S 1084 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PI' It f No
EIJILDING DIVISION APPLICATION/PEWMIT PLUMBING.MECIANICAL k� 1084
BUILDING I'll() :CF IDENTIFICATION
h SANITARY NO. At I.ICAIION WBMI'I'1'AI.DAlli
BUILDING ADDRESS:
' 03 S S NIC C(IMI'NOI.p
OWNER'S NAME' P ONE: CO T OR. NAg1 is LIC NO: C
S4 ew
ARCHIT /ENGINIiIiR; ADDRESS:
oki AF
' e��h 's ^� 9-s'i ❑
G
CONT PHONE: BUILDING PIiRMI 'INI°O
❑ Cansullanl Fees Paid by Applicant(Initial) R! D I.ECLUMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 he^dfirm that 1 am licensed under Provisions o r 9lcammcnetng 1013 DESCRIPI'ION
OWZ Rh Se n csxmns cade.aad myliccnxi.. RESIDENTIAL
FOS n( o Gond enrol. PERMIT ISSUANCE ❑SFDWI ❑KI'I'CHEN REMODEL
aU Gose Class Lias APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
p.Z Dula Conwaar
ARCHI'TIT. SDIiCLARATION ❑MULgT UNIT' ❑MOLIFICAl IO
toy I understand ary shins shall he used an public records 1'ANIU.S MOUIIgCA'I'ION
Z UP1021X1 AMPS ❑INrFRI)R 0C HONEY REPAIR
o a
I.,-„� IiccnxN„�rrvhxxinnal 2a1-IgX1AMlR IMPROVI!MIiN'I' �SWIMMING POOLS
C6,,-M
OWNlik-BUILDER D11.DIiR DEGI,ARA'ITON OVER IIXXIAMPS ❑B61'lI RI?MODI!I1RIil'AIR ❑DI!M(11,1'f10N
y nfdnn thus I Bin exempt from the Comrnemrk License Law file the OTHER
(�6 U following reason,(Seen 703 5,Bio,im"and 1'mtissiorx Code Ac,city or county SIGNS Ii1,liC1'RIGI.
W 3 4 y which requires a perian to construct,ullcr,improve,danalkh,or repair unY xtructunt
1- C)< prior tits issma ,alsorequire.the applicant for such permit o file a signed nlmemern SPECIAL CIRCU IT/M ISC.
Fly (ml hero licensed mr,uunnnlhe puvkionxof the Contractors
❑
ractors License Law(Chapter 9 H 1
W�CO (commencing wilM1 Section 7000)of Uivision 3of the Business and Pmfessionx Cudel nr TEMP.MI!TIiH UR IOLIi INS'1'.
4 4 c C that he Ix exempt therefrom and the basis for the alleged exemption.Any violation of NELDO/ADDITION C]DI!MOLITION
W�h
Section 7031.5 by any applicant lin a Permit subjects the applicant to a civil penally of POWER DFVICES ❑TENANT ❑FOOD SERVICE
a.,mr.than five hundred dollars S5(Xn. IMPROVEMENT 4
ESG ❑Lase owner of the property,or my employees with wages as Nair sole compenmtmn, SWI MMI NG IVOL ELECTRIC ❑OTliER
F.
will do the work.roadie saaauumnatnUCiormsntended oroffered l.it., mle(Sey1.an Busies..
anJ Pmhe work and
dthxtctum is not
License Lawdoesnotapply man ownerof 0011.175-SWI'TCHIS-IT E
pmpeny who builds or improves thereon,and who does%non work himself or through NEW RESIDENTIAL SQ rT
his own employees,pmvidcd that such improvements are not intended or offered for SQ.FT.FLOOR AREA $/SQ.W.
