1183 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPE RTINO PLUMBING.F.1.1!1:1'RICAI. I'Ii/R�htl'I'NI I.
APPLICATION/PERMIT PLU\ENING-VBCRANICAL S 1183
BUILDING DIVISION BUILDING PROJECT ID4:YTIFICATIOry
SANITARY No APPLICATION Sl1HM1'1'FAL DA'TI
BUILDINGADDRESS:
Z-0 P r
OWNER'S NAME: PHO E:• C NTR (TOR' AME,: 1. "NO:I NIC IX)NTROha
ARC! F. /ENGINELR: LIC NO: ADDRESS
^ ❑
CONTACT: PHONH. BUILDING PERMIT INTO
❑ Consultant Fees Paid Ey Applicant(Initial) BLDG ELECT PLUMB h1ECH
r y&Z ❑ y ❑
LICENSED CON I BAI CBS DECLARATION QTY ELECTRIC PERMIT FEE JOB DF.SCRII'TON
1 harhby affirm'I'm 1.111 licenced under pnwisune of Clmpmr 9lcommencing
cdoZ hbg«tion IINll))of DivisionJoftM❑usiness and Pndesc'�ns GNe.anilrpdicensv i. 1,: I TI
AL
typo seat 71 OZS PERMIT ISSUANCE ❑SIVWh [I KITCHEN BIih10DE1.
CW_ in full force and affem.
aUU License Class Lis.4 APPLIANCES-RLSME.N PIAL [I ADDITION O PLUMBING R'LI'IPF
(..ZU Dale cmufavn'r OMULTFUNIT OS'1'RUCI'URAI.
F=yARC]HIECI-S DECLARA'(ON �h� PANELS
to Z I mmdentmd my plans..hall he used.,public recmds MOUIIHCATION
ZO ZNO UPT021X)AMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed professional 2111-I(l(NIAMPS IMPROVCh11iNT E]SWIMMING POOLS
Q .J OWNER-BUILDER DECLARATION ❑BATH RIEMODIiIJRGPAIR ODEMQLI'TIGN
CCC 6 1 hereby ami ran that 1 am exempt from the Comracter'x License Law Int the041
OVER IINXI AMI!ti
x 5:0a U following rwwn.(Section 1031.5,Business and 11 mssiors GNe:Any city or countyIeCI'RICAL *C]which requires u permit nm eonamm.ulnae Impmve,de filch,or repairany euncane1 1, priortonsissiice.alsomquiresthe applicant for such permit to file a signeJsmtamcntCIRC(lll'/MISC.that he ix licensed pursuant to me provisions nflMComretnrs License Low(Chuplur9 I C, (commando,wish Sccdon 1(XXoof Diviien 3ol'Ihe Business and Prnfcw'ium Gdc)ori1'ER OR 1101-171NS'FL 0. a' Ihm he is exempt therefrom amt the basis for the alleged exemption.Any violation of4• Section 1031.5by......l kern,for aptn�l subjects the apdamino a civil penalty ofEVECLS❑E,as ownerd theproperty,or my employees with wage%a their sole compematinn. NG POOLELECTRIC will do the work,and the mmcane is not micndedorotfmadfor salC(See 1141.Business -SW1TG111i$-hIXTUIt IESW3� and P alc,,ions Cele:'NC Cartmetors Liwnse Law duel.am apply am an owner ofproperty who buildsor improves theasm,and who dues such xmk himselfm throughSIDEADAL ELELTR SQ PIP
his own employees,provided that such improvements am not intended or offered for OOR AREiA Q. .
sale.11',however,the building or improvement issold within one yearm c.....E inn,the
erhuilde,will have the burden of pmving that he did nm buil)m improve for pur- y�
pncalsale.). 'TOTAL: Y' A 1 D
1 f the p pa Iy exclusively t t ng with licensed vu :1.
