S 2034 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU
BUILDING-F.LF.CTRIG\I, PE' °NO 2034
BUILDING DIVISIGN API'LICAT'IONfl'F.RMIT PLUMPUNC-MECHANICAL
45A r
RUII,IFINO PROARC'T IDENT'IFIC'ATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
-b AE /RAZ �d /�/ s - - , �.s
OWNER'SN ME: /(ALONG CONTR °R'. ME: ('� LIC NO:
BIC CONTRDI.N
RCF /E GNEER; LIC NO: ADDRESS ❑ �y1
7- + sS c z z ( gyp
SCONTACT: ZVI ptlorvE; BUILDING PERMIT INTO
A / , �r 9 CD ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB _ MUCH�
(r /LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby uflirm Was 1 ata IiccnseJ under provisions of Chapter 9(commencing JOB DESCRIPTION
0092 win iro Sadon]axB nfDlvlston3Mtha Uusiness unci rmfessians Crdc.end my liccmei% RESIDENTIAL;
YI p p PERMIT ISSUANCE
Wf, License
ftwr. Ix }� ❑SFDWL ❑KITCHPLUMBiNREMODEL
E-VZU License Class IX'unnuchur APp1,IgNCES-RESIDENTIAL C1 ADDITION ❑PLUMBING RE-Plpli
F d C. Dom T'S DECLARATION
to a ❑MUl:fl-UNIT [I STRUCTURAL
ARCHITECTS UF:CLARA'HON MODIFICATION
' !-.7y PANIPIS
1 and crxtmd m mans stroll be nsW us Public recoNe
y UI"T021p AMPS
�Z�O
2 [I INTERIOR C1 CHIMNEY REPAIR
Fio,1-
Licensed Pmfessiona! 201-I000AMP5 IMPROVEMENT ODEMOLSWIMMING
TION S
�wo W,,j End I..BUILDER UIPCe Contractors
ontr ON OVER 1000 AMPS E)BATH REMODEIJRF.PAIR DEMOLITION
C Q I hereby v0{nn on I.S.exemnt from the Cssions Code:
:Anyc Law for We
6 U following requires
a fermis t ]onstrct.alncs.c and improve,
Professions demolish,Or epair ay os nanrY SIGNS ELECTRICAL ❑OTHIPR
a1.3 LL h which its iss n a permit also re uimWtl,alma improve,hpermittnr repair any statcture —
ement
F W'OQ poor but he its ixsunncgrsuant to The the
ovisiosofcant for Contrarminofilcaicense Law
SPECIAL CIRCUIT'/MISC.
y shat he incing wJ pursuant 7")of Division 3 of BeBusiness
Licenseelaw(s Code)9
,yp0 (Announcing withSection
had
the
Dlviaion3 the.11Fasincssand Professions Code)Or 'TEMP.METER OR POLE INST COMMERCIAL
6 W�y' that he is exempt therefrom and fhe basis for the ss dad applicant
to Any vinmally of ❑NEW BLDG/AUDITION El DEMOLITION
�"y Section 101 IS by any npplicam far a PenniT suhjauthe vpplicanuoacivil pewlty of POWER DEVICES *2-6
4rrERINT ❑FOODSERVICE
cr t room Than Eve hundred dollars(8510). IMPROVEMENT
2a2C Las owner of the Pmpeny,or my emPlnyees with wager mtheir sole cnmpencmtion, SWIMMING POOL ELECTRIC EI OTHER
W wdl do the work,and the stricture is not intended ormomd for sah,(Sec.]IW4,Bush s'•nd Prfessions Code:The COneucnrfs License law does not apply man owner OEM LIDS-SWITCHES-FIXTUREproperty who builds or improves thereon,and who Jots such work himself or Wrou m his own em In eel,prnvidu!That such Improvemets are not meanded or Offered for NEW RIPS I[)ENTIAL ELECTRP Y SQ.t1'.F AREA $/5Q.FT.owner-builder will have the huNen of proving that he did not build or improve for pur-
poscorsale.y 0I,as Owner of the prupeny,am exclusively commeting wish licensed com amors To construct the project(See.7X4.Rusinessand Professions CWe:)The Contractor's Li-law does oat applym an owner Of property who huiids or improves thereon,and QTY. PLUMBING PERMI �"
who contracts for such projca wlTh a contraemr(r)IicensW puramot m the Commnor's ri �e
License law. PERMIT ISSUANCE
❑I am exempt under Sec. .R&P C for dis reason
III` ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date a 3 o o
co
WORKER'S COMPENSATION DECLARATION BACK FLOW PR(R'IPCf.DEVICE
1 herchy no-,-under phuh,Of perjury one of We following declarations:
