S 1835 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO OUHAUNG-IA.EC'I'RICAI, Pitt I No. 1835
RUILDING DIVISION APPLICATION/PERMIT PLUMNINO-.MECHANICAL.
BOII.DING PROJECT IIIEIVEIFICATION
BUILDING
ADDRF_SS! SAN)pARY NO, APPLICAIION SUBMITTAI.DAII
EL
3( r� .9a
OWNIIRS NAME-: /PIfONh?: CONTRACTOR'S NAME: LIC NO:
J LJa S ti3 . 3 d SIC COONNTROI.a
ARCIIfHiCf/IiNGINEE[1 LIC NO: ADDRESS: ❑ x y O
R C,--IFf767 Z Vl C
CON A` cy A A... A, I PHONE: /- IIUILDING PERMIT INFO
1r- `� eT/�T' kr'/V`7 q9G-.QA,At Y/ ❑ Consultant Fees Paid by Applicant(initial) RIJ,G I']= PLUMB MI CH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
witn sed
I hereby amen maatt I ala licensed
aidde Prov
r]aro)ofnivm 3 nnen ein am Pensions of chapter 9(commencing JOB DESCRIPTION
es
mfesainnv CMe,and my licauc is R�EN'1'IAL,
WOp PERMI'1'ISSIIANCti
W F In full lura and even. .FDJV{ ❑KITCHEN REMODEL
U Licenw Class Lich F
6 U APPLIANCES-RIiSIDI!N'1IAI, DITION ❑PLUMP WG RE-PIPE
hc Q WW Dee Comfactor
F.7y ARC[HIECES DKCLARATION PANEIS ❑MULTI-UNIT' ❑SI'RUC'LURAI,
pm Z_ I understand my plans shall he used as public reuadx MODIFICATION
Z UPTO2W AMPS
F-�.F'.EZ Li,ra,cd Promsinnul El INTERIOR ❑CHIMNBNG POOR
2 OVER
Ih1PROVEMENT ❑DEMOd-SWIMILAINGPOOLS
C C Q 1 hereby Lubin dw,OWNER heUILII3ER I)1 the C nnu�n r'.License Law I"or the OVER Io00 AMPS ❑ TO]REMODHIJREPAIR ❑UF.MOLITION
❑x13 LL U following Leasure,(Section 7031.5.Bu%ino and Profession%Cade:Any city or county SIGNS EI.HCfRICAI. OTHER
y¢ which%.quirea Instil m ummaucl,alersllnpmvc,thin n..lLsh,or repair any swcwre
pnor to its issuance.also require%the applicant for such penotto file a signed xetemen SPECLM,CI RCUITIMISC.
Fes} Lha file is Iiccan ned pursuanit,me,ii,,,i,nsof the Cenlraaa'n License l.aw(Chapter 9
�1'QD 0comnsnciog with Section 71)(00)of Division 3 of the Business and Profession.Code)or TEM P.MISER OR POLE INS'I'. COMMF,RCIAI:
a 4 e yr that he is esumpt theretrot;and IIIc basis for the alleged escnnplioa.Any violation of El NFW BLDGIADDITIO?I [I DIiMOLITION/"
Section 7031.5 by uny.,,Iirm fill.permit.aubjects the applicant too civil penalty of POWER DEVICES ❑'FENAN'1' ❑FOODSERVICE
noln:onedean five hindreldollars(S500), IMPROVEMENT
H yZQ ❑ 1 as owner of the property.or my employees with x-age%as their vise compensation. SWIMMING POOI.ELECTRIC
will dollar work.and fhe,rocantoonol intcndcdinottered fnraule(See 7044.limine,, ❑OTH17R
630, and I'rofmaions Code:The Control License Use does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who nutldwr in+pmvca mnrom,Land who Aon such work banelfor through
his own employees,provided that such improvements are not ieended or offered for NEW KS
ID TIAL ELF;CT R SQ Er
,.It.11,M1nwcvcr,the be dim,on improvement is mold withi none year of completion,the SQ.IT.FLOOR AREA S/SQ_Fr.
