S 1179 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMrr NO.
BUILDING DIVISION APPLICATION/IIF,RMIT PLUMBING-MECHANICAL. O '1 '1 7 O
RUILDINC PROJECT IDENTIFICATION O 1 .L I .7
SAN[I'ARY NO. API'LICAD SUBMI'IR.DAFIi
BUILDING ADDRESS:
O WEBS NAAMME: FHONH: CONT'RACTOR'S NAMHjN 1 LIC NO: NIC CONI�a
ARC IEC'/FN IN. LIC NO: ADDRISS: ❑
tv G
CONTACT: PHONIi: BUILDING PERMIT INFO
V ��sN ^^^ E:1 Consultant Fecs Paid by Applicant(initial) hI ' !LEC'I' PLUMB MECH
G (J GL ^ ` rUL� ❑
LICENSED CONTRACTOR'S DECLARATIONQTy CLI; RIC PERMIT I'EC JAR $CRIPTION
I hereby athfm air,I am licemed under provisions of Chae
p ell)mrom ncirr6
QgtZ with Semina IIXXBafDivision 3oOhe Businessand pndessimm Code.modify license i. EISFD RESIDENTIAL
O PERMIT ISSUANCE ❑gl'DWI [I KITCHEN RLMOUIih
F W F- in full force and effect.
'UyV Lmcem Claw Lich APPLIANCES-RIiSIDFNI'IAI, ❑MUCHION ❑SIRCC PLUMBING
URAL. I'll'li
tb<Q Dalt Con DELL ❑MUI:1'I-11Nll' ❑S'ODIF1URAh
ARCHITECPS DECLARATION PANELS MODIFlCA'DON
'Do,;
l undemmndmy plinsshall To sold.,public records UPT0200AMPS
OZ-0 E]INTERIOR ❑SWCHIMNEY
MING PAIR
Frit- Licensed Profesoional 201-1000AMPS IMPROVEMENT �SW'IMMING POOIti
4'Y�� OWNER BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEI/RFTAIR ❑DEMOLITION
F yam]'6 I hereby affect that 1 am exempt from the Contractors License Law for the ❑OTHER
X O W U following reason(Section 903 L5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
W whish r,,ninan Be mitt,)comloct.adw, otI thert Ilsb P ,.armor[
prior to its - also requires tile pplic t for suchPeniO tile a signed ouricurvol SPECIAL CIRCUI UMISC.
f't�}
that he I,licensed prsu tt thprovisionsoffific Contractors License Lo (ChaPla" COMMERCIAL,
1+)=00 (mourrocingwith Secinva9(X)(fiOf Dlv613m1h.Bminessvnd l4ofcnsiom Cmle)or TEMP.MISER OR POLE INS'P.
tL d e C mat he is exempt therefrom and the nasi.,
fie alleged c.empinn,Any violation of ❑NEW SLUG/AUDITION C]DEMOLITION
Section 9031.5 by any applicant for a Permit subjects the applicant t0 a vivo Penalty of POWER DEVIC&S ',NANT DODD SERVICE
not more than five hundred dollen(SSM). Int MOVEMENT
F=QDI.mo,ssocnithe PntpmY,nnnyetnpinyceawitb wa6eu ustheirsolcutmpensainn, SWIMMING POOL ELECTRIC OTHER
' Iywill do thewtak.; dl hmuuclum isnot imendrdomffered onode(Sce91WY,BusinessW 5,.. and Profession,Coss: [he Con rvaln'a L.,cnse Law Jives not apply to un owner of DTLIi I'S-.' I'I'CIIES-PI%'I11R1!S
�' propeny who builds or improves tbe.,.,and who ones such work Mmolf of I I III
his awn employees,provided that such impfnvmnents arc not intended or offered for NE DENT[A],RECTR SQ FT.
sale.lf.howevag me buildin tio.wlJ within one (completion,the SQ,FL PL(H)R AREA $lSQ.PI'.
