S 2531 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,R'1'INO ]III IL.U:N(:-FLEC'I'RICA L PIeIt MI I'NO,
BUILDING DIVISION APPLICATION/PF,RMIT PLUM R OJECTIIDEN1ICN. S 2531
II1111.DIN1:I'RIIJIiCI'IDL:N'I'IFIG'I'IUN
BUILDING ADDRESS SANITARY NIL nl'I'LICAI'ION SUIT MII'I'n I.DNI 17
/O ,/56y Merrirrmm Rd
OW -3361
5�;. PVh eh 1'H�0S-.262 CON'IRACIORIS'V�/;M Pfr / �SGOh
CULEC'FANIC CON'I'RUI.p ARINOINFER: LIC NII: ADIPKI-SS /V� / /124V ❑
ooA,¢roerBl.�p 8A)ch
CONTACr. I'll NE: BUILDING PERMITINFO
pYv ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELI:C`l FLDMR MECll
aAAA pe,:Lw. .69410 ❑ ❑ ❑
LICENSED CONTRACTOR:S DECLARATION Q'pY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
n=Z with SmOon IlXX))adnividoa 3ofthe Business and prof siom Code,amn,accuse rs RESIDENTIAL'
ulpp ys�3 rrltnllT lssunNrl:
CSF in full form and etre ❑$(DWI. ❑KI'TCIIP.N Rh:MOUICh
9UU License APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMNING HI PIPE
F Z ty Dam Contactor
moa ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F m Z 1 unJcrmanJ in 1 h II de u.md as Public rnroN., PANEL S MODIFICATION
ZOps� Ypan,s a UI'TO 2INIAMI'S
OZ- ❑INTERIOR C1 CHIMNEY REPAIR
Y.�FW Licensed Professional NII-HXMAMCS IMI'ROVIiMISNT E]SWIMMING POOLS
C C-� OWNER-BUILDER DECLARATIONOVER I(XX)AMPS ❑BATH REMODFI/REPAIR El DEMOLITION
Q I hereby affirm that 1 am exempt from the Contractor's License Law fetch,
KO6F. followingrea.nn.(Section 7031.5.liminess and Professions CMc Any city or county SIGNS FLEM RICA]. ❑(ffH1iR
ul3 C)F.. which requires a commit m construct.alter,improve,demolish,or repair any structure
F'a�; Prot t . I. q :m ppT tf hpe 't turnnam'nent SPECIAL CIRCUI I/MISC.
E } than licensed)p a thep of the C t t r l La (Chapter9 COMMERCIAL:
ad CL aO (commencing isth Section](XXB of Division 3 of the Business andl f.:' :Code)or T EMI'.M FI ER OR INHY 1 NST.
a d e C that he is exempt there!@@ and the nasi,for the alleged exempoonAny violation of ❑NEW FLOG/ADDITION ❑DI?MOLITION
X^m Section 7131.5 by any applicant for a mor, the applicantto a civil penalty of (OWER DEVICES ❑TENANT ❑FOOD SERVICE
not nmrc than five hundred dollars(85(X1). IMPROV EMILNT
ASO ❑Lasownerofthe prepeti myearpinyecs with wages a.,theirsulecnmpcmainn, SWIMMINGFOOLIi1-1iCI'RIC
P. will do the work.and the stmnure is nut intanJeJ lir oficred 4n.valc lSm.9Rk1,6usines> ❑OTIiIiR
C 3 w and Professions Cask:The Content Liceme Law aces not apply lit an owner of OUTl.lil'S-SN'll'CIIILS-IIXTU ..
property who builds or improves thereon,anter wbn Jnes such work himself lir through
own n emple,ce,provided that such improvements are not intended or oRemi for NEW RESIDENT[Al.ELEC!"R S
sale.If,howoan the building or improvement is sold within one year ofcrmplenon,me S0.FI'.ILWRAREA SM1Q.IT.
