S 1254APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUU,DING- EhECI'RIGSL PESITN,,
A PPLICAIFION/PERMIP PLUMBING-MECIIANICAL 1254
BUII•DINC. DIVISIIIN ,.,,....:1r.nrsuvT no", a ".Iul:
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✓ T��1JR.I"'�g1CA� Z_ `J ��^�. ❑ Consultant Fees Paid by Applicant(initial)HL
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BUILDING PERMIT INFO
ELECT PLI� MECII
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I,ICENSIiD CONTRACTOR'S DHCLARATTIIIOON. Qpy EI•ECTRIC PERMI'P 17I7E
1 hereby affirm m:n 1 am 1lcnlsed under pnr"I'lonx of Chapter 1) (cn;nmmnting
Srebro 90(XUUf Division 3efine Busines%end Pmfe"ino'Calaamd mylicere. is PERMI'I'ISSUANCE
in full once and cuicVhl 1,ic.a �O/�r
Llsnw CI... V G/ 2146 AI'I'LIANCES-NBSIUI!N'I'IAL
Uac Comnwba
JOB pE$CRII'TION
RESIDENTIAL.,
❑SFDWI. ❑ KITCHEN REMODEL
❑ADUI'OON ❑PLUMBING RI!"PIPE
❑MGUI[-UNIT ❑STRUCTURAL
MODIFICATION
❑IN'I HRIOR ❑CHIMNEY REPAIR
IMPROVEMENT (] SWIMMING I'OOIS
❑BAHIREMODEI/REPAIR ❑DEMOLITION
❑ (Yflllilt
n RCHIT1iCFS UECLARA'I'IONYANEhS
Iundbrun Imy plums shall be used as pub5c reomds UI"I(l &IOAMPS
Licenxd Professional 211-1000AMPS
OWNER -BUILDER DECLARATION OVER I000AMPS
1 hereby uflirm Thal 1 am exempt o n the C,mlmcmr'% Liecnsc haw for the
following reason. (See tion 9031,5, Business and Pntfusxions Code: An, city or county SIGNS EhEVACAT,
which ayuires a perms in coal alter, improve demolish, nn' repair any onecture
prior to it, i%,muuv,al%,,claire% the applinml for such per mile file a. signed statement SIT Ah RC /MISC.
that he is licensed purxuannn tnc provi.a,,ns of the Commcmrs Licenx Law lChapor9
(<mnmencing with Scainn 9lNM))of Divizion3 nftheBminess nnJ Professions CrN4 nn' INST.
thw he ix exmnpl thcreftnm anti she Novi% for the ;JlegeJ cxentption. Any vitiation of
Sation]0315 by any applicant for a pemdt Inflects the applicant Ina civil permltyof
COMMERCIAL'
❑ NEW BLDG/ADUITI(IN ❑ OF?MULITION
'FIiNAN'1' E] TOOT, ShItVICE
W=m
=�
F.
ta:d3
not more (ban five hundred dollars ISS(p).
p Laxrwner ofthe Eaoi .or my mmployccs with wages a,hei... le cnmpemauion, TRIC
will Jo the work, and thentruemrc is sol imm�JN ornlrurcJ for sole lSce. ]INJ, lius;nase
and Pmlauions Codke The Corrosion's License Law Jrtcs rot vpplY m an owner nn' - CURES
poiserty who wads or improves thereon, and who does such work himself nn' through
4NE-crR
ills own employees, provided that such Intprovemnta n o not imendaJ or ofcred Irr CfR SQ FT.
sale. If. however. the wilding or improvement is add within one yearefcmnpledon, the
'ROV EMENT
El of
S0. I'1'. IlAOR nRI!A $ISQ. PE
fir -molder will have the burden of proving that he did not wild or improve for put-
p...nor sale.).
1, m owner of We property. ant exrlu ively contacting with gamed enntracmd u+
rul the project (Sec. A{bi. Rival and Profession, Cone:) Tne Contractor .% Ia-
%c1,ewtires not apply man owner of Property sell,, wi m,u intprovusthereon. and Q'ry. PLUMBING PERMIT FEE
// r
L/V{
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who connects lbr such projects with a eontractur4) license(] pasuunur dm Corrosion'',
r W
I.icensc hw.PERMIT' ISSUANCE
or thi%m:orn
E] tuexempt under See .Irk PCfame,
m
AUI'IlR - DRAIN & V17N'I'- WAI'1!R (EA)
Owner Dale
A
ri
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT. DEVICE
'
I hereby at lino under penally of p Jtlry one ill the fol Inwing dcc larationx:
❑ I have and will maintain a Certificate of ConsrnUo self -insure lbt Worker%Cont'el, DRAINS- TIMOR. ROOP.ARIiA.COND.
scion, as provided for by Second 39W of the Labor Gide, for the perfonnence of the
work fur which this permit is issued. FIXTURES - PER TRAP
I have and will maintain Worker's Compensation Iluurancc, ax raluirrd by Sca'llon
3ANl of the Wbor Code, the perfnnmaacaofthc work for whish this permit is issued. GAS-EA.SYS'IEM-1 INCAODI'LETS
f
S(RIES 'TYPE CONS'I'IZIICf1ON
OCG GROUT' MINE
My Worker's Conn minnl :aceearne,; cPolicynumberare OAS-EA.SYSTL'M-UV[RJ(IiA)
Policy Nu.', / 1C//iI�/t7it5!
