S 1302 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ICt
ITY OF CUPERTINO BUILDING-E:LECIRIGM, PI I81ENO. 1302
BUILDING DIVISION APPLICKPION/PERMIT I-LUMBING-MECHANICAL
I `lUILDING PROJF.CI'HIP\HFICA'1'ION''
UILDING ADDRESS: SANITARY NO. APPLICATION SI1BMI FFAL DATT'.
02; OC,FRD , 0l`r6(501zZ
'NUN'S NAMES: PHONE CON'IA,/AOI(R NAME. LIC NO:
1/-I1pa /r- �i (?w-* pP.76;1044, a/ N/C CONTROL4
. RCH'I'IiCF/L+G Iil!R: r LI NO: UDRESS 7 ❑ g
GT 2 X\
CQN )q. PHONIi: HU ILDING 1117RMIT INFO
XConsultant Fees Paid by Applicant(Initial) _poe!, BLDG MY PLUMB MECH
LICIINMiD CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT Fli'
I hereby amrin Incl I am licensed under pmOkiom,rd'Chattel (c..mme.cing JOB DESCRIPTION
M' Z wile Semina](10(B arDmkion?anhe Ra,roes and PmBs,i...Cde.and my lecn,e is RESIDEN'1'IAI:
WOO PERMIT ISSUANCE,
H'— in lull Farce and etfe CSFDWL C KITCHEN REMODEL
�U Llceme Cbass Lic.M APYhIANCF_S-Rf;SIDIiNTIAL ❑AUDITION ❑PLUMBINGRE-I'IPE
E.ZU Ire CrSBmor
All
RCI Tf:CI'S DITCLANAFION PANELS CMUI:fI-11NIT ❑MODIPICAFIO
tnz IIndm,wnd my plans shall be used as public records MODII9G\PION
ll 11P'1021XIAMl'S ❑INTERIOR CCIII,\1NHYREPAIR
E-4t:ul Licensed Professional 201.100OAMPS IMPROVEMENT' CSWIMMING POOLS
q�y�� OWNICkIIUILDI?RUITCLABATION
OVER I(XmAMPS CRATE REMODEUREPAIR [I DEMOLITION
y a a I hereby storm mal I am cacmpl from me Comacull,Lieeose I've Bn the
x eW.0 following mason.[Samion]n?Is,puvincsv nnJ I'ndcxsion,Cude:Any Illy or county SIGNS ELECTRICAL ❑OTIIHR
❑13 y which requires a permit to comlruct,alms,improve,demolish.or repairany♦Ilnewm
I'-LL'sa pnich,i,i....a,c.m,00vWirea the applicant lin such permit In file a.vigned nminnent SPECIAL CIRCLE IIMISC.
}' that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 COMMERCIAL:
LWa C, (contraction,with Section l(XXBoIDivision lotme Business and Prnlc,innn Calc)ur LEVI,' MLIFIR OR POLE:INS'1.
a 6 1� that he is exempt Ihcrcfrom and the hams for the alleged exemption.Any violation la( ❑NE BLDG/AUDITION C DEMOI,IT'ION
Xn Seainn]0l L5byaoyapplicam linalennil suhjcas the applicvm n+n civil penulp'of POWER
DEVICES
i�QISNANT' [I FOOD SERVICE,
ti amorclh:mf hundmldollurs 1550X0. IMPROVEMENT
FZQ nLe...crel the property.or my employee,with wages as their sole mntpenavuon. 'W IMMING I'U( .IiLI�
Mildnmcwnrk,aidlhc,Imcmrc is noYntwndedorapbmd lnrsvle(See.]1XYI.Business CQT'lllik
W 3 m and Profodor,Code:The Contractor's License Law does nal apply ms an owner n' )U'1'LEI'S-: 11' '1'U
I ropcny who build,lar improv,,mere.....; I who does,u.M1 work hinmelf or mnmgh
his own employees,provided that such impmvmtmnts art not intended or laDcred for NEW RE.SIDINITAI. SC"
vele.IL however.the building ar ilnpnrvelncm i,cold wiflonow ycaral'c aomillion,the IF SQ.FL FLUOR AREA ESQ.FF.
