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CPIT
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BUILDING DIVISION APPLICATION/PERMIT
BUILDING-ELECI'RICA].
PLUMP NG•MECIIANICAL
BUILDING PROJECT IDENINFICATION
PESITN0. 2202
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SANITARY NO,
APPLICA'T'ION SUBMIT I'I'AI. DATE
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(1W'N13I1': NAME: I'{f1YH CON] IiAC OR'SN �p LIC
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BUILDING PERMIT INFO
..a /%7 f ���'J' ❑ Consultant Fees Paid by Applicant (Initial)
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BLDG ELECT/ PLUMB MFCCII
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LICENSED CONTRAC IDR:S UECLARA'I'(ONQTY
1 hereby a{fira that I am licensed ander pm.;.dons or Chill (:'amen=ins
with Sectlnalla)Oof atislon3ofthe Businessind Professions Cedr.andmy licenseis
in fol IfSoac and ell I
Dmens-s^Ires_s� Contracwr_
ELECIRIC PERMIT
-
I'lil<MI'I'ISSUANCIS
APPLIANCES-RESIUENTIAI.
FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFUWI ❑ KITCHEN REMODEL
❑ADDITION ❑PLUMBING RE-PIPE
❑MULTI-UNIT ❑STRUCEURAI.
MODIFICATION
❑INTURIOR' ❑CH IM NEY REPA] R
IMPROVEMENT E] SWIMMING POOLS
RCUG1zCT:SDECLARA110N PANELS
I understand my plans xbnll he cud as public rco ols
UP 1021K)AMPS
Licensrd Pmfaxi°^'1 2111-IWBAMPS
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OWNER BUILDER DECLARATION
eby (isa' ohm 1 stn eaampt famine Gmtrvnnr's License Lis. forme
herT
following reason (Suction ]031.5, Rosiness and Prolbs.rions Code: Any city le county
OVIiR IINIBAMPS
SIGNS ELECTRICAL
B THR MOD{;I li dl BDz 1 LIT N
PIN IT '
uu77 LL. y
f"iLL-•Oe
[yi�>s
which requires a permit to conswn. alar, improve, demolish, Lir repair any structure
prion'its Issuance, at,,, requires the upplicant far such Permit file a signed statement
dim he is licensed puamnt m the provisionsrf the Catamaran, Llecn.re Law(Chapter1)
SPECIAL CIRCUFUMISC.
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(mmmmaing with Sibeion'/000).&Division 3 little Husina,k and Professions Cndq Lir
that he is exempt therefrom and the basis for Ne alleged exemption. Any siddion of
Secdnn 7031.5 by any applicant for a pemniLvunirl, the appllenit to a mall penalty of
nm more than five hundred dollars S500).
[]Las nwnendthe pn+pcny. or my employees wi@wages will their, wde compensation,
willdntha wnrk,00d thestruemre is not va,ndcd in inhered far safe (Sec. 7044, Htsrinear
T1?MP. MET 17R OR ISLE INST.COMMERCIAL
POWER DEVICES
SWIMMING POOL ELECTRIC
❑ NEW HLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
HI?R
W
a'
and Professions Code: The Contractors License Law dues nil apply m an ex's=r of
property who Fakir or improves thereon, and who doc such work himself rr Through
his own cmployecs, poon,s] ohm such improvement, as not intended m otlered for
salt, If. however. the building or imprnvement is sold within one year of completion,the
wnerhadder will have the burden of proving Nm he did not build m impose for par.
01JTLFI:ti-SWITCIII?S-FIXTIJItLS
NEW RESIDENTIAL ELECT It SQ Fr.
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SISQ. FI'.
pure of snleJ.
Las owner of the prnpeuy, um inclusively commends with licensed contusion to
TOTAL:
cnnsavm The pntjeet (Sec. 90W4Hartness and Pul'essions Col The Caracas's LI-
weLaw doer not apply Lit an owner of property who builds ser improves thereon, and QTY.
PLUMBING PERMIT
FEF.
who carnets for such projects with a eomraetora) licensed Portland to the Cn name,
Lunn.,, Law.
❑ I run warm under Sec , If & P C nor Ell
PITRMI'IISSUANCE
Owner Dam
W'ORKER'S COMPENSATION DECLARATION
ALTER- DRAIN& VENT'- WATER
BACK FLOW PROTECT. DEVICE
VALUATION
v
:
1 hereby aflirm under penalty of perjury one m the following declarations:
❑ I have and will nntintain a Cedilicne at Consent o sell-insure for W'orker's Compem
satlnn, as Provided for by Section 39(X1 of On Laboorr Cil fthe peman an,c of Thu
DRAINS- FLOOR, RUDE,, All COND.