I hnvc nnJ will meindrdn aCenifinte of Cnnum nm sulf-insvc Por Wary•es Compcn- DRAINS-FLOOR.ROOF.ARIDA,COND. STORIES TYPE.CONSTRUCTION
Totino,os pmvidW Lor by Sution 3]00 of We Wbor Gxla,for the performance ofthe o
od,far which this Peron is Twain. `JC' la e
0 1 have and will maintain Workers Coumpensation Insurance,m rect ired by Scc/1n ^
3700n1 the Labor Coda,for The penonnoneeofthe work f which his permit is is.cued. C A.SY. I NCAO LETS L`` OCC GROUP APN
My shark nm enaminn sumo¢ d Policy nundsrurt: - It
Carrier rt policy No.: G .S.SYST'EMOVER4(I4A)
CF.RT119CATE OP .XEMIq'ION FROM WORKERS' G $EIl16GgTR1. SSEtlU1LDING DIVISION FEES
:PTOR
COMPENSATION INSURANCE
(Dissection neW not ho ntmpldnlif she Permit isfmonchunlreddoilws(S100) G ASETRAP
Or leas.) I'IANCHECK PIAT
I certify that in The performance Of The work for which this l cont is issued,Island S 'R-SANITARY-STORM IPA.210 F. ^J
not employ uny Iwrsnn in any manner sn w m he<nmesubjat To roti Workers'Compere ENERGY PEI J 2 e, 0
Z ration laws Of Ca iberion.Date I:U
z 0 Applicata --_ GRADING
-
h NOTICE T°APPLICAM':IL after making this Cenihcmc of Eaemntinn,>nu should WATER SYSTEMRREATING SOILS .E -
a ; haeotne subject to the Wedam-a Compensation provisions Of The labor Cole,you must
r,.. forthwith comply wish such provisions or this permit shall b,deemed revoked. WATER SERVICE
QPAID
iz) z CONSTRUCT ION LENDING A017NCY NEW BESIIESFIAL PLMIL SQ.IT. Date Receipt
U I hereby affirm thanbere iso cons8ucoort loading agency for the perfonnmet of
".— the work for which This permit Is issued(Sea.3097,Cm.C.) 'TOTAL:
O U lenders Name
L1a Lendee,Address T
"tiIr 1 ceni fy Orr I have mad this application and sate that the above information is BUILT NG PEE (D g
F.I fail comen.I agreemcomply with allcity and countynrdievnae and elate la—mIsangto QTY. MECHANICAL PERMIT FEE SETS FBE S
U 2 building construction.and hereby aushmix representatives of his city in enter upon the t
above-dannioned property for palpation pmpnsec. PERM]IISSUANCE, ELECfRI :EL' O
(We)agree to save,indemnify and keep stainless The City of Cupcnino against
liabilities,judgments.costs and expenses which may in any way accrue against said Co ALTER OR ADD TO MF.CH. ( DID 1,11 JMBING PEE
cunaequenecafthegranti Of ispctmit.
[CANT UNDERS'TA S NO WE _COMPLY W'I'I'H ALL NO TOIN' AIR HANDLING UNIT(TO IILaOCPM) M[CHANICAI.FEIi
S-URC. GULATO
AIR HANDLING UNITP)VER TO."CFM) CONSTRUCTION TAX
SII, atureu pplicanVCon cu D:a EXHAUSTHOOD(W/UUCT) HOUSING MI'HGATION FTS
HAZA US MATEIH DIS OSURE
Will the applicam orfmurc huildmI,occur or handle hvandous material HEATING UNIT(TO lfplxO BTU)
as defined!by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety ❑IPATING UNIT(OVER 1a1,1xx1 BTU)
Code,Section 25532(a)'1
Dyes [I No VENTILATION PAN(SINGLE RESID) a PAID
Data Recaiptk
Will she applicam or fumrc bnilJinI,acupant use equipmentor devices which BOILER-COMP(31f1'OR 100.000BTU7
emir hamrdous air a nwminnnts as&FIred by the Bay Arca Air Quality Managemont TOTAL:
Districts BOILER-COMP(OVER 100,1100 RTU)
❑Yes 0 N
I have read the hazardous materials requirements We,Chapter 6.95 of the Celi- AIR CONDITIONER ISSUANCE DATE
fomiu Health&Safety Code,Sution%25505,25533 and 25534.1 understand shat if the NIPW RESIDHNTIALMECH, SQ.
building does natemparady lave a mnam,had it is my msponsibi[hy m notify the noaupain G�
of the requiroments which must to met Than m issuanam of a Certificate of Oaupuncy.
Owner or authorized ngem Data A. ISSUED N
OFFICE