S 1451 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I'E I'r NO,
BUILDING DIVISION APPLICATIONTERMIT PLUMBING.MECHANICAL 1451
BUILDING PROdECF IDEN'I'IF'ICA'I'ION
BUR.IDINGAdljjtiS: O Jknc SANITARY NO, APPLICATION SUBMITTAL DAI'
OWNER'S NAMFPw/)l_'1! YIIONF:: CON'rHACfOH:S NAME: LIC NO'. ^ w
NIC CON'IROLa
AH CHI'I'T:CUEN'GINEER: - IJC NO ADDRESS: ❑
Cliffs1. �k \ PHONE: Ii UILIJING PGRh11T INFO
`��. ^SK4l� ❑ COBSWl9Bl Pees Pell by ApphC2B[( BfIIllI) BI.U(1 li ECL' PLUMB MCCII
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
Q'IY. ELECTRIC PIiRMI'I' ItiG
1 hereby affirm tore I am licensed under provisions (cni
wini.nz of Chapter 9 financing 108 )E$CRII'TION
DoZ wpb See,0mlgBofUokka.donne Hpdness and Prof—iona Code,aed my hcen.-is RESIDENTIAL;
F- - full linccmWelTmt. I'ERMIi'ISSUANCIi
y.W r '" ❑SFUWh ❑KI'TCHIiN RI3MODIi1,
aUU l.icenx Class hick API'LIANCIS-kISIULNTIAL []ADDITION ❑PLUMBING RE-PIPE
Of G a. Das GmOueor
ARCIII'I'ECI"S DECLARA'I ION ❑MU[M-UNIT El STRUCTURAL
F.7 y I'ANIiLS
ZOILZ IundvrstanJ mY plans%bull heusW as public record. CHIMNICATION
OG=� GET, ❑IN'I'IiRIOR ❑CIIIMNIiV kfiPAlk
Q4~; Licensed l'mlcsniana] 2M-1000AMPS IMPR'OVIiMEN'f E3 SWIMMING POOLS
S4 OWNER-BUILIIER DECLARATION
C OVER BqO AMPS [J BATH REAfUI IiIJ "AIR r OLITION
C C Q 1 hereby action than I am exempt from the Contractor,License Law for the
4Wx13�f following.canon.(Section 70315,Boniness and Pmfessi.ns CWe:Any city'comply SIGNS Ii1.-C1 LAICAL ❑OTHER
rn which regains a permit to conxlrvet,alta,improve,demolish,or repair any sBOaure
prion its issuance.also requires the applicant for such cannot to file usigned xl:nemmn SPIiCIAL CIRCUI'IIMISC.
that he is licensed pursuant to the provisions of the ConRneor's License Law(Chapter9
If
W COO (a rnmeneing with Section]WO)nf Division JoObe Businesand Prufcssionx C'1Jor 'DEMI'.MEIER OR TOILE INST. COMMERCIAL:
W ye[� that he is exennpl damstmun and the cousin Ln IM1c alleged exennption.Any violation of ❑NEW BLDG/ADDI'1ION ❑DEMOLI"PION
x^ Section 7031.5 by any apocaot I,,,. nod subjects IM1c applicant m a civil permlry of POWER DEVICES ❑1 HNAN'r FOOD SERVICE
t moa than five hundred dollars 15504 IMPROVEMENT
F=Q ❑Las nwneroflbe prpp:d..onny vaalloyccs with wages as how-lemmpeo,ouam, SWIMM ING POOL HIAIC'I'RIC
E F.O li
seihdolhewnrk,mWthestrvemlc ix not It call rnrsalu Nose, B1J,Husines ❑OTHER
a300�° and Prolcv%ions Code:ahe C.ontracmes r's Lmenne Law donot apply to an owner of out LCI
fs-SWTCH S-PI%'TURES
p,,,,ny who builds'oopmvo.,theasm,and who does nada work himself.,Ihr.uga
Ink own cnnployces,provided that such improvements am not intended or offered for NEW RES IDI:N'TIAl.ELECTR SQ I1
xn1e.IL howcvcrJhc huilAing nr improvemim is>nld withinone ye'of completion the SV.FYFLOOR ANiro1,J S/5Q 1-1.
erhuilderwill hnrthe burden ofpmving that hcdidm5l build nr improve torr par- p A
pose of sok.).
