99100116 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 10011 (19
CITY OF CUPERTINO BUILDING-ELECIRICAL. . DT'N(j
(WILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL SOOOI
BUILDING PROJh C"I IDEN'I'II'ICATION
BUI UANGAOIIRPSS: SANITARY"I A'PL.ICAHONSUBMI'UALDXII
Cu N� o o— 2-1NAME NE
OWN X:ti t : CON'1'RACTON:S AM13: LIC NO.
0 �1 11• 2 NAC /pCONIROLO
.ri 06M'f{ITIiCI'IFiWEiFPM',E1C 19
LIC NU: ;A&R ESS 3 ❑
/A G FJ o 6 l LV O
CO I'AC'f: PHONE: BUILDING PERMIT INFO
❑ Consultant Pccs Paid by Applicant(Initial) RLDGIi go PLUMR� MOI
LICENSED CONTRAC I OR'S DECLARAI'[ON QTy ELECT'RIC PERMIT FEE —�I/JOBIL—'DIEESSCRI'LPTIIIOON
I hcrchy u11111n Nat I am licwnsn]under pmvi,fore of Chapter (commencing
09ZthSectica 2BBO)offfimoion 3ofm,Business and 11 fie ons Codc,and my nccnxe is RESIDENTIAL
0000 w� PERMI E ISSUANCE
,W iZ n full fmcc and cffccl. '� Z. ❑SFDW I, ❑KTECHEN REMODEL.
aUU Liceree Class Lie
.N APPLIANCES-RISIDEN'I'IAL ❑ADDITION ❑PLUMBING RE-PIPIT
FZIeI Bum Ciaii. r�
vzw ❑MULTI-UNIT ❑STI2UCNRA(,
ARCHITECTS DECLA ATI PANELS MODIFICA'T'ION
z 0 y 7� I understand my plane shall be used as public records
OZ_, UI"f02g1AM15 El IN El CHIMNEY REPAIR
Lmeaocd Profic,tonal 201-11x10 AMPS IMPROVEMIiNT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION pypR IINXIAMPS El BATH RRMODEI/REPAIR 0 DEMOLI'I ION
C Q I hereby affirm that I am cxcran from the Contractors License Law Fail,
O L U fallowing mason.(Section 70315,Business,and PrnFormal Calc:Any city or county I SIGNS EUiCIRICAL ❑(H'HER
LL13 W i- which requires a permit to commusel,alter,improve,demolish,or repair any xmucture
col
.F.m+Oto'f� Pon no t ' split raidfor such p if to filea signed statement "CIRCUI CIRCUIT/M ISC.
S y math Ipursuant l thep fth Contractors' La (Chaffer9COMMERCIAL:
Gy00 (cnm� nvtn6wth Su"iin"Igq)nfDivision 3 dlhu Rusnu,
ad f... Calc)ofEERORPOLEINST
dy e that he Is cxcmpl Ibuefmm and the Muss for the alleged cxcmpunn.Any violation of ❑NE: AGIADDITION ❑DEMOLITION
iCm� Section 9091.5 by any applicant for a permit subjects lheappB�mnno acivil Penalty ofDI3VICIiS ?NANT ❑FOOD SERVICE
W��
not more than five hundred dollars($5(Nq. IMPROVEMENT
�Za D I,muwner nl the propunY.nnny mnploycee with wage,ue their sole cnmpensmion. ING POOL, iLECfRIC OTHER
f2L,L. will Jn the wurk,.Od lue,mclum is nUl merelvdnrnB"cord fnrsule(See 7044,11-ausc
W and PmRaviuns Cnda The Cmnma7or's License Law does not apply to an owner,ofS-SWI'ICII.:-FIXTURESproperty who builds or raptures thereon,and who docs such work himself or throughhis own cmployce,provided that such Impmvancnls um not intended or offered forgIDI?N'fI H :CTed SQ PTsale.IL however, he buildingnr improvenrenCn sold wiainnnc yearnfenmplctinn. heSUE LOONAREA $ISQ.IN'.
mer-builder will have the burden ofproving that he did em build ur Improve Far pur-
few,of sale). I OTAL'"❑ 1,as owncr al the propcny,am exclusively crmwcting with licensed cantadors to
onxtfuct he projc,t(Sec.70,14,Buxincss and prom xiun,Code:)Tho,Connaato"Li-
cunxeLawdocsnotapplymanownerofpropcnywhobuildo( proveslhcrem,ond PLUMBING PERMIT FEF.who toneams forsab pr jells with a enraua,l (s)licesed parsuanl m the Conant sLicense Law. ISSUANCEam exempt under Scc .R&P C for this reasonAL -DRAIN A,VENT-WATER(HA) VALEADON
Owner Date
WORKI3N'S COMPENSATION Dh,CLARATI(lN RACK FLOW PR(YfLC'C DI?VICI?
