S 3055 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY v—
CITYOFCUPERTINO BUILDING.P:LBcTRIC\L PEBLUt NO. O
55
BUILDING DIVISION APPLICNFION/Fill PLUMBING MECHANICAL S
ItUILDING PROJRC'p IDENTIFICATION
BUILDING AU)H[SS; SANITARY NO, APPLICAI ION SUBMI'ITAI.DAUi
OWNI}I'S NAA11 PHONIi: CONI' 'I')RIti NAMIi: I-IC NO:l/ NICCON'IBULX
^( ❑ .6
IJC Nl
ARCIII'rliCr/li GINEEN: - l: ' ADDRESS: JO FO
CONTACT: 65rC)32PHONE'.4'- O�p PP BUII-DINO PGIt MIT INFO
C
/ f ll I ❑ Cunsullanl Fees Paid by A team(Initial) BLUOe1.ECf PLUMS MC:Cu
LICENSE)CON TRACTOR'S DECLARATION Q'PY ELECTRIC PERMIT FEE
I hereby arum that 1 ar Rcen.ed under pmvddma of chapter 9laommcming JOB DESCRIPTION
x00 w;hllLlo`7(XX))c(Divlxion 3ottheB ncaand P,um,,i.m;Cost,and my licanw6 PER MI'DISSUANCH - RESIDENTIAL:
�T SO ❑SFUWL ❑KITCHEN REMODEL.
QUU Luciano,Cl... � t. APPLIAL IS-RESIUEN IYA), ❑ADDITION �PLUMNINGkIS PUTT
h Q i Dam--L4V( QS DELT
/4/ I ARCHrfECPS DELLA r PAN:1-S MODIF❑MULThUMT ❑STRUCTURAL
ZOhZ Ium,ot,rd Illy plans shall housed ae public me d, CuIL CHIMNEY
CATION
UP'Iu 200 AM I'S • Z0 ❑INFERIOR ❑CHIMNEY RHPAIk
W Licenmd Professional 201-IIXXIAMP1 IMI'ROVEMIiN'I' �SWIh1MING POOLS
OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BN'B REMODIRJRITAIR ❑DFMOI.1'LEON
CC Q i hereby affirm hot I am exempt from the Contmeam.,Lic'enm Law for the
x4�d C,L U fnfowing nL I lSealnn 7031.5.Busmce and Pude, a Coda:AnY city^ county SIGNS ELELTRICN, ❑OTHER
Y13 a-EF x'hieh require.,a permit to construct.alter,,i:nprnve,demoloh.or repair any smicmre
OQ prior to its issuance.also requites the applicant for such pe-1,1.One aeignedetmanent SPECIAL CIRCLE LIMISC.
Sy'P1}
her he is licensed pursuant o the provisiotn of the Contractor's License Law(Chapter 9 COMMERCIAL
�O I,nnuncnciug with S,ninn]IXNI)ul Division 3nl T
the Bnaincs,and l'rolecsinnsCNclor EMP.MISrER OR PULP INSF..
a a e at tbm be is c¢ampt daeado vnd 0e basis ter he d1cged e.entptiun.Anyrbialutifm of / �NI!W NLDG/ADDITION ElDEMOLITION
x 14 a- Section]031.5 by any applicant for a permit subjects the applicant m a civil Penally of POWER DEVICILS ( kp ISNANT ElI--OOD SIiRVICL.
f
F. of morethan five hundred dallart f550). �PROVEMENr
ESQ D I,as owner Ill oho property.nr my nnployces with wages as their sole annpensaion, SWIMMING POOL ELECTRIC
L., will du the wurk.;md the enu,turc is nal imm�dcd nn;Rered for s;Jc lSm."11Wd,Ifamness ❑DTI{I!k
6'3 and Professions Cade: the Cmmracmr's License law does mol apply to an owner of OU'I[.]LI'S-SWI'IClllis-P%'LURES
pmpeny who builds or improves thereon.and who dues such work himself to through
his own employees,provided that such improvements am nor intended or offered for NEW RIiSIDENI'1AL ELECYR SQ FT.
sada lf,however.the M1ailem
ding or impmwcom ie old w rhrom,yaofeempletiun.the SQ.F4.FLOURARP.A 5/SQ.FI'.
owner-builder will have the bund,.of pmving that he did not bulW or improve I...par-
p se of tole.).
