S 1547APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - F.LF.CI'RICAL
BUILDING DIVISION APPLICATION/PERMIT PLUNunNG-NIECIANICM.
BUILDING I•ROdECT IDEN'I IF'ICAI'R
BUILDINU ADDRESS: j/�J //{J N� r�
ri i U /_ A I ,A I/1'Yl N=,i �)/� C/ h r L
CONTACD nutNc:
r� � �Ira-7
,i r ra 7O pp El Cut ... kanl Fees Paid by Applicant (Initial)
WLICENSED CON'TRACTOR'S DECLARNI[ON QTY. ELECTRIC PERMIT
1 herchy allirm that l um licensed under pnwisiom of Chapter 9 (commencing
with Section 700(b of Division 3 ofthe Business and Professions Code. ail my license is PIERstr ISSUANCE
in full force end effect.
License Class Lich APPLIANCES -RESIDENTIAL
)omes--^ �- Contractor
ALI(I'IECT S DFCLARAI'[ON PANI!I S
I understand my plans shall he used as public reeoNs
IJP'1'll 2(0AMPS
OWNER -BUILDER DECLARATION
I hereby afGnu Inas I wino empt from the Cnntionchs s Liccmw Law for the
Iullcng mama. . (Scmlon 913 L5 ii from
it Prumssio s C Ni, city or county
which m,rirea a permit Ra coromod. tutee Improve, demeh,lb, or _- anI %Wcnac
prior to its issuance, also mquim%the applicant lin such crant to file a signed 9men cra
that he is licensed pursuant us the provisions of the Commemrs LEccnw Law (Chapter 9
fmmmenciny with Section 1100) of Division 3 of the Business and forecastle Codc) or
that he is exannt therefrom and the basis for the charged exemption Any violation of
Section 7031 5 by mi,:mplicnm lot. ncnold %ojects the epplaaal run Coll penally of
rot more II live h J l l II 185011
❑ 1 of the pr pent Y employees with wages as their sidepe t n.
% sit dthe k land the varmorm is net intended or offeredf (Sce. 1014 Business
and professions Codt, THe C t t License for., does not apply to an owner of
prolenY what hall Ids or' proves therson, and whit does such,. -k We ., h gh
his own employees, provldul that such lnpnrvetncros all nut'ort, rdw u r offerel Lor
sale. ll; linw,wc, the building ter i pro em is said within one year afcompaion.Ihe
coxnel-builder will have the burden of proving that he did not build or impnne ha pury
piss oLwlc.).
[] L as owner of the limp ny, am exclusively contracting with licensed caro- ctom in
contract the pilled (Sec.1114. Business and Ihofessiono Calc;) The Contractor's Li -
c w Law does not apnly to un uwnurofn,,,pcny who mi ids nr improves thereon. obit QTY.
whacmuuetx hasucL pmjcee with ucanvuewr(el llcensal Pn IId..E to It, Conwemrs
Lirvinat Law.
I am exunpt under Sec. It & P C fir is reason
Owner Ilene
WOR K17R'S COMP INSYI'JUN OF LARAIION
I hereby n lRrm urd,penalty of pcl'In, ono 0 the to lowing dcd unions:
1 have and will im intain o Certifies¢ of Conwnno self -insure tin W..am', (Inlet.
side., provided for by Stud n 3100 of the LoMn Code, for the perfotmaor' of the
svmk fur which this permit is isnuel.
0 1 have and will maintain Workers Compensation Insurance. a% required by Section
3100of the LUMn Code, formal pcdoun eve of the work for Which his permit is issued.
My Winker s CumeensaI ion l miller n`model and Policy number are: VNC.DI O/
SIC NIS ELECT ICAL
SPECIAL CIRCUI'11MISC.
TEMP. METER OR MOLE INST.
POWER DEVICES
7 SWIMMING POOL C. NIC
OUTLETS - SWITCH VINT
NEW RESIDENT AL EIPC
COMPENSATION INSURANCE
Otis section ncN not Mcnmplcmd if the pemtit iz butsuc hundred Julhrs151001
orlcn.)
I ccrli1, that Ia he sertu t a riot the work lar which his f ronit N hoed. I shut
not employ any prsun in any munncr, so as to become subject It, the Workers Contpen-
Z cation laws ar California Date
Z O Applicant
NOTICE Ill APPLICAN'C If, after making his Ccnihcate of Emmupn.. you slmdd
F become object to he Workers Compensation pow ision%none Labor Code, you must
! nhwid, rurality with such provhcines or ads Worth shut he d anted resulted.
7Z CONSTRUCTIONuctNDING AGENCY
U O Ihvreny affirm that mire mncongrominn lrnding agency for mance of
the perfor
LL-1the work for which this permit is issued(See3097. Co. C.)
O ULcndcrs Num.