owner will hese the burden of proving that he did not build or improve for put- _
pea c,is ow.)_ /��
r of the progeny,am exclusively contracting with IirenttJ romrvcusm m L: ! J IV/
efnetiraet the project(See.9044.Bnaimn%s and professions Code:)The Conaactor'x U"
ea Law does n0l apply to an.,net of progeny who build,or improves meson,and QTY. P 11RI •LIMIT ITE
,he comntel%fur%Len nrojean wins a gnnmcmtr%)%sensed pmrstanl tome Cm:trai
Urease Law. PERMIT ISSUANCE / D
❑Iron clean or Sea ,11&PC fulhi%n- :
ALTER-DRAIN&VENT-WATER MA)
VAI.W41ON
x Dam
WOR K12R'S COMM ENSATION DECLARATION, BACK R.OW PROTECT.DEVICE rOO�
ncrI rchYaffrm under penally of perjury one of the follow ing decimations J
❑ In: xandwilDmaintainnCeniicmeof Con%cnttosdf-insured,Workers CompNn- Z DRAINS-FLOOR,ROOK AREA.GOND. Q
%cion,as provided for by Section 37M at the IatMa Code,for the performance of the STORIES TYPE CONS I'RUC'I'ION
work Lor which Thi%permit is ko,N, PIXTURFS-PER"TRAP
❑ I have and will maintain Workers Compen%mion Insurance,;is required by Section
3110of the LaMV C:dc,l imnhe performance of We work for whichuld, mm,it issued. GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GHOUL' APN
My Workers Compmmurne
eation Iac carrier and Policy number r,
Carr,.: Policy No.: GAS-CA.SYSTEM OVER 41BM
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRILAS[VINDUSTRI.WASTE IN'FERCCPTOR
OpIld,etion need not be completed lithe permit is forms,hundred dollars IS had BUILDINGDIVISIONPEES �J
or lcn.%.1 GREASE'I'RAI' PLANCHFCK FEE
Icy any me in the any imenecoas t becioork newhich this the Workr,'Colshall,co- SIiWER-SANITARY-STORMEA.201117r. V
I'll,cngaoy any peraun In any n;anncr soon to becntm xuhjmm m me Workcn'Compno- ENERGY FEE I ��
C) seionlaa.of Califernm me WATERIIENLERW/VENT/ELECTR i
z A,plinmt GRADING IEE
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSI ENG BEATING
hews.subject io me Worker's Compensation.....visions of the Lnhor Code,you moa SOILS FEEj
pJ forthwith romply with such provis;,ns or lhis permit shallMdeancd rtwked. WATER S1?RVICE
Uz CONSTRUCTION].ENDING AGENCY NEW RESIDEYFIAh?LMB. tiV.FI'. PAID
C.1p kf.,eby,hfch thL,,themela..ed(Sce.30]ending agency litmeperlonnwcaof Date kms IX
UInc work for whicM1 ems permit is ic%ued(Sec.409],Civ.C.)
0 U LcndcLx Name TAE:
} Jammer'%Address AL:
I tend,mol I leave read On,ap,lu, o and%tete Itnu me above infonnadnn is BUILDINGE
IF. tai) coney lamrece,comply wim a 11 city and county widinancee and Lae laws retain,to QTY. MECHANICAL PERMIT FEE
U z building conewainn,and hereby aumnri,c,c,mxwraaivesnl m6,ily e:Enter upon me aMme-Inen0i,ned progeny for inspveion yrpoaxPERMIT ISSUANCE 1 WOn,m.to ,oc.indemnify andkeep harmless the City of Cupcnino Lgainsl u .Eliubilities.Judgnents,cons and expenses which may in any way accrue against said City ALTERORADDTOMECII c2 - n a. nw,m ncc ofthe srmming ofmix permitAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT rAIR fIANIJLING UNIT(TO IO,faroCITOLFEE70
lOURCIi R[GULAT ION,. 1 17.AIR HANDLING ON]F(OVER 10.000 CFM) [10N�PA%
Signature of Applaam,Contmnar Dame EXHAUST HOOD(W/DUCT) IIOUSINC MITIOAfION PEE
HAZARDOUS MATERIAI.S DISCI.OSIJRIi
Wdllhea,herator fuwre huilAing mwcupam atom or banJlchaallous material HEMINGUNTr(TO110,001111)
as defiacd by the Cupertino Municipal C d,Chapter 9.12,and the Health and Safety
Cale,Section 25532(.)? HEAL ING UNIT(OVER 10(y100 BTU)
❑Yes C]No
VEN'I'II-XI'(ON PAN(SINGLE REMD) LAID
`
Will thea applicant or future building Date Receipt X
pP 6 ilecapuBay Am.
AnQualli,devices BOILER-COMP QHP OR 110.10OBTU)
mit hamrd,m wf conmminams m ddined by the Buy Area Air Quality Management
UiamOIDistrict?
❑Yes 7 N BOILER-COME(OVER 101,010[1 OUL
I have mead Ilio hazard,nxmatcriu6 reuiremcet%under Chatter 6.95 of the Cal i- DITION ER
4 P AIR CONISSUANCE DATI3
Turbo Hcalm&Salay Code,Semiuns 355115,25533 and 25544.1 undemmnJ aha if mo NEW RESIDENT IAL MECIL SI}FI'. o /J
hifffisgmoncent,weiclinme ammnnt.Ihalnie...renfaCimfi, cmfymence,y,
ohne myuirememr whicM1 moat M and pminr m isxmance of a Ceniticum of(,cups^cy. U
Owner nr mahoved a,cnl DamT 'I'AL: ISSUED BY
OFFICE