S 1981APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO -- BUILDING - F.LECPRI:At
BUILDING DIVISION APPLICATIONAPERMIT PLUnIRING- MECIIANICAI
BUILDING PROJECT IDFN'I'IF'IC,
BIJILE?G
19zoH}
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1 hereby upon, 'but I ten licensed un/pmvi,iom of Chapter 9 (commencing
withScotia/IRH) of Oivrsinnpufthc Rush(( II'tlu vie is Cndu d Iy license,
n full Puree and c l '1 I 1.- '�9
C' ,na/�
Imdcrsmnd my plans,hull he
<y E.{ OWNF,R-BUILUHR DECLARATION
=,=z I hcrehy affirm that I am excn,pl from the Conlrecmr's License Law for the
X6 U following reason. (Section 7011.5. Business and Profmsiom Code: Any city or county
W 3 fy y which votive, a Penni) to construct, IIIc,, improve. anafkh. or renter any ,mature
2 Y�Prinnn iu'Ixnuanca ulw, rminlmn o,ermplicam Ra such pI it, lila it nigmvl,salcnwnl
Ihvlheishr,mcd....unr,It, the prnvirion, of the Cmmnmmr'.v License Law (Chapter 9
WCC, (commcrcing%uh Section ]1NID)nf Division 3oflhc Busine,vc and Vrnfnninns Code)or
daxo C that he is exempt therefrom laid the Iasis for the alleged exemption. Any violation of
W—y Section VIUIS by any applicant for a Permit subjects the applicant h, a civil penalty of
not mare lbtm live lmndoxi dollora($500)
=O ❑ 1. as evnat le the pmlwey. or try cmpluyccs with wa,x,c, mcir.me ont,,,camn,
will do the work, and the.rucmre is not intended m odemd for nolo (See. 00,14. Business
W—en and Professions Code. Tian Contractor's Liccnsc Law docs not apply to an owner of
Pml'eny who builds or improves thereon, and who docs such work himself or through
his non employees, provided that such impnrvemeas are not intended or offered for
.ale II', however, the building or ImproW n ent (,sold within one ycur 0 c'umpletion, the
rte builder will have the burden of pmving Ihm hedid Bol build or improve lot poo
pose of tele.).
❑ L as,m net of the property. am exclusively contracting with licensed commcmn m
construct the project (Sec. ](W1. Business and Professions Code) The Comnume, Li-
st Law don, not apply In an owner of pmpeny who build, or improve, Ihureon, and
win, cnutmws for such pmjccm with a coup acna(s) haemes pursuant It l he C lautmcmr'I
Llccnw Law.
1 am exempt under lees . B & P C for this mason
❑ Consultant Fees Paid by Applicant (Initial)
I oTYl ELECTRIC PERA1IT I FEE
PHRMI I' ISSUANCI:
APPLIARCHS - RRSIDENTIM,
PANH: S
UPI(12(H)AMPS
SIGNS ELECTRICAI,
SPHC1A1. CIRCUIT WISC.
TIih111 MIOTR OR POLE INST
POWIiR DEVICL'S C-`
OUT 1.1.7S - S W ITC] IRS - FIXTURES
NEW RESIDCNTIcll- .,ECTR SQ FT.
PERMITISSUANCE; ` ✓
AINER - DRAIN & VENT -MIKE IiR IFA)
or, Date
�I WONKI?R'R COM 1117NIII ION UECI,A RATION BACK (TOW PROIPC'r. OF P
� I bcrchy ullirm Boder penalty of lmrjury one name Following declamations:
(have and willmainalina Centi,ateof Consent I,, ell-inotre for Worker's Compete DRAINS- FLOOR, POOP, ARBA, COND.
talion. as prio del for tiY section 31011 of an Labe, Cade. for the performance of the
work for which this pmuld is issued. FIX'I'l1RRS - BEER TRAP
C3 I M1me and will maintain Worker's Cemperwtion Imumnex, as required by Scanan GAti-EA. SY$'IEM-I INC, J OU'I LITI;S
9pIH)uf the labor Coda air the Innnunec ol, irk I... which 1111, Penult is in,u .
My Wed Cor�1,�pI{�1Gm lir 'olicY munhcram:
�Cactier: ,g�(/C�O ol'rNi U GAS - HA.SYSTBM I1VIiRJ(IiA)
CERI'll'ICAfEOP EXIih11T1 NFROM WORRIERS' GRI;ASI%INDUSTRL WASTE INTHRCT:PTOR
COMPF:NSA'UUN INSURANCE
(I Iu,,edion mWnot he r ITIUedlf the permit is lbn,ne hurnreddollars(b 100) GR HAS, 'FRAP
orles.1
Ioyaythat,,ainam,...anceof The wor.r, whichthmflac nti,iss Curter. SIiWIER-SANI'TANI'-SNRM 1iA. 21X1 FT.
not employ any person in any mannenn us Io become wbjecl In Ise Wnrkeri ComKn-
Q Z smind Luws of California, Date WATER HEATER WNRIEVIELECTR
Applicant
z(]N NOT IC1710 APPLICAN'I'll: chcr snakingthis Cenifcule el l?.mnplin I, you should WA'I'17R SYSTEMO RHM INC,
recline subject to the Workers Cmnpensnlinn pr wi,iun, it the Luhur' Conte, you trust
forthwith comply with such provisions or this petal l shall he deemed rooked. WAT]in SERVICE
= z CONSTRUCTION LENDING AGENCY SPIN RRTI
SIDENAI, I'Lh18, SQ. FT.
