S 1454 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IIUII.DIN'(:-FILELTRIC\L I'liR!\SIT NO
BUILDING DIVISION APPLICA,TON�PERM IT _ PLUMNI Nf.-MECHANICAL XJ 1454
BUILDING PROJECT IDENTIFICATION
OUIhUING ADDIt IitiS: SAN[PARY NO. APPLICAI'10N SUBMIITALDAIJ!
at//OWNERS AME: 1 IONS: CONT$ACI'ON:ti NAME: EJC NO:
N/C CONT Hill.al
•ARC 1'1' :NCINIiIiR: LIC NO: ADURF.SS: ❑
CON'I'AC'I': PHONE BUILDING PERMIT'INFO
d yj-�1/) ❑ COnsultanl Fees Paid by Applicant(Initial) BLDG BLI!CI' PIAMII MECII
LICENSED CONI RACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm[bar 1 am neetnxed under provisions of Chapter 9(commenentg JOB DESCRIFa'I'ION
WOZ withSeaun 7b)(notlFvisinn 3nrme Ballniv oualPraf ,amm Chok.mal my license ix RESIDENTIAL:
W p p1iHN11I'ISSUANCE
t,'2 t nal ra,c,,m1 pelf ❑bm3w1, ❑Krrcm:N REMonH1.
9zU hic,me Claes Lica AI'I'LIANCES-RESIDEN'I']At, []ADDITION ❑PLUMBING RE-PIPE
F W
Dm'--C....marlo,
vs6a ARCHEI ECI'S DECLARATION ❑MULTI-UNIT ❑S'FRUCI'URA1.
PANIi1S MODHICATION
ZOZ_Z I understand my plans shall he used as public mvmd% UP TO 21X1AMPS
❑INTERIOR [I CHIMNEY REPAIR
1714F'upl Livctned Prom,,ional 2f11-aBAMPS IMPROVEMENT DSWIMMWGPOOIS
OWNER-BUILDER DECLARATION
(�Xa OVER 1(XX)AMP$ [-1 BATH RP.MOIjJyJ�l'-P� U?MOhIT
Ci d I heathy,tIUh t do,1 urn exempt from the Comnmtor'x Luom,s Law lin Elm 9/(x h�
xp U Billowing reason. Sectinn 703L5,Huxincsxtmd Pro&xsions Cmle:Any cityor<nmm, SIGNS E IXC'I'RICAI, ❑OfHER ��
W 3 u.i-, which requires a pelota to cnn.wet.alter.improve.di(it repair any structure
o
primma,kotionce..ko regime,alcolplicam farsueh pemail'nfile.signet swtemem SPECIAL CIRCUIT/MISC.
mot he is lianxJ pnnuammthe pntvisurns nfthe Cummcmfs Li<enxc law(Chnpter9COMMERC— IAL:
.a p0 (commencing with Section 7001)of Division 3ol'the Bminexs and professions Code)or TEM P.MITER OR POLE INST
0.W o C Thar he ix esentpt thervrrom and the husis ter the nllc6eJ exemption.Any-violation nT ❑NEW BLDG/AUDITION ❑DEMOLITION
X, Scainn]lUl Shy:coy uppll<anuurnpennitsubjecls'thwgtPlieuntmncivilpiiallyof POWER DEVICES ❑T1iNAN'1' ❑FOODSERVICE
not more mall rive honored douam 185001.
IMPROVEMENT
SSG D 1.us nwnar of thepmpeny.arnry antployccs with wages us Chair snlecnmpenmlinn, SWIMMINGPOOLIILFCTRIG
F. will do the work.:md the suucture is not in chdrojor ofched for sale(Sec9U4J.Bulinus [I OTHER
63 m and Professions Cade:The Contractor
License law Jae,urn apply to an axvrr of GUI'LITS-SWITCHES-I IX'IURFS
property who h tilds or improves thereon,and who does wch work himself or thrmgh
his own employees,provided that such improvements am not intended or nftered for NEW RESIDENTIAL ELECT R SQ EI'.
,al. If,hnweveq the Nodding or improvement is sold within one year of completion.the SQ.FT.FLOOR AREA 19'.
$ISQ.
et-builder will huvc the humlen rf proving that he did nut hnIIJ ar improv,rut'l,at-
powofs.leJ. - 'TOa'AU.