Burden onvemeu Yearn
twome
r-builder will have the burden Of proving thathe did not Wild or improve for par-
^ �1
of
n
L as owes of the SO, 7reopen,,B siness andvely contracting e,with licensed contractors i-
mse I the pnt)ect(Sec.91W,Business rop rly who hai Gd,uTho Cnnuamoru l.i- A ! D
solawdtsforsapplymatt ill- ofpmpcnywhobudc4numon,, h Conon.and QTY. P, PERMIT' FTC
who eommca iia such projecP with a unurumutlr)licence)Pumutnn m the Contvamm's
Licence Law. PERM T IS, AN
I am exempt under See. ,D&P C for this maromAN 27
ALTER ENT-WAI : )N
Owner Unm
WORKERS DECLARATION BACK FLOW FR(.1'. EV 1; CITY
W
0 I hereby atlirnt underpcnalty of Perjury Inc ofthe following declarations: CITY
i have and will nwintuin uCanlEancnl Cnnscnl msdf-insutu fur Worker's Cumpcm DRAINS-FLOOR Iff ',A lC D. STORIES 'I'YPECONS'fR11C'IION
senium as provided for by Section 370()of the lav rCode.fur the ryHonnvncc of the
work for which This permit is issued FIXTURES-I'IiR TRA('
❑1 have and will maintain Waders Compensation Insurance.as required by Section
37M of the talus,Ctde for he peuturearrce ofine work for which this permit is issued GAS-LiA.S1'STIiM-I INC d OUTLETS OCC.CROUP APN
My Workers Compensation Insurance carrier and Policy number um: GAS-EA.SYS'I EM-OVER 4(CA)
Comer: Policy NO.:
CERTI PICATE OF EXEMPTION FROM WORKERSGREASE/I NOUN FRL WASTI71 N'FERCE111 OR
COMI'ENSAI'ION INSURANCE BUILDIN I ISION FEES
(Thix ncclinn Iced oat be nmtplcteA if the pcmtit or one hnntheddollmx($10) GREASE TRAP PLANCIIECK 1121
orlessJ
Loy any that in the any manner so as twod,(of subjectch to permitkel"C,n".- SEWER-SANITARY-STORM IEA.NOIT ENIERGY RA!
nm employ any Person in any manner so as us Mcotfrc zubjccno the Winkel"COmpen-
OZ onion laws of Cahlorma.Dene WATER IWATER W/VENT/IiLECI'R GRADING ill
O Applicmt
Z y NOTICE,TO APPIJCANT:If,ager makin6 this Ccnifilme of Esempion,you should WATER SVSTIiM/TREATING $OILS 11 i
lu,nom xabim'uo the Worker's CntnPensadon provisions none Labor Cade, on toast
forthwith
hercny offi with
ire thaOherc isaamnmtLNl01X0 sbill he JcaueJ rcvokul. WATER SEkVICI?
a0
CONSTRUCI'IONL GAGENCY NEW NIISIDEN'IIAh PLM?. SQ.FT. PATO
U z 1 to Receipt a
V Oconn lending agency for the performance of
the work for which this permit is issued(Sec.3097.Civ.C.) RMAL:
O V Lembo's Native TOTAL:
Y Leadmro Add... RUII,OIN(11!E
p a 1 certify that I lout mail tots mpllcutinn and store tlnn,hc above inti omm"In is
.y lin s mem.I.,me mcnnoff,with all city and cu umyordinances;nd Inde laws w1miag to QTY. MIiCHANICAL PCRMfI' Ila' SEISMIC 4ili
U building conswetion,and hereby aumori/s rePresentativesnl'this city to error upon the
adverse mentioned properly for inspection PurPo%cs. ' PERMIT ISSUANCE F,LECI'R CI EE
(We)alae lessee,indemnify and keep hmmless the City of Cupertino a6airmt
~ liobilitiesjudgments.mstsand expense.,which may many way accrue against said City AL RORADD TO MECH. R�191s PLUMB E 'E
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AN D WI 1.1,COM PLY W 11 If ALL NON-POINT AI R HANDL(NG UNIT(TO I ROOM CI'M) MECIIANICALF
SOL' CEREGULA
AIR HANDLING UNI'I'(OVER II10ln CIM) CONS'IBUCfION'TAX
I/ Signa are ssfApplieenU nlmcmr ( O to EXHAUST HOOD W/DUCT) HOUSING MITIGATION F '.
I HAZARDOUS MATURIA1 DISCLOSURE
If Will the applicant or future building occupant.store or handle hariaous mmeriul HEATING UNIT(TO IBB,"BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100.000 IfU)
Glc Section 255321,)9 `J PAID
❑Ycs �O No VF,NTII.ATION PAN(SINGLE RIiS11» Daa Rc,ript
Will the aRusen I or future Wild leg occupant use aspipn co,ter devices which BOILER-COMP LUIP OR Mottos)ll'i'U)
mit haroodaae eu lion mreams as deinN by the Buy Ana Air Quality Management 'TO I
District? ` / BOILER-COMP(OVER 100,00 il'IU)
1 ❑Ycs ry{Nn
` AIR CON DI'DUN ER ISSUA 'DATE
1 M1avc rcuJ he hazardous mvk'Huls ayutrements under Chapter 6.95 of the Cali-
fornia Hcalth&Safety CIA tSccon ire=25505,25533 and 25534,InnJemm�d thw it NEW RESIDENTIAL MECH. SQ.Ell
huildln6doc,nol currently hascatcnank ln,l ' ,myasgmsihilirymnaify the nsn0mthennt
ofine ou, en,whicM1mm__'1 Pte r colo Ccnlli'mc tl(kcnP' cy.
P3 on
0 ermoumon. c ISSUIiDB : _
OFFICE /