S 1634 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT,PEN ONLY
CITY OF CUPER'1'INO BUILDING.-Edd UPRICAL ve rr No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL 1634
BUILDING PROIECr BkE.N FICA' ION*
BUILDING ADDDRES5: SANIT'ARYNG. AI'I'I.ICAI'[ON
NSSUUBMI'TIAL DAIF
11H
(1W 'S NAM1f E: Dec �� 1�S. E: CON'I'IIAG,I(llt'S Ah11i: LI(',NO '21
�' ^ s '1 / ry2'�L NIC CONFROL#
ARCHITECrIE 'NI!1!R: • , f` LIC No•',L/ ADDRESS, 10 UJ ❑
�y I
CONIACC PHONE: BUILDING PIiRA71T INFO
❑ Conind ant Fees Paid by Applicant(Initial) HLDG HLFC'IPLUMB MHCH
11 ElLICENSED CONI PACT ORS DECLARATION QTY. ELECTRIC PERMIT FEL'
I hereby mBmm that I 1 1 lirencen ureter pmvidmms m Cla ar,v beonnnencing JOB DESCRIPTION
O=Z with Section Inn)of Division J of the Business and elliom Gala and nay license is RESIDENTIAL:
tat O O �{ VERMI'I'ISSUANCE
1 v12 in full force and cfl'cn. r 3 I I Z ❑SFDWh ❑KI'I"CHER RIiMOOIiI.
aVV IJccnvc Clens IJu.# APPLIANCES-RESIDEN'T'IAL ❑ADEHION El PLUMBING R&PII'I?
inQw 0. Date S Contractor
❑to ARCHITECT'S DECLARATION PANELS ❑MUI.TI-UNI'[' ❑SrRUCFURAL
UP 10 200
[I INTERIOR 11
5��a Litt"`°I liaxlhyvdlirm OWN!nlBUH.Iwli�mo CIARAI IONh License l.nw lin the OVER 10WAMPS ❑NAI BATH REM N4L FPAIR ❑SWIMMING CHIMNEY
ON
Zo roan.. a pu
PS
REPAIR
C POOLS
ty 3 LL F Inllowing rcamn.IScctton A13 L5.Hu.itms.unJ I'mlcxsumx Calc:AnY sty nr county SIGNS r:1.liCfHICAL ❑(7I'HLN
y which mimics a,cone t m,omm c,almr,improve dcmofar,or repair any,membe
Q prior In it,issuancauho ret ull'I,'he applieml l'or-ch pcnnit ,,Glc iuignal nnvcnmm SPFCIN,CIRCUI'I'/MISC.
�.Ny� tha he I,licensed poouanno rhe provisions of the Contmctora License Law(Chapter 9
�ZO� (commencing w ith Section](XIH)nfDividon3of the Baunexnand l'mfaeions Code)or TFMP.METER OR PDCE INST. COMMERCIAh
d c. y that he is exert,,Ihemf ion and the heck for the ullepW rsernsien.Any violuuon of El NEW BLDGMIDDITION [IDIi1"t 1'ION
not mom five hundred dollars
a pcnnit mhjecH the uppGcantm a clvll penalty of POw1iN DEVICES ❑TENANT ❑I`GOD SERVICE
by I PP
dollen($5(MB.
OTHERVC\fENI'
m
< D I, nwner of the pmFcny,nr my employees with wages as their sale comry:nsation, SWIMM1IING N)Oh1!LF,CI"HTC
EZ� wdldw
orl n k,aml thexannremI
r . 'Ix . ne rnor ofFared lbrsalc(S,,.)Ildd,Hnculers ❑OTIINR
F
3 m
and .,who
Code.The Contractors;License Law,rtes not apply m an owner
of (]OTLIiLS-SN'IT'CHES-PI%TURES
n,I"Y who builds or impmvcs thcrcon.and who Jens such work deed o,or through
his w nminycus,pnrvidnl hat such Ilnpms so ld w me not iyearotd or Arae,for NEW NI!SIUF,N'1'IAI.ELECfH SQ17
cads lE m,we..r.mo nwdingaritnpmvelnem i.sold whnin one yens ara,nmre3on.Bre SQ,17.FLOOR AREA g/sQ.Fr.
owner-builder ww have the burden of proving that he did not Wild or improve for par.
Rrsc nfnnlc.).
1,us vwncr of me propcny,am uaclusrvcly rnnmsting with Ilanncd convectors It, 'r0'IAL:
mwuct the project(Sec.7(94,Hminc.s and Professions Code:)Me Contractors Li p w '
me law dtvx not apply to an owner of pmpe y who build,or impmvcs theme ,unit QTY. PLUh1RINGP 1'T FEE r M
wbn mmmc.fnrwJmpmjxb wimuvunnncnrtvl licensed per tan.mthc Gnumeor.
License Law. PERhll'1'ISSUANCIi 1
C3 1.,It emerpt under Sec. .B k P C for this reamu
ALTER-DRAIN k WING'-N'AHiR IA VALIJAI'ION
Owner [)am /.