sale.If,however,the building or impmecment is wild within one year of completion,the
nerbuildcr will have the huNen of proving that he did Bat build m improve far pan,
ryee of mlhe TO
❑1,as owner of the propmy,am exclusively contacting with licensed contractors to /
construct thees ran appl(Secy
in an ownBuser
f am Professions Coati)The
ve%the on.and
cerise Lawdoesfnotapplyman nwnarofsropcny who builds orimproves tbemon,and QTl'. PLUMBING PERMIT E
woo contracts for such projects with a cnmamnrtx)licensed pursuant to the Comaclots — 0 z
License Law. FERMI'T ISSUANCE
Iamexemplundcr Sec. ,B&PCforthisreau
m ALTIiR-DRAIN&Vx I' HA) _ VALUAI DON
�GWacI Date
WOR KER S COMPENSATION DF,CLARA'rION
I hcmny ofEnn under penalty ill perlury one of the m-m inglot do Workers
J5Ihuve Boit will nwimnin uCxrtificute ofConxcm w.wi(-imus for Wnrkcrta Cnmpcn- D MN.-IlUUH,ROUIc,ARi?A,CON 1). MORIFS 'I'YI'I!CONS'fR11LTIOD
nmmn,as
provided for by Section 371X1 of tiro Luton Code,for the performance of the
work lin which this pamil Is issued. 19X'I"I"-I'IiR'I'ItA1'
I have and will naintene Worker',Cungwmaian In...rare,as required by Section GAS-EA.Sy OCC.INC.4 OU'IT
37Wofthe Lubar Cock.lin the porlinn.ance of the walk for which this permit ix i...W. OCG GROUP AI'N
My Workerr,C into Ir mu cu r and Policy n a,,
Cunicr'. �'- ypenxn it a `mic Policy on, Jr-R7 �Z GAti-IiA.SYS'I EM-OVER 1 �
MLCpKl I ICSI'17 01;EXEMPT[ON FROM WORKERS' GREASI%INDUS'TRI.WAST'.INI'IiRC17 PTO R
COMPENSATION INSURANCEBUILDING DIVISION FEES
(lh'rvxclinn need not INenntplced dust Fell know,hundred dollars($100) GREASE'TRAP P 1
or Icxx.l
Ioy any lhalin the pedirman. ol the nklet whimhis permit is r"Coar bu11 SLWIiR-SAN]'IA -S'iORM HA.200 Ff. ENERGY FEIi
notemployany Pi�e 1I.f'y diyn anyanest peyp�xubjenmtheWorker<Comscn-
Z cation lawn ofC l' D.e WATER IIIiAI'. W/VIiNT/Ii1.liCfR
Q NOAppTICE
I 1
�' y NOUCETOca ILhe Wal ev Cormakingthis esio %o of E.creplum.Cod}esushould WNTiRS ,TIiM/IAIiATINC SOIIS FEE
[^ Femme h comp to the Workdx Compenxa is pmvtsi m l of the road Cade you must
a �
forthwith comply with such provieiuns or permit shallbudeemed revoked. WAT' SERVICE
aJ G
a
CONSTRUCTION LENDING AGENCY sW RISIDENTIN,PLMB. SQ.FT. PATO
Z Dae Receipt or
Iherthy uthmuhanherc ixaumxtmninn lending agency for the performance of
V Q
the work for which his patent is issued(Sce.3097.Civ.C.) TOI'A
I" I'mice's Name TOTAL:
r O {ULI Lender's Addacsn BUILDING FEB.
a 1 comity that I have read this application and stale that the above mformanon is
tih ounce,Iagree in comply with all city and umnly urdinarecx and state lawxrcladng to QTY. M ECI I A NICAL PE RM IT FEE " SEISMIC FEE
LI Z building camtruction.and hereby mandie representatives oftok city In enter ascribe
da c-mentioned prepeny far insrycEon mane,ec PERMIT ISSUANCE ELECTRIC ITHE
(We)agree m levo,iadcnmify and keep harmless the City of Cupertino mentill
Iluhll'nies,judgments,costs and expenses whkb(nay in any way ucemc against said City AI:I'IiR ON AUU'IO MI.CII. PLUMBING Igi1i
in n'tapr ncc of the gmnling of Nis sonic.
A PYLICAN" DijRS1'ANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(II'UL XXI CPM) MECHANICAL FEI!
SOURC 1?GULAf10N5,
AIR HANDLING UNI'1'IOV131t I1k(NNI Ch CONS'I'Ii11Cl'IDN'1'A%
.'gnalure or Applinmt/Conlrucmr Dale HXIIAUS'I'FOOD(W/DUCT) I IOUSINGMUNIAIIONPEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or l'ulum hsmidmgocensum stere or handlebumrdou,no.hrial I II!AfINC,UNI'I'll 0 lots,(XNI it" )
as defined by the Caper iso Municipal Cada Chapter 9.12,and the Hcwllh and Safety llli TING UNIT(OVER I 10X1 It IT) L.
Click.Seelion 255320)'1 ✓
EIYcs ICI No VENTLAI'IONFA .INGLERESIDI PAII
1 I, ,a�irt x
Will the applicant or f num building occupant ax equipment or devices which BOILER (311P OR 11X).(100 BTU)mil hmadoas air cunmminunts m defend by the Bory Area Air Quality Mmes,ro eel 'TOTAL:
L
BOILER- OMP(OVER 1(X1.0(10 BTU)
Ye, No
AIR )NDTIONER IS', i DATE
have aced the hvaNrmx maerid,requirements-Mer Chapter 6.95ofthe Cali
ealth&Safely Crde,Seelion.25505.25533 unit 25531.1 mdemaml Iha itthe :W'RGSIDEN'I'IN.MECH. SQ.FT.
does not cutmmlyhmenacnant.thYl it ismymspansibilitym notifymouccu sort
ni<nt stn,metpdmtoissua�eataamhcarearaCU an thuna agent o -31 Dae c TOTAL: ISSUED RY:
OFFICE