50073 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO " BUILDING-ELECTRICAL PERMrrNO. r)�,3.
H1111 OFC DIVISION APPLICATIONOTERMIT PLUMBING-MECHANICAL. �+
BUILDING PROJECT IDENTIFICATION
sU1LUING ADURPtiS: I ` ' 1 SANITARY N APPLICATION SURh11TTAl.DATEi
Ohh'Fl-r)14 LOOP , Nov�l, Wlno� .4 4 p0bo� Cuper�,,, a..
NF 'SNAMIi: 1 P ONE: CONTRACTOR'S NAME: LICNO:
Ip p N� IIL CO� N},Qr �NC. SIC CONTROL is
` \RCI Tr.0 GINEER: ILICN ADDRESS ❑
v e �y$0C, �'ot4 Gt
CONTACT: PHONE: EUILDING PERMIT INFO
�d S I n 9g m q °)7 16q ❑ Consultant Fees Paid by Applicant(Initial)e_., PLECT PLUMP DCII
LICENSED CONT'RACTOR'S DECLARATION QTY ELECTRIC PERM'TI hereby affnn that I am licensed ander pmvionss of chapter 9(mmmeocg JOB DESCRIPTION
Oa'Z withSemim7molof Division3of the Rosiness ane Profession Code,and my license is AL:
Pf;RMI'1'ISSUANCE;in full fora andcll'ca. ❑KITCHIiN REMODEL.OutLicenm Class Li"M APPLIANCES-RUSIDENT'AL ❑PLUMBING RE-PIPE
Datc Cnntmcmr l' ❑STRUCTURAL
ARCHITECTS DECLARATIONm PANELS MODIFICATION
Zp-ZunJecsuWmyplant shall henx+l uspuM1llcresortsOZ.-Q 111"102110 AMT'S � ❑INfl?BLOB El CHIMNEY REPAIR
I-4.F:M Licensed Profcssinnot 201-IE(YAMFS IMPROVEMENT SWIMMING POOLS
qY OWNER-RUILDER DECLARATION I{IrfiiR ("I
aJC J OVER IINNIAMPS ❑BATH RIiA10 x4 gs/y DEMOLITION
Q I hereby u(Sect on I vat eRuna from the Contractors a License Law coli my
pal,O F V following reamer(Section](omism Runaround and Professions Code:Any tiny or county SIGNS F.LCCENICAL ❑(7fHIiR
4134- which requires,a permit h)conswck vloq improve,demolish,or repair any stmnurc
to prior fn it,ismaree,alsorepife,thcupplitmo for such permdito flic.dgned statement SI'I[CIAL CIRCUIT/MISC. 4W-6
_
ay� ,j that he is licensed pursuant to the provisions of the Commena's License Umc Chapter 9 ����
41�G0 (commencing with Section 7(M)of Division 3 villas Business and Professions Coca)or TIiMR MITER OR POLE INST. I`1i W-6U
d 6 c that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of �UI Ny ❑DEMOLITION
1 Section 7031.5 by anyapplicem for i pcnnitsobjecal Ne applicant to a civil penalty of POWER DI:VICfS 'CN Ti�1'�- tI,1�FOOD SERVICE
w not more Than five hundred dollars($5IX11. V
Ez0 ❑I,mnwmcrofinepmpeny,or myempoyces with wages as Neirsole compensation, WIMMINGPOOLELF.CfItIC PROVHMBNT
_ will do the work,and the towns.is am intended mothered for sale(Sm.](W,Business ❑OTHE
63 m
and Professions,Code:The Continences License law does not opply m an owner of JT1.1'I'$-SWI'ICIIFS-FIXTORFS
property who Lish,or improves thereon;and who does such work himself or through
his own employees,provided that such improverecros ore not intended or oficrW for NEW RESIDENTIAL ELECUt SQ FT.
sale.IL howcveo the building or impmvemem is sold within one year Scompletion.the $Q,FT.FLOORARF.A S/SQ.Pf.
etif'suJer will have the burden of proving ntm he did not build or improve for per- _Baa 2 O�
own ID �'�(/ 7
pose of solo.). l
❑consumer property,.l exclusively cvimmeins Cad licensed orator& i- `� TOTAL:
meLathe es jaa(See.7(94.owner
of and Professions Ghor imphevaN diecror's nd
o conwJnetnouch plr nun owner-ofpmpeny who
sedporlmpmvea ConneutJ CITY. PLUMB PERMIT FF.F.