(hcrchy aform under penalty of perjury one of lhu following Jcelara,a s
Ih,cmd will maintain oCertificme ul Comem tuself-insurefin Workers Co'In- DRAINS IIAO .ROOIA COCOND. STORIES TYEE CONSTRUC'1'101
xotion,as provided for by Section 991X1 of the Labor Cudc,for the performauce of the
work For which aix Permit Is issueU. FIXTURES-PER'Ii2AP
E]1 have and will nminmin Worker'a Compensation Insurance as aqui,cd by Semon
3]00of theI ter Gala lonhc pcdnrmm�ccnitha work for which lhn pttmit is hued. GAS-EA.SYS'ILM-I INC,4 OU'I LETS OCC GROUP
M, kcr, - me aPolPols Policy
man yr�r�!0... GAS-HA.Sys'fliM-oVIiR4(EA) (� U!
CERTIFICXIE OF EXEMPTION FROM WORKERS' GREASH/INDOS'IRI.WAST(?INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
ftbissnion need not be wmplcted iflnc pcnnit lxfanmchundred dol lary(81(X1) GRI3ASE'1'NAI' PLANCHECK PL'Ii
or le,,.)
I rend,that robe perfunnanccoftbc work for which Im,enmit ix issued,Ishall SEWER-SANITARY-ST(IRM PA.2(X1 Fir. --
nut employ any person Mary manna,,,as m become subject to the Workers'Compete .-ENE22Yf;FFEG"--'�-
z .cation Laws of California.D:Je W'AI'1?R HCIA]ER W/VENT/ELECTR �.1GRADIh,IG FEC\
z O Appllcnvl I t
NOTICE 10 APPLICANT:It,after making this Cenifteate of Exemption,you should WAIEN SYS❑;M/fREA'IINC (SOILS FEE
PrA become subject to Ino Worker,Compcnsmmm Provisions of me Labor Cudc,you most
W Q forM1with cam with such r vUCTION Lis permit shall M:deemed revoked, WA'I'T?R SERVICE
comply P
a
CONS'1'N ENDING AGENCY NEW RESIDENTIAL RUNS. SQ,UU PAID
(hcrchy allimt that them is a amstaction leadin forme fbrmanccof Bum Recwpt
U Q g0gcncy pees
W P-' the wok for which this pernitls isowd(Se,3099.Civ.C.) rOTA
O U Lemur's Namer
Lender's Addrev,
TOTAL:
W I u ndy that I have read this application untl state thin me abuse iafonnaGat is BUILDING FEE
o-F.t QM anrrccl.I agrees to contpty with all it,and county indicans"umJ slum laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC Epp
U Z buddingenmtruction,and hcebyuuomrim mpresenmuvesofthix city to cmc t,ou.the
a swe.acoaoned property far inspection purposes. PERMIT ISSUANCE IA.IiCI'NIC PRE
(We)agree to save,Indemndy and keep la rndcxs the City of Cupertino against
hnbilitics,judgnams,cr,aand expenses which may in any way au'ruea,imtsaid City ALT ER OR ADD TO MECH. PLUMBING FEE
nn,cNima sof the gaming of Ibis permit.
APPLICANTUNDERSTANDS AND WILL COMPLY V1II ALL NON"POIN'1" AIR HANDLING UNITTO li,opp CPM) MEC({ANICALFUH
SOURCE 11 PIONS. I O'�r I
AIN HANDLING 11Nl'I'(OVER 10.000CFM) CONSTRUCTION TA
Sign: c IiemNContmemr Date P.X HAUS'I'HOOD(W/DUCT) HOUSING MITIGATION I'LL3
HAZARDOUS MAI ERIA S DISCLOSURE
Will mcapplu,nd nr fatarc hui Wingmmn,mr,lorc or handl,harnrdousmaturial HEATING UNIT(TO 00,000 B'fU)
m MEned by Inc Cma,dara Municipal Calc,Chapter 9.12,.,at the Health and Safety BEATING UNI"P(OVER 100.000 BTU)
Coda Section 2592(0)!
E]Yes C]No VENTILATION PAN(3MGLE RUSH)) l'ND
Da Nc apt
Will the applicant or future building uccupam use cyu' nt m dcv c"which BOILER-COMP(3HP OR 100,000 BTU)
!haavrdnnx air atnmminams as dcOneJ by the Bay a Air Quvlity/Mvnagcmem 1;
larlia'1 BOILER-COMP(OVER 101.000 B'I'D)
El Yes F]No
AIR CONDITIONER ISSUANCE
caul the Cods. a mltcrial ro,o5.155 3 al,an and c 'cifol,di 0l Inc if he
Emi Ica k Safety
Cods.Sections 5115.2593 end I nJtdenwnJ that if and NEW RBSIDEN'I'IAI,MGCH. SQ.IT. /1 �x
o.,/
/
h (ling tcmcntly havuatcnt t.that t,is ntY ret xihili�atnotifOccupancpam
ono
' of me i 'p rn w icl I sh•t t arm is,u0 -�Cmillenc of Ocvvpaney.
O acrorrom agent DXIc TOTAL: ISSUED BY:
OFFICE