(11 Lc.i Address
I .irfly that 1 have mud this upplicnlion unE Mart Inst the a aw, infnrmmion is
Hh comsat. I agtec m comply with all city and eumty meinarres ail stmc laws reading it, QTY.
U building annstreclion. and hereby authorize representatives it this city to came upmthe
udwve-mentioned progeny for inspection purlins.
IWe) agree to save, indemnify and keep hmmless the City of Cupertino against
I'mol 'niex, judgments, costs and expenses which may In any way accrue against said City
tscquance of the 6rmnEtg of ilii%pcnnit.
API'L[CAN 'IUNDERSTANDS AND WELL COMPLY WE 111 AIA. NON-Pf11N'I'
SOURCE BIEGTI(INS.
li _ -1i -9
HAZARDOUS Nei BR1ALS DISCLOSURE?
Will the applicant or liauare budng nccupunl store or handle h:nanluns mtneria l
as dinned by the Caroni Municipal Code, Chupicr 9.12, and the Health and sahty
CWc. Section 255321
❑Yea ❑No
Will Lha applicant or Iature building occupant use equipnteal or devices Which
mit huvunlus it con.antintnes ;is dcEncd by the Bay Ara Air Quality Mamgmumn
District!
❑Yc% ❑Nu
I have read the hazardous materials re, mmuncnm under Chapter Avis of the Cali-
fondu Ilculth A Sammy Calc. Sections 25515. 25533 and 25534. 1 understand that if the
building dues not Carmody neve a mural, that it is n y resryntsihll III Iu mddY the orc.pmn
,it reyaimments welch nmst hit met prim m iswanec oi'. C,ditwam of (Renpmcy.
ALTER - DRAIN R+NyfI'- WATBR ICA)
(LACK IrLOW PRfl Cf. DEV1
DRAINS -F O(IR. ROOT. AREAe
FIXNR&s - PER "AI'
GAS -IiA. SYSTEM -I INC.I IIT EFS
GAS -HA. SYS'I EM.OVER 0 (EA)
GREASP/INDUSTRL WASTE INl'ERCEITOR
GRCASETRAP
STEW I?R - SANITARY - S'I ORM IiA. 21X1 Ff.
W'A'I ER HEATER WNLN MXCTIt
WA'I IR SYSTCM/I BLEATING
WATI7R SERVICE
NEN' RE.SIDCN'ITAL VLMB. SQ. Ff.
NIECE IANICAL PERMIT
PERMIT ISSUANCE
ALA OR ADD1'0 MIKE.
AIR HANDLING ONE IL('G Jo mlCPMI
AIR HANDLING UNIT (OVER 10.001 CITU
EXHAUST NMI) (WB)UC19
HITNI ING UNI T('10 NI,000 I3'1'U)
I IEAfING UNIT (OVER 100.000 111I
V ENITANON PAN (SINGLE BESIDE
BOH III -COMP (3111' OR 104his) B'1 LD
BOILER -COMP(OVER 100.000 It I U)
AIR CONDITIONER
NEW RESIDENT I AL MECO SQ, FI'.
OFFICE
FEE
._.S...... 154 7
NI'I'ARY NO. APPLICATION SLIBMI'1'I'AL
L( -2Z- T$
NICC(lNi'ROLR
° X77
BUILDING PERMIT INFO
BLD(: CI.P.CT I'LUMB MIRCII
❑ ❑ ❑ ❑
J013 DESCRIVIION
RESIDENTIAL
ENERGY FEE C)
❑SFIIWL
❑ KITCHEN REMODEL
❑ ADDITION
C PLUMBING RE PIPE
[I MULTI -UNIT'
❑ S"INUCTURAL
MODLFICAI ]ON
❑ INTERIOR
❑ CHESNE.Y REPAIR
IMPROVEMENT
SWIMMING POOLS
❑ BATH REMODEL fftEPAIR
DEMOLITION
❑ EYE 'I Ii
COMMERCIAL:
C1 NEW BLDG/ADDITION
❑DEMOLITION
O'IHNANI'
❑FOOD SERVICE
114PRGVIa.MEN'I'
❑ OTHER
AREA S/SQ. -L
IWAY 20 AVO
FEE L)'
lir 1. 'CrT)uVU
/) VALUATION
I / o d c,
IEF"_5
1'LANCIIECKII:E
`ri
ENERGY FEE C)
D
GRADING FEE:
SOILS FEE
I'AIU
Uum R� ipaN
BUILDING hili
EEE SEISMICFEE.
ELECTRIC FEF:
PLUMBING FIT
MECHANICAL FTE
CONSTRUCTION TAX
MOUSING MITIGATION FEE
PAID
Date Reccipt p
I OI'A I.:
ISSUANCE DsrF
ISSUED BY: �' `