I hereby at firm mat there is nmsuuction Tenth ng agency for the performance if
� . dm work our I11"ll oris loner Ix i,sncd is". Ilw], Civ. C.)
C FU' I.eaders Name
Isnder's Address
%" D.1
a 1 elicit, that 1 have mad this application and ,hili that the vMrve information is
Ftg enrmev l agree In conlply with all city unit county urlinunces and state laws relaling In QTY.
U r7. houldill cocsuuenon,m,d hcrehy mnhorlac reprscrucivea off iI citym emer uP,o ole
aMwe ncmioned pmpmly to, in,pcmion PITn,ev
(Wc) agree a, save, indemnify and keep hnre lea, the Cil, nt Collection agniml
liabilities judgment costs and expenses which may in any way accrue againul said City
in consequence of the granting of this permit.
APPLICANT UNDIERSTANDS AND WILL COMPLY WITH ALL NON-POINU
SOURC; IdEGULA'I'TONS ,
Signemre of ApplicanaClar.11nr Date
I IAYARDOUS MATERIALS DISCLOSURE
Will the upplinmt o, fum. bidding accapent dere ar hurdle haeurdex, material
m dulined by the Cupcnino Munlclpnl Code, Chapin, n). 12, and the Ihudlh and Sultry
Code. Section 25532(a)'I
❑Yes El No
IiWill the applicam or future had,lag mecupant use equipment or devices which
reit hunudnu, air eonlmniours m dmincd by the Ifay Arca All sintlily Managen "a
District?
❑Yes El No
III Ilhsh d t I q t:underCM1 pt 695 fa,cCli-
to I Ith & nfcly ( I S I 55115 25533 12553) I J T d N t l dm
I IP,I[ 1y ,d I y-.1 In b'ryl syn r Fol
o,I 0'u,"c Inc (rte . jo Notation nl a Ctui tl'O(suPI SYn
MECHANICAL PERMIT
PIER I111'I' ISSUANCI;
ACI ER OR ADD TO MHCII,
AIR I IANDLING UNIT' (10 1BA1I CIM)
AIR HANDLING UNIT' (OVER 1000 CFM)
EXHAUST HOOD (W/DUCT)
HEAPING UNIT (TO I00.000 BTU)
III;APING UNIT IOVI;R I(NL(MNI ITfUI
VENTILATION FAN ISI NOTE RRSID)
BOIIAR-COMP(3HPOR I0(LIH101111H
ROILFR-COMP(OVIIR 100J)(HIB'ITU
AIR CONDITIONHR
NI.W RHSIDEN'1'IAT, MECH, SQ, FI'.
OFFICE
1981
-■l
BUILDING PERMIT INFO
tl.DG HI PCCIII PT.UMB MSCI
❑ YJ ❑ ❑
JOB DESCRIPTION
RF-SIDFN'1'IAL:
❑SPDWI.
❑ KOCIIHN I EMODIII,
❑ADDITION
El PLUMBING RF. -PIPE
❑h1ULT1-UNIT
❑STRUCFURAL
MODIFICATION
❑INI17RIOR
❑CHIMNEY REPAIR
IMpROVIENEN'T
F-ISWIMMINGPOOLS
❑ BATH REMODEURIiPAIR
❑DI'.MOLI']ON
❑ (TTHPR
COMMFRCIAL'
❑NHW BLDG/ADDITION ❑DEMOLITION
[I TENANT ❑ FOOD SERVICE
I MPROVHMFI`T 1
❑OTHIiR
6 G]
Y QiWLIBIa}(iIHSI Nr111!S
Cit I'LANCIIIi'K l9ili
ENERGY ITH
GRADING FIE
SOILS ITH
PAIDI \ It
�_ Bpd _.. Rccciplp
1(�C �r(rinl:
BUILD IT TE
FEE SITES FHL - �S_ 1 n EFAP, ,t".a1
K7 rt;I;1C:IR]' PERT" JG
PLUMBING ITE
MECHANICAL. FEE
CONSTRUCTION TAX
HOUSING MITIGATION ITE
PAID
Dam Hcceird p
SISQ. FI',
10ISSUANCED� ss
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