L as owner of the property,am excluvively contracting with licensed contractors it,
construct the project(Sec.7014,Hminess and Profusions Code:)The Comeme-or's Li-
st Law does not apply to an owner of properly who builds nr imprmxs rhemam,and QTY PI. NIB, e M FEE
who contracts for such pmjecte with a commtons)licensed Pursuant to the Contractor's p /
Liceone Law. PERMIT ISSU ry D
❑ Icon s.s mpt nmmr Sec. .N&P C for ihi.rea.on
,e ALrE11_DRAIN&VE I' i !AI VALUADGN
Owner Date
WORKER'S COMI'IiNSAT1ON OFCLARATION BACK PLOW PROTECT.DIiVICE
1 hereby affair under penalty of perjury one of the following declarttions:
I have and will maintain a Certificate of Coastal to elf-innum for workers Compel- DRAINS-FLOOR.ROOK A RLA.COND. rL STORIES '1'YPI?CONSTRUCTION
sation,us provided for by Section 37(10 of the Labor Cafe,for the prafmmunce of the C
work for which this permit is isw st I EG,,[Rr�SIVINDUSI
ER TRAP
I thou I will hn;ua,a Wod.ds Camlematin i btsurmce,as mquimd by Section
39(X1 of the Lubar Gxlc,&r the Performance oa the walk for which this permit is Issued STI?M-I INC.JUI]'ILETS - OCG GROU1' ANN
My worker SYSTEM-OVER(IVERJ(I!A)
Come+: cit/—darf4/G—Policy Nn.: /�A
CIiRfIP(ICCO i PENSAiWTION PROM W'OHKERS RI,WAS'1'Ii IISFERCEPIORC(IMPENSATION INSURANCE BUILDING DIVI51(1N 1'IiES
TbisxmtionneeJnotbe completed fthepermit Lsfor mnchundmJdoller,H100) P
I'hANCH[CK 19i1i
ms.)
Loy ay that in the pert nnroal is)asthe work m %uhicll this thepermitWorkers
Con shell SIIW IiI<-SANITARY-S'IUHM I?A.2U11 P11
tut employ Iuty Per any manner sir m to M1ecmne mhleet no the Workeev'Cnngmm 1!NI!RGY ICI?
Oz smio,lawsmf Culeurnia.DaniWAI'IiK HEATER W/VENTIELECIR GRADING Igili
z O Applicant ' _
N NOTICE TO APPLICANT:If,after nuking this Cenificam of Exempnon,you should WATER SYSTEM?RI HNG SOILS FEIi
[— become subject to cite wooers Compensation provisions of the Labor code,you must
a � forthwith cnlnply with such provisionsmT his peman,ball he deemed herded. Wilt UR SERVICE
WC
CONSkll(:'IION LENDING AGENCY NEW RIiSIDI!NTIAh PLMB, $Q,FI'. PAID
Iherchy ullint that them is x<ootmctian leadin lint the rharanmreot' .t cciptp
U 6agcncy tk
the work for which this permit is issued(Sec 30oG.Civ.C.)
I-' Lenders TfrrnL:
V LendeR Address 'T(YI'AL:
1 certify that 1 have read this applicnttnn and state that the above information Is IIUILUING PEI:
Fro correct,Iagree to cnply withall city and conmy nmmtale e laws rdming at QTY. MECHANICAL PERMIT FEE sPISNt cot
V Z mnldimgnmrulion,am[hemby nuWuriee rcpmmnwtives of this city to enter upon dm '
ohne-menti..ned ph"ity for impmimn purposes. PERNU 'ISSUANCH 1; F( IC PIi
(We)agmen,save,inalmmonly and keep haralless am Cay of Cinema,against
Iiubilitiesjudgntents.casts and expenses which may in anyway acemeagmmt said City AITI:R ORADDTOMECIL - PLUMBING i1:
in coosequen<c of the granting of this .it.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UN['1'(TO EI.00)CFM) MECHANI Al.FEE
SOURCE?REGULATIONS.
AIR HANDLING UNIT(OVER IQ(XX)CFM) CONS'N C1 ION
Signature of ApPliranl/Comra,tnr Dole EXHAUST HOOD(W/Irt)C'11 HOUSL MH'IGAIIONFEE
HAZARDOUS MAI'HRIAIS DISCLOSURE!
Will the applicant or future building occupant aow or lunJlc ha`atdnus material / HHATING UNIT(TO 100.0X1 BTU)
ax defined by tit,Cupertino Municipal Code.Chapter 9.12,and the Health and Safuy HEATING UNIT(OVER 100,001 BTU)
Cade,Section 25532(m!
E]Yu' E]No VENT ILATION VAN(SINGLE RESID) PAID
Dam Receipt If
Will the lgtplicum or fumm buhit ing xcupant use cyuipnem nr desire,which BOII.I!R-COMPQHIPOR 100,0m)BTU)
emit hwunlnus air nmmminnnts us detinet by the Hay Arc.Air Quality Mvnugnncm 'T OI'A L:
District! BOILER-COMP(OVER 100.00JHTU)
❑Yes No
I bavemad the bmardous nauvriahrequimments under Chapter 6.95ofthe Cali- ALR CONDITIONER ISSUANCE DATF
formic11,abb&S'(my Cod,,Se,lion,25505 25591 fit25,514 I androsta I lou the NI:W HIiSIU1,NTl AI.MI!CII. SQ.FE
hold ,oku,nua,uu...Ilyletcn1,linat Y "al th'If,noneunly them"pool
tfm y9j' to with)) IM. tpri I Lo( n'I�t//y(kc/yp' 'y.
1 .fif' iusNM✓ 7/l /O,F TOTAL
O crormajorired agJ It ISSUEDBY:
OFFICE