S 1749 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,CI'RICAL PEtll'NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 1749
BUILDING PROJECT IDEN'TIFICAT'ION
BUILDINGADDRESS. SANITARY N(1. APPLICATION SUBMITTAL DATE
X23 �t�5�c7CLp
Pn A '1038 d?j (�EI3
OWNB 'S ley. i K-1' N t' CONTRA RlS NAM11 E: e LIC NO:
`G �s0, NIC CONTROL It
•I ARCURECf1ENGINEER: I.ICNO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) th III.EQ' PLUMB M1�I
LICENSED CONTRACTOR S DECLARATION QTY ELECTRIC PERMPI' FEE ❑ PTIj``
1 fill anion IIIat 1.,it licensed ander Pownioreof Chapter 9mmeing
lsoneJOB DESCRIPTION
BOZO isish Scctinn]IXXI t 3nf the Bnsiressand Pm^fcsi�� CA Jmylicensc is PIERMII'LSSUANCE RESIDENTIAL:
�1y� nfull lbrccnndc 0 ❑SPDWh I'CHEN REMODEL
Q UU License Class Liex APPLIANCES-RESIDENU AL ❑ADDITION �LUMBING RE-PIPIT
tF Q C Date of ala
A . (ITP S %T ❑AfD1.T1-UNIT C1 STRUCTURAL
F ,t z I w umm�s my p ens,tall used Public c PANELS MODIFICATION
C)Z-n t UPT0200AMI'S El INTERIOR ❑CHIMNEY REPAIR
F-�F-W Lnlnwd 11..fesoored 201-10WAMPS iPR0VF.MIEN.7 []SWIMMING POOLS
S,yE_ OWNER-BUILDER DECLARATION OVER Into AMPS •TH RIih10D1?(/REPAIR [I DEMOLITION
5 0.Q I herehy aBirm that 1 am exempt fntm the Contreurrs License Law for the
3 W UE. billowing rccoon.(Section]11.31 5,Buenas and Professions Code:Alt,city or mal tY SIGNS EhECI'RICgI. 0114Elin which requires,,tenni,m...nsvnct.Auer,nnprove,demolish.m rerydr airy shroma,
�Q
prior o its issuance.also requires the applicant lot such permit to file a signed statement SPECIAL Cl RCUIUMISC.
that he is licensed pu,,.art to the It..marvel Cementite,License Lsw,(Chapter9
�C<p fcommemcing with Semion]IXNII of Ui.isinn3nfthe Rusinasmnd Professinvs Ctdc)nr 'LEAP.ME i IIiR OR POhE INST COMMERCIAL:
0.0. that he is exempt Ihcrcloon and the basis births ulle,at cstra,u nn.Any vlohdio III ❑NEW RLDG/ADDITION ❑DEMIILITION
WSection 9031.5 by any applivent fora permit%miNcsthe a"Heam toes civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
nrethfive hardluddollan(55001.
E=0 nnman IMPROVEMENT
C]1.as owner of the pmpenY•or my employees with wages its their sole compcnsaion. SWIMMING POOL ELECTRIC []OTHER
F. willdmhework,andheamemrc is not ineendedmnRnmd bailout,(See 7(4f,Buse
C w and 11 l'wsimir Curie:The Cnntrnnnr's Liceme Law dose,not apply m nn own^rof Oil I].I.I$-SWITCHES-FIXTURES
6 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements me not intended or offered for NEW RESIDENTIAL ELIEC!R SQ FT.
sale.IL howcventhe buildingor lmpro,cledissold within one ycansf completion.me SQ.ITPLOORAR. fl ElS/SQ.Em
r-builder will have the burden(if Proving that he did oat hand or itnpnrve Tia par- J
po a of-ealy). V(/
L.
