S 1208 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECYRICAL 1`171µ+1T NO, O H
BUILDING DIVISION APPLICAT'IONMERMIT PLUMBING-MECHANICAL J
rBUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS SANITARY NO APPLICATION SURS11TTA1,DAFli
OZn9-41 AL W' L S M E: 0� I'lIONLi: NTRACTORS NAME: LIC NO: 2;-4r--9f
NIC CONTROL#
itARCHITECT'/IiNGINFER: LIC NO: ADDRESS
• ❑
G
CONCOCT PHONE: BUILDING PERMIT INFO
❑ Consultant FCes Paid by Applicant(Initial) BLDG 1:1 Oct PLUMB MECH
ED ❑ ❑
LICENSED CONTRACTORS DECLAItA'I]ON QTY I?LECPRIC PERMIT FEE )OB DESCRIPTION
I bemhy nIRmam I(bat I licensed underpmvisiu I,of Chute,1)(tturnamncmg
oizz wilhSmrion 7lNNp nrDiviii( 3,ddm Businc,and PmFe,sionx Cndc,and any l'ImmIci, RESIDEN'rinL'
m O O P17RMI'I'ISSUANCI:
C F n full Ilamanderten, ❑SPOWL ❑KITCHEN REMODEL
aUU Liman,Clara Lice APPLIANCES-RESIDHN'I IAL ❑AUDITION [I PLUMBING RE-PIPE
FZW Dam Comrvcror
v <=. gRCHITECI'S DF,CLARAFION ❑MU[9'6UNI'F [I STRUCTURAL
Z~OyZ I understand my plans shall be used as public records PANELS MODIFICATION
OZ-Q UPTO2I0AMPS ❑INERIOR ❑CHIMNEY REPAIR
Fl.21Z, Licensed Pofiecsional 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATIONOVER Eaton AM1tl'F C]BATH REMODEIJREPAIR EJ DEMOLITION
6 1 herehy allina tam 1 am escmtheew,
pt from e Contractor's Lic law for rbc
c'C)W F following onewan.(Section 70315.Business and Professions Co.Fe:Any city or county SIGNS ELECTRICAL ❑UIIIER
ca
y which Inquires a pond to conwam,alter,improve,demolish,or repair any structure b
^u'O�
print it) isomeric,ala)requires theapplicam forwch permino file asignedrrntemem SPECIAL Cl RCUI'17M ISC.
� that he is licensed pursaanuprevisions o IM1e pvisions of the Contractor'.%License Law(chapter 9
C $y.6 Iconuncncing with Smunn7(XXp of Divicion3m ire Raciness end l'nafescinm Cilli TENIRMITFIiRORPOLEINS'C COMMERCIAL:
d y o yOy� that he is exempt therefrom and the basic for the alleged exampdon.Any vineninn of ❑NISW SLUG/ADDITION ❑DEMOLITION
Km4. Sccrion7(IlI56y any applicum fitapcmair snbjecte the upplicnnn nna dvil pcnupy o[ POWER DEVICES ICIiS ❑'IHNAN'1 ❑Fool)SERVICE,
N arinam Earn live bunArddollon(SS(Xp.
F Z^Q I,as owner of the n LMIROVIiMIN'I'
pngaa yor my empinyacr with wages rev Eheir sale eonlpen,mlinn, SWIMMING I'(1(ll,IiLliC'DtIC
Cl will do the work,; didemondare is not intended or offered l or.sold(See.7194.Barinecs ❑GLIIL.I<
a'�-'m and Profession,Code:The Commemr'v Llcemc Lew docs nor a I Io on owner nI OUTLETS-SWI'FCIIIkS-I•IX'f URIs
�3- pry
property wen h Ids or improves b rhsuch and who docs such work hinssclf or through
his awn cnarloyttw,provided ohm such impnavcmcnu arcnm intended nr oflcred liar NEW RI!SIIIIiNTIAl.Iil.liC'I'R SQ FT
xala.if,hnces,IM1e building orimprovement I,,.Id withinane yeondenmplehato the SQ.FT FLOOR AREA 5/50.1'11
oroxned-lbrilder will have the burden of proving than he did not build or improve for par-
pnm of sale.). TOTAL_ O
n 1,as owner of the progeny,am exclusively contracting with licensed corral to 1
construct me pnajttn(Sm.70,14.Business and Pmfocions Cocc:) Comme'nt's Li-
xa law does not apply to an owner of properly who build or improves thereon and QTY PIA aPERMIT FEE
wan ctmtmcts far such pmkcts with a cammodua(y Licenwd pursuant m the Contractors -
Liceme Law. PERMIT ISSUANCE
1 ren exenapa under Sec. .H&1'C for this reason
ALTER-TRAIN&VEST-WATER 1 VALUATION
Owner Dme
. WORKERS COMPENSATION DECLARATION BACK II.OW PBOI'I;C`F DEVICE O O
1 hereby affirm under pcnaloy of perjury one of the Following Jeelarammr
I little and wilhnniumin'CcnifmareA ConscnuosclLlnnure lar Workcr'x Conapen- IIRAINS-IZ.00R.N(H)F,ARIA.CONI) ,FORIES 'Typo CONST RUCI'l(IN
,aron,rx provided Iia by Scoliun 3700A[lie Labor Co t,for the Iwdmnaancc rel Tec
work Ga which alis pe nait Is issued. I'IXTl11i13S-PI?R'I'RAY
I have and w111 maintain Worker,Compensation Insurance,tax required by Section
37X1 Ache laor Code.for(be performance of the work far which l laic permit is ix\aoil. GAS-EA.SYSTEM-1 INC.40CrIld,I'S (ICC.GROUP AI'N
My Will ❑nnPcnwuon Inv cc c and Palley nunnlm
Cumicc � m Ynlicy Nu.:�o�2Z- GAS-EA.SYSTIiM-OVL'R 411?AI
Cli AICA' oPPIINN FROM WORKERS' GREASEIINIXISI'RLWAS'lli INI2RCliPfOR
' COMPENSATIONENSATIUNATIONINSURANCE: Il11LUINC DIVISION IBES
(This.secrionnecdnmbcoompimed ifrheprofit iOuronchundtd Jollarx(SIW) 6116ASIil'RAP
I'L\NCIIIiCK FEE
Lmnify thatinin anymannrofinewesubject
chis'he W rkm,'C.Ishall S17WF.R-SANITARY-STDHMEA.2W FT.