I,as owner of the pmpvri.am eackwively contracting with licensed comraaom in
mama the project(Sees Vlldd,Business read Prom,,inas Code.)The Contracho's vcaw Law does n t apply m an owne'of pmpcny wbo bnilds m impmvcahcr,I and QTY, PLUMBING PERMIT PEE
who cualrans lle such projects with a commctorl.y licensed pageant to the Cor macrons (T
Lxemc law. PERMIT SS' CI:
I ton exempt under Sec. .R k P C for this reason
AITER AIN.4VENT-WATER EPA) VALONE 11
Owner Date _
WORKER'SCOMPENSATION DECLARA'HON BACK PLO UI" .DEVICE 3., 5o0i W
i ' I hereby aRrm low
under penalty of one of the follow declinations: ✓Cl"
Ihave and will mu;ntxinnCenificane or Contend a.sell-insure for Workch Cnmpen- DRAINS-FL00 .ARBA.CONU. STORIES TYPE CONSTRUCT[ON
sitiun,as provided for by Scaion 3110(,1 the labor Cotyle,fur Ne perlbmnana:of the a
per
art which this prit is issued. Il%'1'l1Rli5-I'13R AP
have and will maintain x'orker's Conmensmion Insumme,as inquired by Scainn
of the Labor CNB for the perfnmwnce ofthe work for which this permit ocssuctl. CA: 'A. STEM-11 UILE7S (KC.GROUP APSE
Ca Wnr is 'aye mmlun Tcumncncurzivand
Policy
Win
GA' 'YS'I'EM-OVERd IIA)
C' -'IMP ION FROM 0.' ta
S PION INSURANCE :ASF%li' LWAS'IEIN'ERCI!19i)R Nl11LOlNC )TVI. )N PEIi.S _ __
hiss,in.need not beeumplctcdifthelter isfor onehandreldollar,15ff)01
GREASE'BAP
or less) PLAT III!CK IT!I!
Icenifythat in thepedannerecofthe work forwhichthi,permit isissued,1.shall Sl:WlIR-SANITARY-. > iA.21X114.
not employ any Person in any manner so as to become subject o the WorkersCompen- F.NI!RGY I'li
OZi cation Lawxof California.Date WATER H' i WNENIdil.l! GRAIL
Z Q Applicant
NOTICE'TO APPLICANT:If,after making this Ccmficam Ill Ei c nptinn,you should WAI'1!R SYS' /' TINC Q I S( Iqi
= '
become subject to the Workers Compensation provisions of the ladr Code.you must
tonhwith comply with such powkions orthi,permit,ban M deemed revoked. WATER SERVICIi -
1 (�
,Jrum /b',M SQ.FT
z IX)NS'rRUC'IUN LENDING NEW NLSIDIN'I'IAh I
Rccdp(Or
U O I hereby affirm that mere is a construction lending agency for the performance of
the work for which this permit is owned IScv,3119,Civ,C.)
TOTAL:
Q ULenders N..ne T
Isndcrs Addres
1 cenily that I have read this application and state that the above information is B
UILDING
a
UN rorcall,ocotocomply hirebyanyand county ntaiivesofand stem hwsrupngm QT}•_ MECHANICAL PERMIT Fh:F,U z bnildivgeonslmain,unA hereby umhorim reprewnmrivewfthis city tocora urym the;;hove-mmmiOnN properly Ionnepeetimn loollo em, VERMI'f ISSUANCE ((We)agree m save,idemnifyInd keep M1 modes,theCityofCupcninngainstIiabilities.judgmeuts,costs and expenses which may in may way accm,against said City ALTER ORADD'IOMECIL in nsequence of rhe granting of this Permit. OAPPLICW'1'UNDIIRS'rAN A Il WILL COMPLY WITH ALL NON-POINT A I R I IANDLI NG UNIT(rO 10.000 COWL SOURC RE AIIONSI toAIR HANDLING UNIT'(OVER IB.INNICI:M) CONSIRUCHON'IAX
Sign, n Ap hem Cm actor Dam EXHAUSTHOOD(W/DUCT) HOUSING MITIGA, PGIi
I A% tD(IU9 MATERIAI.S DISCLOSUIt1!
Wil cupPlium;rl'entreM1�ildingoxcupamsumcnrhandlchamNousnmlcriul HILA'fINGUNI'1'('I'DIINI,IIINIIi'1'l17 / ZO
as hue by the Cupenimo Municipal Code.Chaper 9.12,and me 11,A M1 and Safi+y
Code,Scaio.25532o)Y DEALING UNIT(OVER partial)BTU)
p Yc, ❑NnPAID v t2/
VHN'r11,AP10N VAN(SINGLE N&SID) Unto RcaiptM
Will the applicant or future building occupant use equipment or device,which BOILER-COMP CHP OR BEE).NM B'rU)
emit hurmdous air contaminants as definal by the Bay Area Air Quality Management
Dismcd' BOILER-COMP(OVER PRO.010 BTU)
❑Yu, No ((((((......
I have madthc hae-vdomccurnalsrvyuiren¢nos antler Chapterfi95ofthe Cali- AIR CONDI I'Il)NIiN ISSU I'
DATA / ay
hoop health k Sufcry Ct ,,tions 25505.255]3 and 2553],I undentunJ the if tlw NEW RESIDFNIIAL MITCII, SQ.14. '�-� U\(/
hin , ado un cum:nl buv atcnan6 thinII is my on"msibility to notify the oxculmm
aft antswhic he netprinno issuance of u CrifieacIll'Occupancy.
TO L' Z
O OILIlam ISSUED 13Y
OFFICE