I,as Owner of the pro,l am exclu,&cly contracting with licensed commatots to 'ID'EAL: n,ry1fp`k
mnmum the t Istt.]BW.Business and Pmfe,,ionn GdeU The Contractor',I,i. Nor
ps con Q APR 1 NAF
mase La.does Rosapplym,, in,a Of pr.peny wh.ImilJs'oI tov he C one,and 7y, PLUMBING PERMIT FEE
who c mtrm'h Iia such projects with a amtrucm�al Iiccn.wA pm,no to he Cnnv:utor'n
License law. PERMIT ISSUANCE
eWropt under See �`_ .B&P C fnflais reason /sITV Ur VUI Glllil\
\ _ n ALTER-DRAIN&VENT-WATER HA) V 1 1 VALUATION
WORKER'S COMPENSN'ION DECLARATIONBACK PLOW PRO[LCI'.DEVICE
I hereby affirm under penally of perjury one of the following declarations:
❑ I havemad will TaimainfiCenificamof Corwn0.se14imure for Worker's Compen- DRAINS-PLOOR.RUOEAREA,COND. STORIES TYPE CONSTRUCTION
,:tion,a,provided for by Section 3700 Of the lab'Calc,for the Performance of the
work for wloich ni,permit is net ed. TEXTURES-PER"BAP
❑1 have and will malnOhin Worker's Compensation loWnf ce,as require)by Section
37Mafthe Labor Code.for the ocif'manccoftho,nock]'ot which this permit Ls 1%suc.1. GAS-EA,SYSTEM-]INC.4 OUTLETS OCC.GROUT' APS]
My Worker's Compensation Insurance carrier and Policy number are:
Carrico Policy No: GAS-F.A.SYSTEM OVER 4(EA)
CERLII9CAI 13 UP EX17MPl'ION FROM WORKERS,
COMPENSATION INSURANCE GRIL\SI%INUU51'RI.WAS,If,INGdRCPIgON
BUILDING DIVISION IliliS
Trois sccBnn Decd urn he coniplmeJ if the pemnil is foams afted dollars lSlgq GREASE THAI' -
access) I'LANCIIIiCK PEIi
I cenily that in the perttunhuncmhfthework forwhich lhi.vpentil isissued.L shall SEWER-SANITARY-STORM IEA.2W IT.
not employ arty person any% nwso item become subject the Worke¢'Compcn- INIiRGV RB
Z union laws of California,Data an WXF17R I LEAfHR WIVIiSUELEC'1'k
9
ZO Applieun ` GRADING FEE
NOTICE.TO APPLICANT If,after making chi%Certificate nt laemption,you should WADER SYSTEM?REATING
a , become%object to the Workers Compensntinn previsions of the Warr Code.you tu%, SOILS FEE
hadviilhcomply soithsach provision.,up this permit shall be decnredrevoked W4MER SERVICE
WQ
a z CUNSfRUCI'IDN LEN DING AGENCY NEW RESIDF.NTIA1,PLh1B. SQ.IT. PAID D:ne a t
V Ihem.1tiod on,per it I hsaann(See 30lcpding,gency fur IM1c peRommnce of
the work torr which thin permit lx issued(.A•a JI19),Civ.C.)
F" [,ads,',Name
0 V
>1 41 Lenders Address TOTAL:
-
E_ 1 1 certify that have react This application and slam that the above information is BUILDING FE
L IA as met.I agree in comply wda all city and county ordinances and ante laws relating lit QTY, MECHANICAL PERMIT FEE
V Z building conwrnction,and hereby authored representatives Oflhiscity to enmrupnthe SEISMIC PCE
.move-nmntioned prol'eny for inspection p.rpows.
(We)agree to Amo,indemnify and kttp hnmlos the City of Cupertino against PERMIT ISSUANCE ELECTRIC FIT
Iiabilitie%.judgmetts,costs and expenses is Inch may in any way acme against said City ALI'17R OR ADD'10 MECH.
i ncnmequenceofthe mingoftai,'raid. PLUMBING FIT,
4P '1CAN'T UNDERSTANDS AND Wit C(ltYP1.Y WITH ALL NON-POINT AIR HANDLING UNIT[TO 10.1101 ChM)
tt NS.i RLGULAL'IOh11iC11ANICAl.1�.li
AIR HANDLING UNIT(OVER Io,1pI10EM) CONSTRUCT ION I'AX
Signawre olppbaan ontracmr am EXHAUST HOOD GODUCT) HOUSING MI'IMAI'WN IFI.
L IAZARDOOS MABRIN.S DISCLOSURE
Will the appfidaalor 0mne building.,enpmnnorcor handle ha/ard..s mmenol HEATING UNIT IID I003M01 loll)
us Jdined by the Cupertino Munici,al Code,Chapter 0.12,uad the Health and Salcty
Code.Section 25532f,1^ HIiAI ING UNIT(OVER 100.000 BTU)
Ycs
FlrD No
VENfI1,A'I'ION PAN(SINGLE RP_tilU) PAID Date ktteipta
nr fch m bolding occupant¢w channel...n or Jcviccswhich
IW.gq I3Rl)BOILER-COMP(31111 OR
emeitnhair contaminants as defined by the I3ay Arica Air Quality Munagmmnl
l'W. i"thepplicant
TOI'Ah:
❑Yes ❑No BOILER-CUM P IDV Ek 1013000 B'IUI
I have read the hauudons materials tequncipcats under Chapter 6,95 of the Cali. AIR CONDI'I'IONHN
ISSUANCE UAI'fi
him.Health&Safety Code.Sanas 25505,25531 and 255,14.1 understand Thal if the NEW RESIDI sD[AL MITCH. SQ.Fr.
h riding does n'eunenty lmvc a teem,thin it many responsibility m policy the occupant '
Of We mgviremcm,wbidh must he rep prior isnuanm of a Cenilic"m.f Occupancy.
Owner or autharirN"gent Date '1'cy1'N,: ISSUED if Y:
OFFICE