not anploy any Person in any manner so u,ro become subject Ire the workers'Compere E
NERGYE
Z ration laws of California.Date WATER BEATER W/VENT/ELECfR T:
zo Applieant
y NOTICE ro APPLICANL':It,after making this Ceniticme of Exctnption,You should WATER SYS'IEMO`RVXI'ING SOU_S
a ? becnnic subject to the Worker's Compensation provisions ut he labor Coda.you mut
tunas lh calnply with.such prow en or this Permit shall be Jen red revoked. WATER SERVICE
0. Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDIiN'I'[Al,PI.MIL SQ.IT.UOI hcmb Linn d,flcm isamon,f( lcndiagnga'aacy loansFb1bonb ac col Dutc Rcanipl itIbc work tar which Ieix pcnnn it ixvud(Scc.3(197,Cv.CdTO'pULenders Nunc
Lvndcrx AJArcry TOTALQ.7 I Oaify mar I mice tend[his arpremion and,tam Baal the above ial union is lat
a
F mer
to c men.l lglcemcoanply within city and county otltnamen and state laws reaaringw QTY MECf1ANICA1.PIiRM111'r FEE SEISMIC FIJI
UZ ad,on ngcnnsrmcrinn.ary hereby aumon prposel.nmrivcr rel thiocity nacmcrurym the
aMaca(Weinndpfofindmnify an keep ha. PERMIT ISSUANCE Ii1,liCfRlC PER
(We)agree lost,inJemnif)and keep hannlexr the City of Cupcnino against
Iiabifikim,judgmmnts.euxrt andexpen¢z which mayinany way accrvc againa lid Cip' ALTER OR ALI)to MECI. PLUMBING ITE
in consequence of the granting of this permit.
APPLICA NT UNDIiRSTAN DS A ND WE LL COMPLY W ITE ALL NON-POINT AIR HANDLING UNIT Drs 10d000CFM) MFOUNICALF617
SOURCE REGULATIONS.
AIR HANDLING ONE'1'ROVER 10.1900 CPM( CONS'I'NUCFLON'I'A%
Gl Signature of Appliennt/Conownsr Ilam EXHAUST GOOD(W/DUCT) HOUSING ME'TIGAT10N PER
1\VIII IV HAZARDOUS MATERIALS DISCLOSURE
\Y' Will the applinana or future huilding weupnnl store tar handle hemrdotsomerlal HEALING ONIEll(TO HIFF(k)BTI I)
'ns Jotined by the Cnpcnino Municipal C dc.Chapter 9.12,enol Glc health and Sari HEATING ONE'I(OVER I(XI.(mO 111 GO
Code,Section 25532U07
❑Ya, E]No VENT I LX[ION I-AN(SI NO LI!RES I U) PAID
Dane Rucipr a
-� WIIl the applicant or future bmidialt,,upon me ofoun rnt it,device which BOILER-COMP OHP(1R 100.0)(U BDL) latilla
suit haaanloux air co human,a,defined by the Iny Arca Air Quality Management
Cont BOILER-COMP(OVER I(X).fXX)11'1 GO
❑Yes 13 No
I have read he hvallous d1 mmene under Chapter 6.95 of the Cali- AIRCONDIDONER `�$SUANCE.U41FE
fomin Health&Sulity Gde, m 2 5 S,2 533 and 25531.1 mxlerswaad that if me NEW RESIDIiNT1Al.MliCll. SQ.FT 2�- J ^9 CJ
IOh- huildingdortaxxmmml meat t s y revrymxibilitylomxify the sccupant
Iklll�p'4E7AI of ahs raidemenw ch must t n a Cenificme.1 Om.pE=r ^
OwnernramhuriI agent 1—lata y TOTAL. ISSUIDBY',�✓� --T
O
OFFICE