STORMS
TYPE CONSTRUCTION
•
n forwhichthispemnit is issued.
FINCURES-I'll
I have and will nommain Worker's Csnnpensation Insurance, as required IV Section
lot the Lohnr Ctde, Ibnhe Perfornlunce of Om work for wlticb thio permit ividunl,
GAS-EA.SYS'IUM-I INC.40U'lLE1S
OCC. GROUP
APES
My Worker's s peon In. ra e c d Policy n miler t 84
Currier. n carrier
No.:
GAS- F.A. SYSTEM -OVER 4 TEAT
CE TI GATT? OP P.%BMI'I'ION PROM WC iKE S
COMPENSATION INSURANCE
GREASDINDIIST'RI. WASTE INTERCEPTOR
BUILDING DIVISION 1'UIEI
CInk,tectloanrnlnrI becomplcad lithe permit In future hundred dollars ($100)
Lir Icsa)
GREASF.TRAI'
VLANCHIiCK PEE
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I certify that in the Performance of Ne work for which this pent is issued, l shall
not employ Lilly perin any manner so its to Mantle subject Lit the Workers Camper-
smina Low's of Colin mit. Date
Applicant
SHWER- SANITARY - S'D)RM EA. 2001"'.
WATER HEATER W/vENUELECIN
ENERGY ITT.
GRADING Fl
NOIICH TO APPLICAN"f: II, alter making doss C'ertilicnte of lixemption, you should WAT17R SYSTEM/TREATING
I.ecnme subject to the Worker's Cnmpensntionr ,ar,kions in he L.Is Code, you ams
forthwith comply with such provisions Lir this permit shall ba deemed revoked. WATER SERVICE
CONSI RUCTION LENDING AGENCY NI?W RFMDF.N'GAL PI.MB, SQ PI1
l bereby aftimt that there is a construction lending agency for the performance of
Iha work for which olds parra i,,,,.cd (Sea. 3097. Civ. C.)
Under', Name
SOILS PER
PAID
Date Receipt
TOTAL:
Lender's Add.. TOTAL
BUILDING s'I
1 coni ly ohm 1 have read this application and name that the stone initiation. is
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carrea.l agree In coonply with oJl city unA cnumy oNinunees nnA some hovdutittgm QTY.
building construction, and heavily nuNmia representatives of this city to enter upon the
MECHANICALPHRMI'r
FEF:
SEISM1IICIUE
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move-nientiuned property for inspection purposes.
(We) agree to save, indemnify and keep hamdcns the City of Co,dion again'
PERMIT' ISSUANCE
ELECT
C I
liabil'nies.judgmems. cols and expenses which may In any way accrue against said City
in estsequence of the 8rnndng of this permit.
ACI ER OR A DD TO SUCH.
PLUM
TNG il?
MI[CIfA'C I LFEE.
APPLICANT ON DF.RSTANDS ANO WE LL COM PLY WITH ALI. NON-POINT
SOURCE REGULKHONS,
AIR HANDI.ING UNIT ('1'010,INK) CFM)
CONESTRU'll TAX
AIR HANDLINGtRiTiTPOVERI
Signamreof ApplicantlContral Doc
HAZARDOUS MAI HRIALS DISCLOSURE
1?%IIAUST TIO' DIILT
HOUSING MIT' ATION FEE
Wllmvi,lieant Lir forum hili neanlutmsmre or handle hozvrdnusmmariul
1117KING UNU 000)(I [fill
is dutiond by the Cupertino Municipal Cala, Chapter 9.12, and the 1{ealm and Safety
Cod r, Section 25532(0!
I Ih?A'fINO UNI 1VER 1011 gXItB egg
F1 Yet 0N
equipment ser Marta which
Lir future building by the pay
Will the air contaminants
emit i aardous air contaminams as defined by the H:ry Area Air Quality Management
Dlsriet?
E) W, ❑Nn
VFNTILATIO PAN (SINGLE RAISED)
BOILER 1 �1P OR 111(1,000 ]GOT
BOILP.R-COMI'IOVER I(NI,INNI BTI
PAID
Ilia RnciplN
TOTAL:
I lmvenadlhe hazaNam macrisls actuations, under Chapter 6,95 ofthe Cali-
AIR CONDITIONER
ISSUANCE DA•PE
fnmia Health & Safety Cala, Sections 25505, 25533 and 25534.1 understand that if the
buildingdresn mnrantly have a Tanana, That it is lily tel('m.ribility to notify the a:cupunt
NEW RESIDENTIAL MECH. SQ. IT
Z
Cee_d cc pa
nl Nc require t h nmsT rnLia of oh m
(peat
V1Y/W
ISSUED BY:
Owner ar uuthnrizal 'gam Uma �f' TOTAL:
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OFFICE