L an owner of the prupcny,am exclusively announcing with licensed cnmrac on un
onuam the project(Sec.71114.Bu,i...%and Profession Cmlen The Communis Li- yy�� Y YEly
c law does not apply to an owner of propcny who builds or imevunhcrenn.and QTY. PLUMBINoLt]F1V11' EE �'`
.It aonvactsfnrxneh pra,,n,withacontmdugs)filmset pursuanuothe Contractor, I if IIJH�
License I,aw, PIERMIT ISSUANCE
❑ I am exempt under Sec. ,B&PCfonhi,am,,m Np
AI:1'Er.R-DRAIN&VENT-WATER(IEA or VALUA'T'ION
Ovencr Da
• WORKER'S COM of nomr,ONDECLNtAT1ON BACKFLOWPROTECI'.OEVICIE
1 hereby alliin under Certify of perjury ane of the insury mg Worker Tom: ES
❑(rn. ,pro,ide maintain ation 3700of ConsentaCAR,fare for Worker's Crmpcm DRAINS-FtOOR.RIX)E AREA.COND' STORIES TYI'Ii CUNSTRUCflO}
smirk,ur provided for io Sermon 3](p of the labor CAR,for the performance of the
work Thr which this Imnnit is insucd, FIX'1'URP_S-I'ICR TRA('
❑ I have and will ncentlem IN..on,Conywns dun]a...unce.as retptircd by Section
0-
3700(it the labor Code.for the p ndormuccof the work for which this Permit is issued GAS-EA.SYSTEM-I INC.4 OUTLITS OCC.GROUP APN
M,Wmrkd C�t�}J� � 7mce carrier and Policy number ate:
�Tansr. - Te Policy No GAS- SVST M-UVIER4(EAJ
CERTIIICA'1'L'OI*EXIEM I"HONPROMWORKERS' CRFASPIINUUSTRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION PHIS
(TTis.seeliallneedkothecomplmN o ffic Permit Esforamehundreddo11ars06100) CREASERAP
or less) YLANCHCCK FEE
I eenibrinn inthe perfmrmanee nfthe work for which this permit is island.[,fall SEWIER-SANITARY-S'H)RM EA,21111 FP
not employ any pernkn in any manner at ns n,becone,subject to the Workers'Cmtpen- ENERGY I EE
O Z nation law,of CUHbar ire.Date NATER IIIEA'1'ER WNENTELEC R Hili
Z O A,,licca GRADING
NOTICETO APPLICANT:If,after making this Ci nifiene of Esempuon,you should WATER SYSI'EM/BEATING SOILS FEE
(•` bean..otese,m the Worker's Cn Ter a i..n........it ill the labor Cad^,you nnut
{0. forthwith comply with such pncisioo or this permiuhall be deemed revoked. WATER SERVICE
n.
U� ' CONSTRUCTION LENDING AG
ENCY
NEW RESIDENTIAL PLNH. SQ,17. PAID
C) I mthat here,is.emtlendingaiseny further pmfomunm of
� work for which lhi,pcnnitis Liston]](S,,.3097,Cie.C.)
Leaders Data c' 'pt
Name TOTAL:
U LcndcrAndre
I s
T
ronify Tum I have read this rep..licaion and stem Lha the aMwc information is � 1 BUILDING FE
I �
Fi VA correct.I agree it)ttmtply with nil city and urntnty ormnaneen and state luws rclaing w QTY. MECHANICAL.PERMIT FEE
U Z building crn,wction,and hereby authorize r cosentmive,lib tu
this city to SEISMIC Bee
aMwclnennoned Romeny for im,lorm p.,,,n' PIERMIT ISSUANCE
OVc)agree hisave.indemnify and keep I:umlca the City of CuPertqkio�n+a�gainst ELECTRIC FEE
flnuditie.jadgments.ai and expenses which may in any way acemcagei-�Ci AUFBR OR ADD'TONIECH.
...sifuncnofthe orntir,ol this permit. '////��tt PLUMBING EP.e
APPLICANT UNDERSTANDS AND WILL COMPLY WITH myxN 1 AIR HANDLING UNI'f(1010,000 CFM( MF,CIIANICAL EF.
SOL' REGULATI
ONS
. /'/fes/'% �I�SV�'
AIR HANDLING UNIT(OVER 10.NpCFM) CON$TRUC INTAX
Signature of Applicant/Crntucntr [).in 17XIIAUST HOOD(WIDUCI) HOUSING MUDGNU EE
HAZARDOUS MA9'ERIA S DISCLOSURE
Will the applicant or future builiikgtecupaut uorc-fondle barallons material DEALING UNIT(TO 100,00)BTU)
as defined by the CuPenino Municipal Code.Chapter 9.12,and the Ilcalth and Safety
Code,Section 25532(n)^. IEA'PING UNIT(OVER H00,000 BTU)
Cl Yes ❑No P 11)
VEND ILAf1ON FAN(SINGLE BESIDE Dam Rcca)
Will the applicant or future Wilding occupant use equipment lir devices which
e
mit haonnous air contaminants as defatcd by the Bay Area Air Quality Management BOILER-COMP(3HP OR I00,000 B'N) 'TOTAL;
District'!
0Ye, Nn BOILER-COMP(OVER In11,1XN1 N'1'U)
I have read the hmardouc materials requirements tanker Chapter is 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
form^Health&Safety Ccdc,Secnlom 25505,25533 and 25534.1 undervand that If the NEW RESIDENTIAL MECH. SQ.FI�
building does not enrrcely haven tenant,lint it it my m,lnm,ibillrym notify the occupant
of the requiremem.,which el h met far ,I ie mnce life CenEli,an of Occupancy.
Owner or mutual ted agent Cam TOTAL: ISSUED BY:
OFFICE