.n,l.l do,protect(S c 7644.Ines es and Pmmv,,on,CWe:)'.a C u
tmm,ILi-
ven Law due,mA apply to an owner A property who builds or imp thcrc and QTY. PLUMBING PERMIT FEE
who I 1%lor such projects I,'th a commeboWlicensed p an,l lie Cont tors JAN 27 a,
License Law. PERMIT ISSUANCE
O lam exempt under see. .B
&P C far this reason
At:)ER-DRAIN di VENr-WATER(EArte f H yV DATION
Owner Data
• WOR KERS COMPHNSADON DECLARATION BACK FLAW PROTECT DHVICIE
1 hereby affirm under penalty of perjury one of the following dedarutions:
O l have and will maintain a Certificate ofConsenrm self.inure for Worker's Compen- DRAINS-FLOUR.ROOK.AREA.COND. STORIES 'TYPE CONSTRUC710
v fon,as provided liter by Section GrX)of the Labor Code.for the performance of the
work fur which this permit Is issued. FIX'TURFS-PERT RAP
1 have and will maitnnin Workers Compensation Insurmer.as re robed by Section
311N1ofthe Lnhnr�Geds the e PoEmotnnceof the work for whi,bbbi,c Permit is issued. GAS-LA.SYSTEM-I INC.A OUTLETS OCC.GROUP APN
My ara carrier and Policy III
CameeItogmIIaz"OF EXIiMPT10NyFROM 6e,el Y,
_ � GAS-EA.SYSTEM-OVER4(EA)
CERCOMPIENSAI'ION INSURANCE ORIiASIJINUUS'I RI.WASTE ENI IEItCF,PInR HOLDING DIVISION FEES
(This section ncedne be completed ifthe permit,6nnnehurdmddollan(5100) GRFAS17THAP PLANCHECK THE
orIa,,)
Loy any lMtin the any roranceof the ketonewubject,.fictthe on WinlxwC,).,, -- SEWER-SANITARY-tiTORM EA.200 IT. ENERGY FEF
not employ any petro in any manner u,as m become sohj¢t Io the NSrrkeri Compen-
Z, at i Laws of Culronia.Dom WATER I I EATER WIVEN'I IELECI'R GRADING 17171E
ZO Applicant
y NOTICE TO APPLICANT:If,after nuking this Cen,rcam of Exemption.yea should WATER SYST£M/rREATING SOILS FEB.
a >
ban mne'aloes,m the Workers Compensation pbeii....ns of be I.nbor GdC,you must
l!J forthwith comply withsuch pro vision
astir this permit shall6C Jemncd revoked. WATER SERVICE
Qa PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENIIALPI.MH. SQ.Pr. [)am It c It
UZ Meffintom 1abamere is a construction[coming agcrcy for the performance of
W I-' the work for which this Perrot is issued(Sec.3011.Civ.C.) TOPIC:
O V lander'.Nanta 'F(YI'AI:,
r D.1 LcnJtu,Andres, BUILDING FEL
ff.... 1 certify that I have mad this application and stem tial the above information is
0/) ELF'
F. Ic rccl.Iagre;mmmply with all city urd'unty aNha
inanv,and n1.1C ws relating In QTY. MECHANICAL PERMIT SEISMIC FIT,
U Z building construction,and hereby amhonce mpresentatives of this city to enter upm the
amm.e-mentioned pmpeny for inspection puolwws. PERMIT ISSUANCE ELECTRIC 192E
(We).gaa m nwu,indemnily and keep hamJeee rhe Chy of Cu1'c'nion agaiml
Imbilities.judgmems.costs and expenses which may in any way accrue against said City AI.TERORADDI'OMECIL PLUMBING "
in consequence of the granting nfthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ONE'](HE 101000CFTvD MECHANICAL] '
SOURCE REGULATIONS.
AIR HANDLING UNTFOVER 10,1100 CFM) CONSTRUCTION IA
Signature of ApplicantlCormanoe Dam EXHAUST HOOD(WMUC) HOUSING MITIGATED FEE
HAZARDOUS MATERIALS DISCLOSURE BEATING UNIT(TO IIXI,INN111TU1
Will time applicant or rumre building occupant come or hmalle hmandam matedal
as defreal by the Cupertino Municipal Cuda.Chapter 9.12,and the Health and Solely HEATING UNIT(OVER 10400X1 BTU)
CMc,Section 25532(a)E
E:IYcs VENTILATION PAN(SINGLE RESID) PAID
Dam HCc '
Will the applicant or boom building occupant use equipment or devices which MOILER-COMP(31111 OR 1000)0 B1111
coil IS.emdo.,air snntaminants as ddined by the Buy Arca Air Quality Management If AU
District.' Y BOILER-COME(OVER 100.000 BTU)
❑Yes U�p
AIR CONDITIONER ISSUANCE
I have read tee b ode.Sou mataxis 25 5.2.1533 a under .1 and rsta of the if he
Lmmiu Health n Safety Gdc ea ani 25505,2s ni,and 255Ji.1 understand ILat if the NIEW RESIDENT AL MIiC11. SQ.F-I'.
building data not cutrcnlly have a¢noon,tint II is my rcalamvbility to nobly Ibc ecupum
.(the oxgo� hchm.,IPqnmt prior m inumse of a Canniest,of Occupancy.
I'DE'A ISSU¢D IY:
4n�
Owner or authc -ecd agent Das ' h: I
OFFICE