S 1049 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAI, r11HMm rvD.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MEICUANICAI. S 1049
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANIIAHY N(1, AY11C NSU. Ij;111-rA Tli
OW' H'S AM1Iii� �� � PHONE: CONTRACTORS AME LIC NO:
RF` L NIC CONTROhp
El�KCHITECIENCINEER. LIC NO: ADDRESS:
to a Co►yHg2c DR-
CONI'ACT: A PHDNF,: ( HUILUING PERMIT IN14
G /�'U Cq 0�)fZ G (' y�L ❑ Consultant Foes Paid by Applicant(initial) + EgF PLUMB Meal
LICENSED CONTRACT OR'S DECLARATION QTY, ELECTRIC PERMIT FEF, JOB DESCRIPTION
1 hereby allinn that I:nn licensed under previsions of Chapter 9(commencing
��Z with Section 7(XX))of Divnion 3 ofthe Business and Prolessions Code.and my license is1'ERMB' SSUANCIi RESIDF,NTIAL:
�LLO in full litrcc and dlect ICSI:DWh CKITCHIiN REMODELaUZ0 Lcense iClass bete# APPLIANCES-RESIDENTIAL ❑AUDI TION [I PLUMBING RE-1'11'17
in Q d Dwc Contmmor
ARCHITECI-SUP LARATION PANELSCMUI:I'I-IINI'1' ❑STRUCTURAL.
~.z I nush I]in Lmsshall be novel as Public recors
dMODIFICATION
Z Od
YI' UP 1O2A)AMPS ❑IN'I'IiRiOR [_1 CHIMNEY REPAIR
E+
o41 W�ty Liwnecd Pndcaionnl 201-InNNIAMPS IMI'ROVIiMIiN'I' C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER Its )AMPS C HATH NEMOUEIJREPAIH ❑DEMOLI"f10N
C C 6 I hereby affirm that I um exempt from the Contmmor'.License Low fnr the
k 6 U following re-o.,(Seaton]IBIS,Business and Professions Code:Any city or county SIGNS HIA=RICAL ❑OTHER
W 3 LL y which requires a permit m uryrc
consuct,alter,improve,demolish,or repair any stctu
�yae,< pontons i....rev.do,requires the applicant for such Permit to file a signedstatement SPECIAL CIRCUITIMISC.
ms
E } that he is licensed pursuantto the provisions of the Convannr's Licenu law lChapmr4 COMMERCIAL
WE a0 (cmmmencin6 with Scninn7(XNI)of Diviainn Jn(the Businos and Profcsmiuns C.,dc)nr TEVIRMFUERORWLEINST.
61 c C that he is exempt therefrom and the basis for the alleged exemption.Any violmion mf ❑NIiW BLDG/AUDITION ❑DEMOLITION
XlhSation 7031.5 by any applicant for a permit subjems the applicant a civil peraltyof POWER DEVICES a NANT FOOD SERVICE
not more than five hundred dollars($5(X), IMPROV71D
_� O has owner of the pmpenY.or my employees wirM1 wages as their Dole comp•nwtinn, SWINIMINC FOOL ELECTRIC COTFBiR
F. willdothe work.andthe nwctutoisnot imendcdoroffiamfor.wle(Sm.71 .Business
W m and Profc,,kne,CnJc:The Contractors Liemov law does nut apply to an menace of OUTLETS-SWITCHES-FI'
'L 3 pnpeny who build.,ur improves thereon.and who does such work himself or through
Lv
his own employees.provided that such improvements Ins not intended or offered for NEW RfSI DRNTIAL I"LEC RR S FT.
.sole.ILhowever.ihebildingorimprovcmcnt isoldwithinone yeandmmpletiao.the SV.I
owncr-NildeT will have the barren of proving that he did not build or improve for our-
pm ul set e.). T TA
❑1,es owner w lot"open'.ant exclucivclY...main,with licensed contrannn,to
constmet the poijen(Sec.NW.Business and Professions Code:)The CarameII I%Li-
c eLaw does nal apply n:mowne,ofpopcny sono builds or improve,thereon,and QTY. PLUMBING PERMIT EE DEC
rns
who cnmmetx for.otdt profane with n ttrmmmurCs)licensed pursuom to the Cnnvnnors
18
License Low. I'CR MIT ISSUANCE
❑ l
an,exempt under Sm. ,R&P C for this rws"mn
AhTEN-UIUIN&VENT-WATER(EA) (a VIY�UpTIfJ�
Owner Doe UTr tUAf1Y
WORRES:$COMPENSATION DIiCLARATION BACK FLOW PR(YI'ECT.DEVICE.