WORKER'S COMPENSATION DECLARATION HACK FLOWPROTECT UI!VICE Cltl I�I nU
I hcodt,al,bounaren under Penalty
iLwafl,Cornu.ofmchmowing decWork...0 /
want,
andwilll for
Section 3700 of the IsmCode.fml'm performance
of the URAINS-FLOOR,RG01',AREA.COND. STORIES TYPHCONS'I'RUC'IIUN
smirk,o. hick provided for ri 5s isi u J]Ip of Nc IaMr Gde,for the pcdormnncc of the
ark for which this pemtitis orkcr PIXTURI!S-PI!R TRAP
❑ Ihmcand ,Iformnirtmicire ,f'a -crotnLie work
whihralnocdby Scotian
97I0 of Lubarl:alc fur the puronnuna of the work furwhich lM1ly permit uixcucJ. GAS-IiA.SYS'I'IiM-I INC.,OVI'LETS OCC.GROUP AI'N
My Weaker'.Compensation Insurance carrier and Policy number are
Curried Policy'i GAS-IA.SYSTEM OVER 4(EA)
CI!IffIFICA[Ii Of I XI MVI ION FROM WORKERS'
COMPENSATION INSURANCE GREASEIN'DUSI'RL N'AS'I L INTIiRCEPTOR
BUILDING DIVISION IBES
(This taction need not xu,mpletm ante permit is for one hundred mtnhn 61 uB
or Icss.l CR&ASG:'CRA(' PLANCI HICK PSIS
I candy that in the performance of the work for which this permit is isrmk I shall SEV,ER-SAN]ARY-S'FORM EA.300 I.-C
not employ any rytvon in any man .1 'It 'lc xnbjecno the Workers'Compcn- ENERGY IPE
Z cation lawsyfCahto@' Unlc `'1I WATER IIT?TTEII W/VP.N'I'/ELECfIi
Z O A,gs,ant 'r'e kf�N U� CSS r Q GRADING PEE
NOTICE'fO APPI,ICAN'T.If.after making this Certificate of Exemption.you should NATER SYSTE\VfHEATING
(✓ ? incentive subject m the Worker's Contpenvann pea .mon.of the Labor Gde,you most SOHN FEE
� �.... fnnhwimh amnply with sbsh,00,i,i( nrthlslmnnn\hdl be deetum revoked. WAT ER SERVICE
a0
CONS'IRisact LENDING AGENCY NEW RI!SIDF,NTIAL PLATE SV fT PAID
T hereby affirm that lM1am I'
mn(Secion lending agency fat the Perfi.I'nl:mm of Duh
r le
the word furwhich thh,emit is'recd(Sec.J(Yl].
U. F" Landers Nmnc TOTAL:
V Lcndcr's AJdrms TOTAL:
aW I emfy tnul I have read this application md.stnm Ihm the aMwe iel tenon is li U1LD1NG Pli'
E' (A earns,l agree et comply with all city and county andiwnac.s and state law%norm,a' QTY MSCI IANICAL PERMIT FEIi
VZ building contraction,and hereby authorize repmwrativcx of this city to enter upenthe SEISMIC .Ii
nbovo- Nolo'ned prnl en,fie inspection p0rposee. T'1!RM (ISSUANCE
(We)agree to save,indemnily and keep hared...the City of Cupertino against Ii1.I[CfH 'IBiE
70
Iiabilltics,judgmcnts.costs and expenses which may in any way uccrucagainsuaid City ALTER OR ADD TO SEC](. PLIJhf Hlh,143E
in atttlua¢c or'he grunting of t1Js permit.
APPLICANT CINDERS LANDS AND WILL COMPLY WITH ASI,NON-POINT AIR HANDLING UNTI TO 100)0 CFM)
SOURCIi R",ULAI'10N4 M1tl!CHANIL\1.FEE
5-x-98 AIR HANDLINGUNIT(OVER f1,ah)CFM) CONS'IRUC'TON'IAX
SignmumofApplicand memernr D.I. EXHAUST HGOO OttmuCI) HOUSING%it CATION FET!
HAZARDOUS MATER AI S DISCLOSURE
Willtheoprplirmn or hllnre building nccnpant aomor ib n lie halaNul.e mwcrval HEATING UNI'I'('101 a),0a)[IT(]f
as definat by the Cupertino Municipal Corte.Chapter 9.13,and the Health and Safety
Code,lection 25532nd? / HEATING UNIT(OVER I ,(M B'['U3
cs [J
VRNI ILArION IAN(SINGLE RESIDI PAID
e Will the o Bram m furore building t Aro e - t or devices which Uum Recnpt x
applicant Sttccupan equipment HOILER-COAtI'11HP OR IW.IXMI BTU)mit ha'mNous air comummana as JdnrJ by the Bq Arca Air Quality Management
Dixloctl' Torn :
0Y" ,__/ BOILER-COMP(OVER HXI.UUIIB'T'U)
It...mad the Lnxanln I,m:nerlals egn1notenw under Chapmr 495 nI IIm Cult AIR CONDITIONER
I'SUANCF;DAA'li
forma HezIlth&Safety Code.Sections 35505,25513 and 25537.1 understand that if the NEW RESIDENTIAL MI CH. SQ,IT.
buildingdmv not curmmly have a mnam,that it is nay responsibility to notify the occupant
of the re4uirctnen,whim mint M met prior to issuance ul a Certificate of O¢ap:mcy,
Owner or amhnt3eed agent Dam TOTAL: I ISSUED BY:
OFFICE