who conanmt lin such projects with a cnnavemgM licensed pursuant m the Cnn¢ucmr's t
License Law. PER MIT ISSUANCE
Iunh• hp un j See ,B&PC nr his.'son
w ACI'RIt-DRAIN&VENT.-WA 'R(LA) VALUATION
—
Do"
W( KIiR'S COMI`ENSATION D. LARATION BACK FLOW PROTECT.DEVICE
Ihcrchy aflin mderpenalty ofperjuryoneo efollowingdeclnmmirs.avcmmD {a yL-V
�JlhunJ willnwimvin uCcnifcatcnfCmmes -insure for Workers Compah- DRAINS-I1.00R RODE AREA, . STORIES TYPE CONST RUCTION
.orlon,as provieed for by Sitcom 3700 of the Inbar Glide,for the perPormanve of the
work!nr which this pennir is issuul. 1'IX'TURNS-PER TRAP
❑ I have and will maintain Worker's Compensation Imumnce,is required by Section -
3t00oftheLabor Code,for the perfmmnncc of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number ere: _
Carrier. . Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CHKI'IFICATI?OF EXEMPTION FROM WORKERS' GRPASFIINUUSTRI.WASTE INTERCIiPfOR
COMPENSATION INSURANCE li ell 1.G I ON FEES
fDhissection need not beconspleedifNeperstit isformichundredduliun(SIM) GREASETRAP
nr less.) PIANCIIEC ai `LA /P
OLy that in no fur esud.I shall yEWER-SANITARY-STORM EA. FT
nun employ any Canon in anymanner so as to become subject to the Workers'Counter.
F
znws of California Date WATER III?AIER WNENTELECTR NFR Il
ZApplicant GRN EE
rNi NOTICE TO APPLICANT:If,atom making this Certificate of of Exemption,Cod you should WKTER SYS'IT?M/fREATING SOILS PEE
(~ bur subjectto the Workers Conn or this provisions of the LaborCNB,you most
Gakl� forthwith comply with wet provisions or permit shall be deemed revoked WATER SERVICE
Q
� Z C(1LENDINGAGENCY
f NEW RESIDENTIAL PLMDSQ.FT. PAID
Doc ReceiptM
Iherehy union that Ibcm is comwaln leading agency loo heprfomnfneeo
U ntc wink Poli which fills permit is issued(See.3097,Civ.C.)
Lender's Nnmc TOTAL:
0 �. Centers Addrsst - T A.:
yyf ly cenil'y that 1 have acre this,application nN late that the above information Isis NG FFE
RUiIA
F-f is
h correct,I agree to comply with vol city and county ordinances and sone lows ofaling to QTY. MECIIANICALPERMTT Pf
U Z huileingcnnsamlion,undherchyvuthorie mpresenolivesafthiscloyoenrerupanthc SI?IS IC d'I?E
above-mamboed propcny for inspection purposes"' PERMIT ISSUANCE
(We)agree as sale.i ndcmni fy and keep hamtesnhe City of Coped into against I:LHCI' 'EE
liabilities,judgments,costs and expenses which may in any way uceme against said City phIALTUR OR ADD TO MUCH.
in conscyuence of the groping of this peormt. Pl.UM11RING PE.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON-POINT AR HANDLING UNIT TO 10,000 CFbU
MECHANICAL PEE
SOURCE REGULATIONS
AIR HANDLING UNIT(OVER 10,000 CFM) CONS'I'RUCfION TAX
Signum.of ApplicaMCmmomor Date EXHAUST GOOD(W/DUCrI
HOUSING MITIGATION F i
HA%ARDOUS MATERIALS DISCLOSURE
Will the applicant Olt future building occupant score carhaMle hazabloua material HEATING UNIT(TO IOBIXM BTU)
as defied by the Cupertino Municipal Cede,Chapter 9.12,and the Health and Safety
Cods,Section 25512(a)? HEATING UNIT(OVER 100,000 BTU)
❑Yet Fl No VFN'I'ILA'I'[ON FANS INGLE RESID) PAID
Date RecciplN
y WJJlthe applicant or future defused occupby the nt Bay Arco Air Qualitment of y
ManaiCes gement
RGILER-COMP(3HP OR I(M,OW BTU)
mit hmaNnus air nmominunts as JefneJ by the Bay Arent Air Quality Managemcm � - TOTAL:
uistrlci l
❑Yes 0 N 1101 LER-COMP(OVER 100,100 RTU)
I baverwJ Om bar vJous nfnlaivls rcquiremems under Ch,m,r6A5mfthc Cali. AIR CONDITIONER ISSUANCE DATF
Ruin 11.111,&Safety Cnde,Scvlir 25505,25533 and 25534.1 unecoond that if the NEW RESUMN'I Al.M1121. SQ.PC
building duel nnf currently have a onaot,than it Ls my responsibility to nmify Ilse occupant
of fire rcyuiremcmn which most be oeipri s,to ismance of a Certificate of Occupancy.
Owncroruohnriredngcnr - Date T ISSUED BY:
OFFICE