ownct,hatilder will have the burden of proving that he did not build or improve for Bur- Q ����
❑ Inm
s owner nF Inc ppert>',vn exclusively contracting who licensed Contractors Ito
construct IM project(Sea.]PLL Business and Pr lessions Coic:)The Conorcmr's Li
se Law doe.no apply toanowner of property who builds or improves meson,and QTY. PLUMBING PERMIT FEE � D
who contracts far such projects with v rolnmeoi licensed pursuant m the Contractor's
I.iren,c Law. ,pgl'Clin OR,rcannn PEEWEE F ISSUANCE A
C] I on eaame N4
ALL
Se
ALL ER-DRAIN Xr VENT-WATER(EA) PION
Date
WORKERS COMPENSATION DECLARATION BACK PLOW PROTECT'.DEVICE YUP
ser l hereby af6nm under Fahy of perjury one of the following decimations:
F1Ihmvc anJ willnminlaina Ccnihcalcut Cunscnl mndhin,ure for Worker',Campca- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES 1i TYYECONSTRUCI'ION
nation,as provided Rn by Sectio 3700 of the Labor Edo,for the performance of the
a,'od sur which lhi,permit is Issu W. FIK'I'URES-PER'FRAP
❑I hmv:md will maintain W'orker's Con,scrietion Inarmnee,as Occurred by Section
---
3700 of the Lubin Ede.lot the performance afthe work for whado,'colt in issued. GAS-ISA.SYST17NI-I INC,J OIITLEIT OCC.GROU' APN
My Worrkay% Tim uc!)icrPolcy No
C — -�T '21CAS-I:.A SYSTIiM-OVER407 I
n T CEk'i'IPICATl:04 h%tlMPTION PROM WORKERS'
COMPENSATION INSURANCE? ONITASIIINUU$ RI.WAS'117 INTERCEPTOR 1 D I XVISION FEES
(Thowctinn I'M III(hecumplclel fthcpcnnill,broe hundred dollar,IS l led)) GREASEI'RAP
ar less) I'hANCIIIiCKM1
Ic.nify that inmryrerif...a we at tire work ba hick Ellis pcnnit isissucl l,hall SEWER-SAKE'LARY-STORM ITA.2(X)EL
I...c le,any A'nnero
on in troy nwnr an to became s.bjw to the Workers'Co.,.- ENERGY 1'171' —�
Z ,min.law,of California.Date WAFER IIIiAI'IJt W/VENT/ITI.ECI'N
z 0 APPlicmn GRADING FEE
a
NOTICE 10 APPLICANT.If.mi,,nmking this Cc itic:nc of E¢ntplion.you amid WATER SYSTESt/fRRAI'INC
I, SUITS 1=E1?
C ? become xu],yo m'he Worker's Cmnpenstnio..promsionv of the labor Cade.you am"
forthwith comply with such Pmvrsionsor'his Permit shall he deemed revoked. WAFER SERVICE,
PAID
p'
CONSTRUCTION LENDING AGENCY NEW k1iSIDl?N'I'IA1.I'LMIi. SQ.1'1'. Dare Rcccip p
U 0 IM1erehy vmnn thio there is.vromwminn lcaal'mg..geocy for theperfimemaecof
>� the work Fur which mi,Form,,is iamed(See.3097.Cir.CJ
TOTAL
O 1 L:
Lenders Name :
V Lmdce,Addresn
>" d 1 vcmif,that l have read Thi,appfcvtin I and slam Thal the above Information i, BUILDING PIJi
LF. (A) a salt l:Igrcemcalnply with all ciLyand clammy ordinancuand,rote lnwsrelatingto QTY. MECHANICAL PERMIT FIiE SEISMIC FEE
U building cOsounworivad hereby amhmiercprclrhmoc,of If.,city to cuter upml the
tr,,c-owntiol.d pmpcty for invpwnion pallor,. PERMIT ISSUANCE ELECTRIC FEE
(We)agree m save,indemnify and keel hamtless Ihc City of Cupertino against 1 �
I Ii.KIaic,.ym,mmn,.co,ts volt calwn,e,wb,tmaym any way recmcagairo,,md Cily ALTER OR ADD TO ME(IIL PLUMBING ITE,
inconsequence he gr al,m0,permit.
APPLICANT' OF ANUS AND WII.1,COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,00ECFM) MECHANICAL FEE PA
$OTRCER 1. ' R 'S.
/ AIR HANDLING UNIT(OVER QmXECI'M) CONSTRUCITf
SlgrmmmoM Ed UConlmanr ,,c EXHAUST HOOD(W/DUCT) HOUSING "FIGAII 11 S
HAZARDOUS MA'I'F.RIALS DISCLOSURE
Will applievnl inr hme Nildingnvcuparn,tnneart handle hueardeu,mr1r,ml IIEA'I'ING UNIT TO IIN),1XX1❑TUI �/-
uv dined by me Culn_e'mu Municipal C..tic.Chnpwr).12,anJ the Hevllh and Suety III?ATINC UNIT'(OVER 100.0)(S)❑TUI
Gde,Section 255320)? n/ll yV
0Ye., ❑NuVIS'DILAI'ION IAN SINGLE RESIDE PAID
Dam NcaciplN
Will the appli mit or Rome building lamup:ml use a apocrit lir devices which HUILIiR-COME'OIIP Ok IhQ1NNE 11'1111
chit hazardous air contaminants as defined by the Bay Arca Air Quality Management 'IUI'AU
Dimdci! BOILER-COME(OVER 100.010BIT)
C Yes [-1 No
I have call'he hmmlous inaterials rc9urcinenu under Chapter 095 of the Cali AIR CONUII'IONI!R ISSUANCE DAT'li
forma Health&Safety Cole.Section,255115,2551?..125534.1 mndenwlad dial o the NEW BESIDES'1'IAI.MIKE. SQ PI'.
building down nut cumendy hove a mnunl,lbw it is my respmnibilhy..+notify Ihc uc,vlrum
of the mgaireoomns which most be mel poor m issuance of a cennicate(if Ovapancy.
Owner or author:cd agent Date "lir IssUED BY t
OFFICE
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