,u�--+�—
CHRTIPICATE OP EXEMPT ION FROM WORKERS' GRHASFANDUSTRL WASTE IN'MRC17111 OR
COMPENSATION INSURANCE
B 'G D ISION 1:1:1-S
PI,ANCIIIA'K wi
1Thixscdiun need nut he canpWeJ it the posit is l.a one hundealdollans($ 11X0 GREASE I AI'
or It,,.)
Illy anytheinthe anymannerof thevvd.frewhichNis theparatoW ekes' Caulhall SEWER -SANITARY -STORM F.A. 21X1PI'.
rte nnpiny oily peons in cry manner so as u. Ixcomu wnjcet m one Workers' Compenl-
ENERGY FET? .
GRADIN
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cation Cmes ill California. Dare WA'1'li HI!AI'IiRWIV. "11:1.1:CI'R
Applicam
NODCE TO APPLICANT: IL after making thi%Cenilieam of Exemption, yru should W I . YS' . C
become nuomp o tic Workers visions r this pmvit halmes of she nuadr evoke you req
forthwith comply wits such provisions or lhi%permit mall be Attnad revoked, WA :RS I li
CONS 'I'ItIJC'GON hIiNDING AGENCY NI!W ESIDI!NTIAI, I'LMN, SO 17.
I hereby affirm that shore is a conametion lending ugeney for the performance of
the work for which this permit is issued (See. 3097. Civ. C.)
Lrndcr's Name 'I 'AI,:
5011 4 PE
PAID —D Lie 'ccip
T(YrAI.:
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,r Bd
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Lender's AJdrmx
I eenifY that 1 have read this application and pate that the above information is
correct. l agree to comply with all city and county ordinances and%rate laws relating to QTY. MECHANICAL PERMIT FEE
building comunnloq and nerehy aumnrice rryrecenlelvex nfthia city to unser upon'hc
aMwomentioned properly for inspection puHanes. PERMIT ISSUANCE r
BUILDING E. /i
SEISMI
ELECTRIC FF .
(We) agree in save, indemnify and keep Warless he City of Cupertino against
I'ntbilibe,inigmcoal. antlsol es,coscswhich ntey In any wayaccrim against said City AJl'I7R OR ADDTO MECII.
PLUMIIING I• t
' rnnoce,core dine gWrin,ul this prnnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH All NON -POINT AIR HANDLING USE r PTO 10.000 CFM)
MECIIANICAI•FL'
SOLI tCIi RI!; (lULA9i ��9X%
i��j�A AIR IIANDUNG UNI'I'(OVEIt 10,0MCPM)
CONS'IRUC'II(N I'A
Sign:nn.(t APpliwnVConuacor Dare EXHAUST HOOD IWMUC)
I' 1'IGATIONtl?
HOUSING MI!'
HAZARDOUS MA'1'I(RIALS OISCLOSURIe
Will the applicant orfumm building mcepat wore or hunJlr haaaaJousnaoda] I IIIA PING UNIT IID 100.001 It I' U)
as defined by the Cupertino Municipal Coda Chapter 9. 12. anti the Health and Safety UPATING UNIT (OVER 1003100 BTU)
Code,Stan 255321ur1
0Yn ❑NrVEN'TILA'T[ON FAN ISINGIX RESID)
PAID
nate Radpt a
Will the appllcamur fidome bOldiage,ce,ud use ecripment it dcviccs which BOILER-COMP(3HPOR 1100.00BIU)
mit M1a gnu%air nmemimm�x as delincJ hY the 11uy Arca Air Quality Munngcntent
-
'FOI'AI•:
District? BOITER-COMP(OVER IM.000 RTU)
C] Yes ❑No
ISSUANCE DAVE
AIRCONINI'IONER
1 have J me hm e, t do Chapter ( f theif
25requirementsa
be
film Health fry Code,5 i .25hali I,'I, d2553)Iunderstandteltdtie NEW RESIDI:N'1IALMECH, SQ FI'.
full 1 t hl' 611 I y :p NI'gl l'lytl Pawl'
of be retain,ncnts wh sh must be act prior t ssuJ uc du( n1 �t I(hcup cy.
.... If
ISSUED BY: