S 1135 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
ItUILDING-ELFQRICAL FERMI r NO.
CITY OF CUPERTINO PLUMBEV;;-MECHANICAL S 1135
BUILDING DIVISION APPLICATION/PERMIT
ItU11.DIN1:PROJIrC'1'IUEN'1'IF'ICAT'IUN
SANI'1'AItV NO AI9'1"ICAl10N SUI'M I'I'IAI.011 1;
BUILDING ADDRESS:
V
OW 'R'SNAME: PHONE': CONTRACOR'SN Ft LI(-NO NIC CON'IRULa
Sir
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AR III Cf1EN'INEENOUR.S
R: LIC : S: (7 G '' . 1 1-1r V 4 2—
BUILDING PERMIT'INFO
CONTACT: PHONE:
' �'` ❑ Consultant Fees Paid by Applicant(Initial) HO ELISCr i IT MIR MECH
ll -2}3 IrLrQI/ ❑
LICENSED COST RACTOR;S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that 1 am Iicemal under provisions of Chapter 9(commencing
ac4Z wilt,Section 70m)of DivisionJnf,W lhaorr_,,mad Professions Code.and'I,license lx =201-1ZNIPS
ISSUANCE O RESIDENTIAL'
Woo in full force and cB' ❑SFDWI, ❑KI'TCH17N RLMOLI;l.
dVU License Gloss Lic.M ES-RESIDENTIAL [I AUDIT ❑PLUMBING REPIPH
H Q L Omc - ^ Cnntmcmr_ ❑MULTI-UNH' ❑STRUCTURAL
ARCI II'rECTS DEC LA AI'10 MODIFICATION
zba�z
rend'v�'lans s✓allhu.eJ as pub, Jv UP 200 AMPS E)INTERIOR CHIMNEY REPAIR
Q�F� Licenx Jl f1slon [�y� IPS IMPROVF;MI?NT SWIMMING I'OOhS
NIiR-BUILUf!R DIiChARAT10N AMP'S ❑BATH REMODEURF.PAIR ❑DEMOLITION
1 hereby allimt that 1 um eaanpl Iram te Contractors Liense law fur the ❑(ffHER
following hxom.(Sixtion 71315.Businessand 1'ns(caions Code:An,city or county CTRICAL
u1 LL�p N which 9 a permit t t t Iter p demolish.,), p Y t emrc
e pnot t ahs y tM1applicantl hpemtt flsigned.Pmment SPECIAL CIRCUIT/MISC.
j J thmh dpursu a th p : m' Ith Contractor's I L (Chapter 9 COMMERCIAL;
odI Irommeaeing with Section 7gX)of Divislnn 3.1 the Hudnc,,mal Professions Code)or T'I:NI P.MI?'CER OR POLE LNST.
a a c m that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEN BI"DG/AUDITION ❑UIiN1DL.IT'IQN
W_H Section 70715 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
m more than live hunJrul dnllum 155(X)} PROVEMENT
ESC ]1.as owner of the properly.or my employees with wages as their sole compensation. SWIMMING POOL 17_LCI'RIC
❑OTHER
F- will do the work.avd thestructure is not intended or offered for all,(Sec.7041.Business UU'rLETS-$WITCHES-FIXTURES
W 3 m and Profession,Code:The Contractors License Law does not apply to an Owner of
e. progeny who hnilds or Intpnrvcs tt,emen,and who does such work himself or through NI?W RESIDIiNTIAI.EI.l. SQ Er.
his own employees,ptavidcd that ouch impmvcmcnts are no intended or offered fnr SQ.PE TLoo 2 AREA
$ISQ.PT.
.calc.If.however,the building or inammcment is.mld within one year of eotnplatinn.the
owner-builder will have the burden of proving that he did not(wild or impnoe fur Pat
pool fsale.).
1,as owner of the properly,am exdwivelY enntfnchng wilt,Il rar,ed eunnacton to -2)5
construct the project(Sts.76 ,Business and Prolcssiom Cash,:)The Contmetors 1"i-
xLaw does not apply manowner of properly who builds),improves thereon.and QTY. PLUMBING PERMIT FEE
who wnnacs Ensues projects with n oommmog0 licensed parmant m the Contractors
License Law. 1.17RMIT ISSUANCE
I am exempt undef Sec. .It&P C for this reason ,
ALTER-DRAIN&VENI'-WATE (F VALUATION
Owner Umc
vWOR KEG'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVIC70 wO
1 herby aRan under penalty of perjury one)f the following declarations
I1mvemad will mviomm-Cialf-cono(Consent)Self-insuelm Worker'sforepaw DRAINS-FI.00R.ROOF AREA.CON STORIES 'TYPE CONS'I'RUC'I'Ed
satin,as provided car by Section 3700 of the Labor Code,for the Performance of the 171XTUR17$-1'EN TRAP
work fnr which this gonna ix.....L
I]1 have and will maintain Wndarx Compensation Inmounce,.s required by Section CAS-EA.SYSTEM-I INCA OD'T"i" UCC.CROUP MIN
3700 of the labor Coale,for the perlorromwe of the work for which his getout is noted.
My Wca j[ .Com tionit urunce ca IPolirynunlberme: ,,LL
'J' - p�,�_��y tic Nn:� Q67 �TYI- GAS-EA.SYS'IEN-OVIiRJ(F.A)
Cartier:�}�p.1✓fy IFICAI .OREXE CVI IO Y T —
CENI'IITCCTMPFNXIiIONINN FROM WORKERS ❑NIiASPJINUUSTRI.WAS"TE IN'TIiNC1iI'I'O
COMPIiNSAT10N INSURANCE
BUILDING DIVISION PliliS
(TLissection need not becomplemdifthe Piamon is bulawhundreddullar,0101) GREASETRAP PLANCl1ECK ME z
or le".)
Loy any lhmlnthe anymnnor of the work liar which th,,),hc itlsis Carol"- SIiWER-SANITARY-STORM Eh 210 FT. ENERGY[;]:],I
nsn employ any ifs in any manner w as L M of suM1ject n'the Workcn'Cotnlan-
z .motion Laws Of if)faia.Date YS �114 WATER HEATER W/V IiNT/ELECTN GRADING IEE
Z Applicam ??G07
Nfi fICH 1 O APPLICANT:1f,aflcr ,ntvking this Cenilicule of EsemPlam,Yon shmdd WATER SYSTEMIIREATING SOILS PER
F"
become subject to the Workers Compensation provisions of the Labor Gdc,you ores,
Wforthwith comply with such pmvisions orthis pecaut shall he deemed a.00d. WATER SERVICE
QPAID
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.14. he Receipt If
1 hereby vflimt that there Is v eoastmfnr etion lending agency the perllnemnee of
lO~" the xvrk for which this permit is isweJ(Sec.J(Y9],Civ.C.1 'IUl'AI.:
Lender's Name TOTAL:
U
L.cndcrs Address BUILDIN F
, tTythtI d0'. ppl t d:tmd 't 'M1 Rvm'i n is
linO. Icorrect I g tcomply all It 111,and ostal,affineraccl-adstate I ollicalm QTY. MECHANICAL PERMIT FEE SEISMIC IT.
U Z building e .t f and hereby authorize alammanatives Ofth ity to enter upon the
ahrvomtmioned pmpsnY fonnspnonp rpa : PERMIT ISSUANCE T:LCCIHI ItiE ,
(We)nKec o,xrvc,ardcnn ity and keep ham0ess the City of Cupertino agnalt -
livbilitiesrydgments,costa and expenses which may in my way acme agairut said City ALTER ON ADD TO MUCH, 1'LUNIHI TEF:
in conscyuenec of the gmniing of this permit. /T
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT ITO 10,000 CFM) MECHANI(M.ME V
SOURCE REGULATIONS.
AIR HANDLING IINI'T OVER III,fNXI CPM) CONSTNU NTAX
Signature of Appitamm Contra@x Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant Or future building occupant store nr handle hvardous material HE ATI NO UNIT(170 100.000 BT U)
as defined by the Cupcninu Municipal Coda.Chapter 9.12,uad the Health and Sally HEATING UNIT(OVER IOT X011ITE
Code,Section 25532(a)'t PAID
❑Yat, ❑No VENO'I LATION FAN(SINGLE RESID) Date Recci tM
Will the applicant or future building)ecupam use eyulpmcal or dcviecs which BOILER-'COMP @HP OR I00,D0 BTU)
ono horrendous air ommminants as defined by the Bay Area Air Quality Management T
'c, Uivfic(! BOILER-COMP(OVER 100,000 BTU)
❑Yes LD No
AIR CONDITIONER ISSUANCE DAI li
1 have mad the hamrdnus materials 5.255mcnas under .1 moJ(x95 of the Cuh / i--
madiHealth&Solely Code a a"nes 253115,26533 and nshifi 1 tademuml that if the NEW RESIDEhT1Al.MECH, SQ,FT.
huilding Aires not eurrcnlly have n hmunt.IM1m it in my rcnpawsibiliy to ntnly the Occupant _
of the rnNimments which mast be prior r to i.xaance of n Cenificme nl(Aeupancy. ��/
o vnc,,n.mho,ed.gem Date TOTAL. IESUI!D as'
OFFICE