S 1337I-
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CDPD.RTJNO RIIII.DING-KI.KCpRICAL PIE IT NO
ISBn BJNC, 1)IVISION APPLJCS1'ION/PERIVNT PLUM
PROO-MP:CENTIFIC 1337
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COMPACT. PHONH I, .BUILDING
PERMIT' INFO
BLDG IT Cr PLUMB MULCH
T4tps'
r0 ^ 1:1 Consultant Fecs Paid by Applicant (Initial)
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LICHNSIED CON 'rRACPOR'I IIHCLARATTON QTY. ELECTRIC PERMIT' FEL,
JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of chapter v Into wmang
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whM1 Scmi..n LX)00 of Dtvisi..a3oD cirri Calc mit my I nseix
PERMIT ISSUANCE
RESIDENTIAL:
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nfull farcc:md cOc
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❑SFDWL ❑KI"rCHF.N k13MODFa,
QUU
hiccnm Ela Lica APPLIANCHS—RRSIDEN'I'I AI.
❑AUCHION ❑PLUMBING RI: -PIPIT
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pate Comracmr /���
❑h1U1.T1-UNIT El STRUCTURAL
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AR F.CTS 1'ANCIS
MODIFICATION
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or
1 undcrsmnd my plm.s xhWl be Deed ns pa m rccnnk Oil 'CO2fX1AMPS
❑INTERIOR 1-1 CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
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Licensed lYofessional NII-IfX1U Ah1Ps
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OWNI7R-BUII.DFR UECLARATION OVER IfkNI AMP$
❑ Bad It RFMODE1/REPAIR C3 DEMOLITION
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I a01na that I ant cxeuipt I'mn. die Commdm's 1kerma Law I,,, the
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hereby
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following reason. (Semon 7031.5. Business and Pmlcsaions Cede: Any dly or aoumy SIGNS HLECTRICAL
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y
which requires a permit to construct, alter, improve, demolish, or repair any sweture
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pr t is I :thapplicantf x. hltt signedsttement SPECIAL CIRCUIT/MISC.
pjY.,that
he licensed pursuant tile Provisions III fh C t' t I' L (ChaphrY
INS' ll
COMMERCIAL:
C OQ C)
(commencing with Section 7000) of Division 3 ofNc ltuincss and Profuvom Cock)... 1' EMP. NIFTER OR POLE
❑NEW HLDG/ADDITION EDDIih1GLIT10N
y
XX
that he is emorm thcnm froand the basis Birdie alleged exemption. Any violaion of
,
ticchon 70.11.5 byuny uppin,nt forupcnoul waffect, the upplil,mr m n civil puwlty of POWBk DIiVICES
❑TENANT ❑ FOOD SERVICE.
am marc Ihim five hundred dollars (S500).
IMPROVENIHN'I
El SWIMMING owner of the pmpeny. nr myeniployceswitM1 wagesmd+cirxole compensation. SWIMMING POOL ELECT RIC
❑OTHIiR
'EFS
will da the work,and thcmmumm is not intended crofercd[ornate (Sec. 7144, Business
nmr'x Lee., law docs urn apply loan owner of OUTLI?IS-SWI'1CfIEs-PIX'rURES
mid 1'...imisCn 11,1heCnuuc
mI
dam
property who builds or improve.\ Ammon, and who dies such work himself or through
NFW RISIUENTIAL [LHC!'k SQ 1"1' .
SQ. FT. FLOOR ARHA LSQ.IT.
provided that such improvements are rad or offered for
his own employees, prom int
sale. It. however, the building (Itimprovanenl is sold within nun ycar.femnpleamr. the
v
owner will mise fire hunlcn of pm Ing that he did not build or Inip.ove for per
Iroxc of sole.) TOTAL:
❑ I. as Owner of the pmpcny am exclusively contracting with licensed couracmrs m
p�
P
msavct the project ONre. 7044, Business and Pralessiuns Cada:) The Contractors l.i.
