S 1873 y APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-h1{R:CIRICAL - —relJ rr NO.
RUILDINGDIVISION APPLICA'YION/FERMI" PLUMBING-MP61ANICAL. 1873
..1111.)ING PROURC'r IDF:YITF1C'A'1'ION
BUILDING ADDRESS: I I I I a jSNIrAIRYNo. APPLICAE ION SURMITI'AL DATE
o w01," b, cN�1 7OWNI!R'SNAMR: YIIONI!: CON���JJ :T�
A{yACTOR'S NAME!: LIC O',X � - � -/ir CON'I'ROI,p
as
R'fll l'.Cr/IiNGINCIiR: LIC NO' ADDRP_ti5: N
Cor
PUDv2 BUILDING PERMIT INFO
C0N'I'ACT
❑ Consultant Fins Paid by Applicant(Initial) BLDG IiL^li PLUb1R nE!!t,
LICHNSEDCONTRAMORSDECIARAf1ON QTY ELECTRIC PERMIT FbE tr�J�/ L`_T `ir�l' rLJd
I heresy alfmt fra Into Iicenaad mider nmeidar,I, Chnpmr 9(o,mareenamg JOE DESCRIPTION
OC2 with,ectinn](KKII nfDiviainn3of,he Business and Professions Code.ant my licenm i. ^) k'�O RF,SIDENTIAh
alp PERMIT ISSUANCE J r/
�LLO in roll fitrcc and ell ❑SFOWI, ❑KITCHEN REb10Uli1.
QUV Joey �Fz Lic'n APPLIANCES-RF_NIDEYI'IAI. ❑AUUI'1'ION [I PLUMBING kI:PII'li
'rZW Dam L'nntmctar
r�Qy ❑IVELLO-UNIT ❑STRUCI'URAI,
AHCHI'I'ECTS UIiCLARATION I'ANBLS
ZOO, Z I undersand my plans shall M wind us public record. b10DIFIC,\TION
UPT0200AMPS ❑IN1U1UOR ❑CHIMNEY RI!1'Allt
F-�FW hicensd Pnffcsinnal 2111-lam AMPS IMPROVEMENT 0SWIMMING POOIS
OWNER-BUILDER DECLARATION OVI!N IfXXI AM1f PS
3 E)RATH REMOD:LRFPAIR ❑DEMOI.IIION
E hereby union that I am exempt frons the Contract i,menac haw mr opt
x d O loIIowi ng rn ssm.(Sect ion 703 1.5.li asincex and I'rote xriow Core:Any city or county SIGNS F,I.i!CTRICAL El O'IliliR
VJ tL y which requires a permit to conmtuct,o ltc,improve,demalkh,or rcpoir any auucmre
ilp� for In he 1,1male.a111,retluirch fila upplic'am for Itch ret it flaaaigned watentem SPECIAL CIRCUIT/MISC '
not he is licensed Pur.ment wlhe Provisions of the Commmor'h Livens Law(Chapmr 9 FR 1 1'
�3apO orrmnencing with Sc,rnm7000)of Division 3 of One Burin:,and 11 fcaamm Codc)nr 'I Pit 1'.M BEER OR POLr .S .
G.L q that he is escmpt therefrom and the basis for the alleged exemption.Any violation of EW ItLDGIADDI'I'ION
❑DfiMOIJ'IION
Section 7031.5 by any uppllcanl Be a l'<rmit sOilo ,the applicant m a civil penalty of IOWIiR DI!VICY:S / ❑TIiNANT ❑I�OOU SIikVICE
I mom then live handled dollop(E500r IMPROVEMENT
n
. xm �l.us ownerofthe Propeny,nnny entploycea whb wager na their rot mntpewmlan, SWIMMING I'110LICLECL
RI-
�'=p willdothevnmk,i it the'manare lr molimmmdcdo,offimd fm sulc(Sce.704J.Ruaiocss ❑OTHER
Cf"o O
at ars nal Professions Cede:The Commctor's License Law door not apply Io rot owner ti Otill LE-1 -SWITCHES-PIXTUR..
propcny whit huildr nc Improves there .and who does,wch work himself onhm ph
his own a ifloyceh,provided that mch impmvcum n,arc not immndcd m offered for NEW RESIDEN'I'IN.ELE(C.'R SQ IT.
%an.IL howover.Nin haildtng or lmprovemcal it sell within tine year of completion,me SQ.PI'.FLOOR ARBA $ISQFI'.
.