7 I hereby Infirm under penalty of perjury one of the following declarations:
I have and will muinmin a Cenificmeof Consent o self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. SIORIES TYPE:CONSTR UCI'ION
motion,as provided lin by Section 371X1 of the Labor Code,Sir the performance of the
work lin which this permit I.,issued. PIX'1'UHES-PER TRAP
C 1 have and will maintain Workers Compensation Insurance,as required by Section
37W of the Labor Gale.for the performance of the work for which this permit is footed GAS-IiA.SYSTEM-I INC 1 OUTLETS OCC.GROUP APN
My Wnrke[a CoJ^pensminn lnsumnce carver and Policy numMr am: GAS-EA.SYS'1'EM-OVER G(FA)
Carrier.
CF:RTII:ICATI3OPSATIONIINN FROM WORKERS' GHEASI%INUUSTRL WASTE INTERCEPTOR U .D G DIVISION PEES
COMPENSATION INSURANCE.
(This section veal not Ni completed ifthe permit is torose hundred dollars($100) GREASETRAP 1'LW 'CUECqi 20
oil ss)
Loy an,tpernthe any..unttml the work forwM1ichthis the okt to er%C. pen.shall SIiWIiR-SANITARY-STORM EA.200 FT I3NIiRGY IT' (®
nun employ any person in any manner so as m bjm to one Workers'Compen-
Q'z, smimn laws of ahG Dara - - WA'1IiR IIIiA'TICR WNENT/ELECrH GRADE hili
O NOI i0m� rafter -�
N NOi'IC13 TO APPLICANT.It,alter making this Cenificme mf Exempnon,you should WATER SYS'IEM/fREATING SOILS PI li
become subjat yo the Wnrkef's Cmnpens am,provismno mf the Labor Code,you must
forth with comply withwchpro,sime,or this permit shall he deemed revoker. WAIF SERVICE
n' CONSTRUC'UONLENDINGAGFNCY NEWRESIDENi'IALPLMB, SQ.FT. PAID
Doc tk
I hereby ul'Ilrm nhuuhcre in a ennxwebnn lending agency fanhe pcdinmancc on
WS) the work for which this permit Ix iA.ud(Sas NA7,Civ,C.) T
1-' Londe,Name 'IOTAV
ALULender's Aeries UUU,GINCI-
0t I cenify shut I move read this application and state that The abovc'mGnnmtion is
FtA correct.l agree to comply w lne all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V Z building cmmwdimn,and berehy vuthnrice represenmtivco ofthse city bs mmntpon the
imnov mentioned pmpeny for inspection pugarse% 1'17RMI"1'ISSUANCE 11.1.1; FRIC FRIT
(Wel agree to save,indemnity and keep harmless the City of Cuperne,ugnimt
Iiabilitiee,judgmenns,costs and expenses which may in any way acerae against saidCity ALTER OR ADD TO MECH. I'LUMBING FEF:
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO."CFM) MECHANICAL FEE
SOURCE REGULATIONS,
LL /2/O
AIR HANDLING UNIT(OVER 10.00f)CFM)
CONS'FROM[ON'FAX
/
. 0 p
Signature�ApComIowmn
EXHAUST HOOD UODULT) HOUSING MITIGATION Fi e
HAZ RDOUS MATERIALS DISCLOSURE
Will theapplicent or future building occupant store or handle harandous material HEATING UNIT CTO I00.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER Ilia"BTU)
Code.Section 25532(x)1
❑Yes ❑NoVENBLATION PAN(SINGLE RESID) PAIU
Umc HecciptM
Will the applicant or future building occupant use equipment or devices which EOILEH-COMP(3HP OR I00,000 BTI))
mit hanninun air contaminants as defined by the Buy Area Air Quality Monagentem TOTAL:
UismietT BOILER-COMP(OVER 100.000 BTU)
CYcs [-1 No,
AIR CONUI BONER ISSUANCE DATE
I have read the hamNoux remotion,requirements under Chapter 6.95 of the Cah-
forme health At Safety Cnde,SrOi 25505,25533 and 255]4.1 undefmmnd Ihil if the NEW RESIDIINf[Al.MITCH SQ,Pr.
htdlding docs not eumemly hamar tenon.that in Ls my mspons binty to nmiry tee mcnpmt
of the requiremm,ifs which trout he met prim br ixxmnee of a Ccnineam of Occupancy.
Owner tar.,amort�agent Done
TOTAL: ISSUHD I3Y.
OFFICE