curve law daesnnt apply to ah I ime,ulp. f,riy who bunds or....proyes thumon,and QTY. PLUMBING PI?RMIT FF,E
D
who ctomicw for mch projects svitM1 a conlowto (s) licensed pursuant la the Cor anclnrs
Liccnxc Law. PFRMI"1' ISSUANCE
AR 9 ,
I uT exempt under See , It k P Clint this reason
ACR?R-URAIN&VENT- HiA) C/"
LUAl'ION
Owner [)are
_
Ul• `Urr'IIX�
La /
WORKER'S COMPBNSATIIIN IIECLARACION BACK FLOW PER F 1)' CF
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I hemby tti'lion under pnndly nr uTjr, one of the f lluwing dcclaral us:
I have and will maintain a Cctificac of Comentfn.sdf-insure, for Worker's Compen- DRAINS -FLOOR, RI '.A .A,')NU-
STORII3.q '1'YI'13 CONS'I'ItUC'I'ION
which, as Provided for by Sermon 3710 of the lamor Code, for the performance Of the
work lit which this petnnt. issued. FIX URGS- PF.RTRAP
❑ 1 have and will n.mnudn W ..kers Cntoper"Bon Insurance, as re,ured by Scainn
3]1X1 o1'Ihc Labor ClNq ht the pcdnnnuncc of Ne, sod for whichd.isqpem.itisixsed, OAS-:A.SYSTEM-I INC.40U1'LI?'I'S
OCCGROUP MIN
My Wnt n w sure currier and Polic, GAS-BA.SYS'1'Cht-OVLR4(EA)
Currin Polity NO.:
CERTIPI'AIIi OF E%13MITION FROM WORKI:RS' GRHASIYINDUS'I RL WASTE INTI HRCIJsrOR
COMPENSATION INSURANCE:
- BUILDING DBES1ON FEES
(Ihi,melimirecdent hyeanple,sfthep,mat is fineaehandreddonasCMOU) GRHASETRAP
PLANCHECK Flit:
�
,it less)
ENERGY FEE
I ccnify lh:n in 0e, perli.rmancc of the work lit which ihitj�I�m.i',,,,sued. lshill SEWER -SANITARY -STORM IiA.NXIFT.
notemplay an)'pcmmm ilflDbr nl�ubilA age Wnrkcrs'Compcn-
anncr so qI
GRADINCI FEB
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.motion l r C C] WATFR HFATER WIVE PHLECfR
nppl
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Cenilicalu Exctnplinn, xhmld REA'1'ING
NOR�U . GANr: 11: after making Ihiv nl Ynu WA'rFR SYS'rliM/1
SOILS IIFF,
F
become Whjccuo the Workce% Compensation pmvisiam Of the labor Code. you must
ti
fonhwith comply w ithsuch provision% or this I vani I shall M deemed revoked. WATT:R SERVICE
❑
PARI
y
CONSTRUCT LENDING AGENCY NFW k151DEN'1"IAL PLMH. SV. IsI''
pace Receipt is
UO
Therebyefine thatmitissacansteefi3097,Cng agencyfur the performuncc of
me.i,oro-car
'1'O1A 1.:
the work for which this permit is issued (Sec. 3010], Civ. CJ
W L~
Name,
0ULenders
TOlA1,:
Address
RUILUING FEC
}�...st1
Iami
ccnify that I have mad this application and was, that the ab se infom.minn e,
Fry
cnrnru logreum comply with all city and wu...yoninuncun;aid slate laws relming lir QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
U
Wildingnmstiumion, and hereby aulhnrisc rcprexmtaiivex nl iFis city lnemermion lire
ELIiCfRIC FEIi
above -notions: pmpenY for inspection porpmec PCRMII' ISSUANCE:
t Wq agam lex save, indarmly and keep Iwmdass the City of Cupetihn against
PLUMBING F1313
liabilitics.jud,,,em.. costs ondex,r, whlchnmy m any vveynecme again.asaid City ALI'HR OR ADD1'0 MI:CH
I. nmsequentt of Clic granting of this permit.
MECHANICALFcE
APPLICANT UNDERSTAN NO WILL COMPLY WITH ALI, NONPOINTAIR HANDLING UNIT(TO 1O."C1M)
SOtJkCF REGULAI' 1
CONS' I'RUC10N TAX
Atli HANDLING UNH'(OVFR 000
Atli
k
•ofA r/Confburn, Dale I EXHAUSTHOOU(W/DUCT)
HOUSING MITIGATION FI3F
HAZARDOUS MAr1:RIAI.S DISCLOSURE
Will the upplieanl or rummbuild'mg.ReupunI.tent handle huaallous railroad HFA'I'1 NO UNI' 1'(10100,000BT0)
ase definedby the Cupertino Municipal Coda, Chapter 9.12, and the Health and Safety
BEAT UNIT (OVER 100.00)H'rU)
Calc, Section 25532(.)?
E3 Ycs ❑No VEN'I'1 LATION FANS I NGLF RIISI B
PAID
pant Item, 4
Will the applicant or future Wilding mousing use equipment or devices which BOILHR—COMP (3HP OR Hlo.(X0 BTU)
gecnt
our Nvmdoos air conumlnanu as defined by the Bay Area Air Quality Munam
TOJ'AL
Dreman? B011.1:11—COMP (OV HR I IXI100 BI HE
❑Yes I]No
ISSUANCF DATE
I have read the hwsWous materials rsag.irenems under Chapter 6.95 of the Cal i- AIR CONDEI IONBR
retain: health IN Safety Cole. Sections 255115, 25.533 and 255,14.1 uadewand that il'the NFW Wild DFN'I IAl. MIiC 11, SQ. Is1�
building does not currently have a Ruanl that it is my responsibility to unity the occupant
of the requimmu ns which must be nett prions I\wuance of a Cetificatcof(keupmicy.
'rfYlAl.:
ISSUED I{Y.
Ownarntaullutinsl agent Dam