owner-builder will have the humen of proving that he did not build or improve for pur-
poarr0sale.). l 'A 2'�
❑L as owner of the propcny,am exclusively contracting aim licensed!centraetnra m O O C
Or mmrua Wm numb(Svc.714a,4brionoss and Pole,,ions Code'.1 TIN Cnniracmr',Li- /
sense Law docs not apply to an owner of propertyx'her bunts or improves thereon and QTY. PLUMBING PIRMIT FI7E
hornntrvar orsuch project.wish a cont rcloo(X)Ecmtsed P,Or.uunuo the Comnmmr'e
Liccn.ac law. PERMITISSUANCI! S• OQ
0 I am exempt under Sec. .II IN P C for this roan.. '
ALTI!R-DRAIN ON,VI!Nl'-WATI!R Book) \ l(r
Owner Dem
WORKpR SCOMPF,NSATION DECLARATION RACK FLOW 1'ROfECI'.DEVICE! /
I hcrtby affirm unokr penahy of perjury one o,the lbilnw
I huvc and will mainimnn Ccnifcalc nl Genion,mxlf-Insure dcc ' m ,
STORIPq TYPE!CONS'IRUCI'IODfee Worko,r',Cnmpcn- DRAINS-FLOOR.RODEAHACONU. 20
,mind,as ryovided for by Section 3700 of,he Labor Cole,for the performan or of thin
��` ���yyyk nor which do,pros,is lx'ucd. FI%TURKS-E'ER TRAY
JIQ I have and will mainuin Worker's Compensation Inaumnce,as required by Section
-PlOuf file Labor Cost,go he vnikenranceot the work fur which flus'permit it issued. GPS-6A.SYSTEM-I INC.JOUTLITS f -Z C.GROUP ) "^
My IN dO r'a Csm nsI lmuraneccarler and Policy numhc
y Carrier: CT'X EFUND Polity No:/3. an A32 � GAS-IiA.SYSTI!M-OVERJIF.A1 v
IQ CERf119CATROFRXEMPT[ONFROM WORKERS' GRHASI9INDUSTRL WAS 117 WfERCPP`[OR
COMPUv SA'I'ION INSUIIANCIi BUILDING DIVES NPEIi.R
OThia.,,,Nm,cednm W complmcd Tile III lir,forma hundred dollars($I00) GRI!INSTRAInf�O
It
'FEIi
or l
Ic,mymm in lilaperformance ofmc Turk for which his peril is issued l'hall SEWER-SANITARY-STORM EA.'-IM FI'. O
not employ any person in any nmnterso as to become subject u the Workers Comp:..-
Z 'mien Lawn of Call l untie.Data WATER HEATER WNI?NTIM.ECR GRADE GITBE
z 2 Applicant
NOI'ICC'I'G APPLICAN'C It'd Rcr neaking lln.Cttfifcate of Recantation,you hhnuld WATER SVSTEM/IREATING 5011 FEE
become abject ,,,he Worke(e Comscalla on pmvisiom of the Labtn Cale,vee mart
W Ionhwim comply with wch pit si'tonx ro disk permit shell be dcer ed revoked, WATER SF.RVECIi O O
QPAID Xa
CONSTRUCTION LIiNDING AGENCY NEWRCSIDI'.NTEAL I'LMIL SQ.19'. Dam Receiptar
ZD Z
affirm
O I leachy am that there is it carolmction landing agency for the paffarance of
U
UF the weak for which this Penni,Ir i,aned(Sec.9097.Civ.C.)
U. Lcndcr'h Nnnte
C) W Lcoi Address BUILDING 1717E
I ovnily dhm 1 have nand this application cart sum that the aMtve information is q
F' N correct.l agree to comply with all city and county onllnance,and.cane laws rimming to QTY. MECHANICAL PFRMI'F FEC SEISMIC Flit: -3 p Q
V Z buildingcnnrtruction.and herebyan,hnrircleple,wmaroo,rolthiecity to cmcrupen the �/] X
aMwc-mconeopc
ntiJ pro far insp,zuon puRwss. pl!RMI'I'ISSUANCE (% I7IJ2Cl'RIC Irp
(We)agree to aavc,indent atify and keep hunnlcax me City of Cupertino against /
Iiabilhiea,juJgmenls,co..oinedexpen,eawhichmayinar,v,Yeecroealrou'lsaid Cit AL'IERORADD'TOMECH. ERIN / 0
I. m.,pon a of fhe granoug of thi,permit
APPI,ICAN'1'UNDVRSTANUS AND WILT.COMPLY WITH ALL NON 1'OI AIR HANDLING UNI'1'(TU IU.1Xq CPM) { Z MHCIIA LI'I!ii p
SOURCE RIiGU I Its
AIR IIANUhING UNI'I'(OVER IILgxICPM) CONS' 71[ON TAX OQ0.
Signmurc IIIApp fcfML'nntmc4a Dam Ii%HAUST HOOD IWfDUCT) HO 41 MITIGATION II!li
HAZARDOUS MAA ERIALN DISCLOSURE
W'dl f he upplicunt nr l inure building acvpam"onemhandlc hmurdouv material HEATING UNIT(TO 100,000 RTU)
as deGted by the Cupenino Municipal Code.Chapter 0.12,and he Health and Satcl} 111!ATING UNIT(OVER IIXLIXXI BTU)
C...R Scctian 15572(a)'7
OYev ❑NoIN
VI!NTILA'DON FAN(SINGER kFSID) Date Receipt X
Will the applicant or future Wilding occupznt use equipment or device%which HOURS-COMP Ca Ul OR 100.010111 GO
mil Imrardor.air contaminants a.dciined by thin Boy Arca Air Quality Mnnxgonenl O T\i l' L: O
I � Uininm'.' ❑ MOILER-COMP(OVRR IIIQIIW R'rU)
❑Yo No
AIR CONDITIONER ISSUANCII DATE
1 hose scat the baeallou..ntmcrialh mnalemcm..and Chapmr 105 if Wa Cali.
foraiu Uealth P Safety Code.Section'25505,25533 and 25534.1 understand that if,he NF:W RESIDENTIAL MECH. SQ.I.11
buildingdoes no,currentlyhavea tenant.thm'n is mYmsp anility to unity the occuPan,
it the rcquirentenlx which loom be met prlono iaro:me,of..Cenif,aouf Occupancy.
OwncroraumarircJ agent U,nti T ( ISSUED BY:
OFFICE r