wner-builder will have the burden of pricing that he did not build or improve for pur-
pw ersalc.). 'RIVAL:
E]1,as owner of the property.am exclusively contracting with licensed contractors to
construct the e pmjmt(Sec.704L Business and Pmfes,ions C(Na)The Contractor's Li-
crew Lawdue.not apply loan ownerofpropeny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who comracn for such projects with a comricmrts)licensed pursuanuo the Contmctoh
Limns Lax'. PERMI IISSUANCE
I am exempt under Sec. .B&PC for this reason I I
ALTER-DRAIN&VI;NI'-WATER(UAE VN1L T ON J
Owner Dae
WORKHR'S COMPENSATION DECLARATION BACK FLAW PROF ECT.DEVICE
I hereby affect under,penally of perjury one oftha following declar iow: A O
Q l have and will maintain a Certificate of Comem mxi6insure for Worker's Cnntpcn- DRAINS-FLOOR.HOOP.AREA.COND. STORE: YI� S'I RUCTION
s tion,as provided for by Section 39(M of the Labor Code,for the performance of me
r which this permit is issued. PIKfUNIS-PER'IRAI'
r o it will maintain Workers Compensation Inmmnce,as required by Section
39Wn be Under for the perminummeeofhe work for 9w bh�ichprt�his Pemba is issued. GAS-Es.SYSITM-I INCJOITILFTS OCC.GROUP APN
My Carrier'I �tk/Cf UNag[,z eaaierand Pniky NoYn/TIl�Z�yg GAS-EA.SYS"rEM"OVER J EFA)
CERTIFICA'U?OF EXEMPTION FROM WORKERS' GRGASUINDUSTRL WASTE IMERCE2111OR
COMPENSATION INSURANCE BUILDING DIVISION FFIS
(Thissceinnncednmbecomplenal ifthcpemtit isfortmehundreidonaes($100) GREASE TRAP
I'f.ANC111iCK FEE
Foy any ahainthe mymnnerof the week for which do,thepermitWisivs'Comibni SIiN1iR-SAN]fARY-S'1ORhl lin.21X119'.
not employ any person in any manner as m become object m the Wnrkeri Cnmpen- ENERGY PER
Z satiric laws of Calderon..Date WATER NEATER W/V ENTXLECTR GRADING FEE
.�C) Applicant
NOTICE TO APPLICANT:H.after making this Ccnilicae of Exemption,you should WATER SYS Eon HEATING
N SOILS Plili
fvcnmc subject to the Workers Compensationprovisions of the Lala Cole,you masa
� Eforthwithforthwithcomply with such provisions tariffs
Pentair shall Mdecmnl revoked. WATIiR SERVICE
Q PAID
7z CONSTRUCT ION LENDING AGENCY NEW RESIDENTUM,PI.MH. SQ,17.. *117H
t4
1 hereby affirm that there is a construction lending agency for the perlimmunec of
- the work for which his parry,is issued(Sea.3097.Cis.C.) s
OLinder,Name ,�` TOTAL:
U Lender's AJdreo T(y1A1.: w
1rk..t 1 1 certify that I hm'e mai this application and state that the cursive infnmatinn is
Lh correct.l agree m comply with all city and county ordinances and Stam laws relating It) QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representatives of this city to enter upon the
above-mentioned property for'mspmtiun purposes. PERMIT ISSUANCE!(We)agree to save,indemnfy and keep hannle,,the Cry of Callum,againsthabiloies.Judgments,costs andeammses which may in anywayncemengainst said City ACI'ER OR ADUTO MECIL
in Asequence oflhe granting of this permit.
APPLICANT UNDERSTANDS AN 1)WILL COMPLY WITII ALL NON-1'01 NT AIR IIANDIANG ON['I'(To IBJXXI CFM) MECHANICAL FV;
SOURCE REGULATIONS.
AIR HANDLING UNI'I'(OVFR 11,0k)CFM) CONS'IRUGUON' X
SigaaturoofAPPlicvnVContracua Date EXHAUST 1I001)(W/DUCO HOUSING MITI GAI Ik FITE
HAZARDOUS MAI'HRIALS DISCLOSURE
Will the applicant or future building occupant,tore lir handle haeadom mamrial OEM INC,INTI(-I0 I(ANX)11'1'(1)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Seelion 2553201" IIHA'IIN I UNIT(OV FIR 100,000 If'I'U)
❑ye, k7 Nr VHN'IILATION VAN(SINGLE RCSID) PAID Fur Revi"a
Will the app}iea rfulum huildingrmcupant n,o,cquipmnn lir dealce,whish HDILIiR-C(IMI'OIII'OIt ltNkfXN1III'U)
mit hmardnm air mm
nlanant,as deGnetl by the Huy Area Alr QualityManagmncnt T(YD I
Disvial it,ILBp-(]OMp(GVCR❑nton)If1'U)
❑Yes OSin—
AIR(ONDI'1'IONER ISSUANCE DATE
II' Ith J 't ''I t. I CI'an ona fid 11 he
0 H'Itt &SftyC 1 e '255052s my 1255I41 I .t ItEt'I Ac NIeW ItaSIUIiNI'IAL n11iCI1, SQ I'I'.
ba 11 6J t' dyl 'n,lhad t Y ivs,ponsibil'yt fay the tocripcot
of the istpiran shm I 'rtre sett¢t. t'aC ,halo of(hatya ay.
Ownaro,call fmrlage t"—" IAau O'IAL: ISSUED Ry
OFFICE