 4(ISN
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRl.WAST F.IN rl,RCEFIT)R
(I'his section need not bet completed ifthe peamiTis tonic hundred dollam(SI00) - WILD DIVISION FELLS
or less.) GREASE TRAP PIANCHECK FE' �1
I comity that in The leAamunceofthe work for which this permit is issued,lsball SIiW1iR-SANITARY-STORM I.A.NXI PI'. so
no(vmploy any person in any mantras so ns 10 econu.abjec(m the Worker,Cnntpcn- ENERGY FEF,
OZ 'min.Laws mf Califoorm.Dam NATER HEALER W/VONT/ELF,CfR'
Z O Applicant GRADING PER
NOr[CF.DO APPLICANT If,offer making this CCnificum of Exemption,you%hoold WATER SYS'I EN FPREA'TING
C > become subject to the Worker's Comperetem provisions of The Labor Code,you most SOILS LER
forthwith comply with...to provision or Thi, .,it shall be JmmcA revoked. WATER SERVICE
Z CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL 1'LA1H. SQ.FI' PAID
U O kforsoywth Ild bm..at isac,1S,,,30 lending agency for The perfnmuncc of Ume Reec
� F the work for whicM1(Inis permi(is issued lSuc.AT9],CivGI
OMIecr's Name 'TOTAL
Lender,Address
E" y 1 comfy that I have read This application trod sum that The above interaction'. �. BUILDING FEE
co!) codes(.)agree bt ermply with all city and county oMinance%and-%was mwnremTingto QTY. MECHANICAL PERMIT FEE
U Z laiding comweion,and Tachy authentic nprescmmivesof this city m cmeru.mfhe SFISM ,1'4i
abneanen(ioneJ 0,roperty far impostion purprscs. ` PF.RNIII'ISSUANCE
(We)agree nt... IMenmiry and keep hamilcs the City of Cu"ma against ` ELIiCI' 'it `
Iiabiluic..)uJgnoult costs andex nay in any wayaccmc again%,said City ALTER OR ADD IOMECI1.
i To nseyuencc of The gmmin6yyyyyy is Nnnit, PLIC C '.
APPLICANT UNDERSI'A S AND W'11.L C(MPLY WINI ALL NON-POINT AIR HANDLING UN XI CF ) 1/7
SOU ULATIONg IECIA (CAI,Fit, �• 1 `s'
AIR HA, D Gl1NIT1 11,111X1 , ) CO. f HUC 1101 TAX
m AppliemmCom ah, Y' IO EXI4AUS 1)(W/UUCT) f10USING MI"r ATION FEEtL\Z,g1tD0115 Nil AI'ERIAL: IS'L(1SUkE
Will lbeupplicam ar Tamm building wcup nrhmdle by:¢Jou.m:eeriul HHA'HNG MTO kliIALDB )
as defined by the Cupertino Municipal Cala Chapter9A2,and the Health and Safety
Code.Section 25532(.)' HEATING I'(OVER T(X),(XX)11 N1
❑Yes ❑No
VCN"rILA'FR FAN(SINGLE RESID PAIU
Will the applicant or future building occupant use cyuip scut or devices which Dore Receipt k
hvmilous air aaNnninrml%ns damned Thy Ibe ILy Arco Air Qualify Management BOILER-C(1 I ,14X1 BTU)
mi( an
0Dis(fic,I TOTAL.
�Yr, E]NC BOII.HR-COMP(OVI?R 100,00I)BTU,
I h a T IM1 b N I I' AIR CONDI(IONEN
y I: J Ch'pt fi)5 IIM1 Culi� ISSUANCi: DATE
fomi Health&Sfty1 S5c1 2110125531 J SSi41 d T ldr TOc NEWRI SIDIiN'r1ALMECH. SUFI / -2 - 7-
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