S 2572 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ov CCPEETINO BILI LDING.ELFJC'I'RICA L PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL C+ C7
flUll.DINC1'ROJliCI'1[)ENTIFIC'ATION lJ 5J 1
BIJILDI G ADDIy-S' SANITARY NO. A1'PLICA'1'ION SURMITI'AL DATE
>RR'S � PI '�� C TRATIO'S NAME: LIC NO:
� NIC CONTROL
1":C'1'/ENOL ER: .IC NO, ADD Jt .S: ❑ D
407
Co 'ACT: PILON [/ BUILDING PERMITINFO
t
❑ Consultant Fees Paid by Applicant(Initial) BLD(; - ELECT _ PLUMB / MIiCH
,ICENSED CONrrRAAMORS DECLARATION Q'ry ELECTRICPERMIT FEE ❑� ❑/
1 hereby affirm that 1 am Iice rmd under provisions of Chapter 9(commencing JOB DESCRIPTION
ogz with SccIxm7aq)ofDivisiaa 3ofthc Busina,,mal Pmfaxslma Code,and my ketose is RESIDENTIAL;
ty O PERMIT ISSUANCE
F W P l full form enA affect. ❑SFD 1. El KITCHEN REMODEL
JA
QUU License Class Lic.p APPLIANCF_S-RESIDENTIAL. 01TION ❑PLUMBING RE-PIPE
F.zu) Too Cnmmcmr
snQa, ❑MDI ThUNIT ❑STRUCTURAL.
ARCHHECTS DEC ARA'I'10
~HZ Iundemnend my plansxhall lwuncd as pulah"ianrds P LI MODIFICATION
OZ`40 T Lv 2, ❑INTERIOR ❑CHIMNEYREPAIR
I,— Licensed Professional 111-1 TAMP IMPROVEMENT ❑SWIMMINGPOOLS
�.��'; OWNIiR-IIl1l1.HER DECLARATION OVE 1'S I BATHREN"m L�RETAIR�- 'f41L17T
C K Q 1 hereby affirm That 1 au exempt frons the Contmnor's Licence w I T the /
X�X d U 11
following reawm.(Section 7031.5,Business.nd P Rdsmns Cale:Any c Y 'I(: FLECfRI (7gr�j�R
W 3 LL y which nsc irea u permit m umamc6 abet,improve,demolish,or repair an 11 �-
�Q prior te,its issuance.also mquitus the applicenl forsuch P-rminnlllcnsigncJ suncman' • EWALCIRCII' M pJ1 _
(commencing
cme ccauat Sectio(mThepmvisianso ofT eBu'amm'x Licenselnw(s Code)9 3'�{�����
apo (commene xempth Section 9l and the
basis or of Theeged exe andon,Any
Code)or IMP.MB'1'1?k OR POLE INS'1'. •LDGIAi'
d P.e a
that he is exempt Ihtxefrnm and the hurix for the alleged cxcmntion.Any viohninn of f ❑ iW PLDGIADDITION D13 EMO I'19
y Section 9031.5 by any applicant for a permit subjects The applicant to a civil penalty of EC ER DEVICIiS ❑ ANT ❑I'OUD VCE
(mora Than live hundred dollars(SSINp, 1:V+ ROVEMF.NT
^=Q ❑ Lmownernr thcpmpan..army employees with wagesartheirsole compensation, SWIMMING POOL ELECTRIC f�
fF0 will do the wink, m]mo.Iruclme is not imendedaroffcrod hirsute(Sea 7044,Business ❑ H
last m and Vmfcs,in is Cale fl a Commaorx License Low Joos nor apply m an mvoer of OVR.ITS-SWI'TCHFS-FI%TURFS
a' property who builds or Tunisia,thereon•mW who does such work himself or through
his awn employees,Provided that such impmvemcers ore out intcndN or irritated for NEW RESIDENTIAL ELI:CIR SQ FT.
sale.If,hnwevcr,ma buildingor improvement is sold within one yearof completion.The SQ.IT.FLOOR AREA LSQ.IT.
owner-builder will have The humen of proving that he did not build or improve or pnr-
pro or what.
El 1,as owner of the Property,am exclusively contracting with licensed convacmrs to T(YTAh:
nnstruct the project(Sec.9044,13riamos and Professions Crude)The Contractors Li
cense Law does not apply to an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE a.✓a�� 5�
whocontodx forsuch pr�jectswith a contmcmr(s)licensed Pumuentmthe Cnnuumnr's
License Law. PERMIT ISSUANCE �(,I {:✓� C./ /
❑I am exempt under Sec. .B&1'C dim this reason
AI.TfiR-DRAIN&VENT-WATIiR(EA) �( ♦ VALUATI N
,no, Date
WORKER'S COMPENSATION DECIARAI'ION BACK PLOW PROTECT.DEVICE O O
hereby affirm under penalty nfperjury one of the I'ollnwing Jalarutinns:
I hrvcand will maintain a Comfort.of Conwta m,rlt-insure for Wmkcr'x Compcn- DRAINS-FLOOR.ROOI(AREA,GOND. STOR TYPE CONSTRUCTION
ation,ux provided fm by Sort lnn 3700 of the lahn Cale,for The performance of the
work far which this peound is issued. PI XTl1RES-PER TRAP
❑ I base and will maintain Worker's Cntapcnsafion Insurance,as mquiral by Section
3900of the lrMnCsde,for The perfommnce of The work for which This person is issued. GAS-E3A.SYS'1'EM-I INC.4 Oil'I'LITS OCC.GROUP 'N
My Workers Compcmal on Insurance carrier and PnITY number out:
Carrier Policy No.: GAS-EA.SYSTEM OVER 4 TEA)
CEiRTIIICAI'E OF EXEMPTION FROM WORKERSGREASE/INDUSTRI.WAST(?IM'IiRCEP7Y)R ,
COMI-17NSKI'I ON INSURANCE ILDING DIVISION ITES
This section need not be completed ifthe permit is forone hundred dollum(S 100) GREASE'1'RAP
or less.) a� PLANCH ITE
I cenify that in the perfnmTmceof the work for which This p damilis imuW.I shall f tiEWlik-SANITARY-STORAf 1eA.2W Fd'. (�D•
nm employ any peom ymmtner so as to hecotnc suhjem baba Workcrd Camper. / ^ �•� IiNF. YP
O Z satian Lnw�f Culi nn WATIiR IWATER WNEWICLECIR y-VV GRAD( T.H.
z Q Applicant ��'��'IIVVVVXXTTTT
•-t .~Ns NOI'ICI!'O Mil IA Il:It,alcor nuking This Ccnifrne of Hiworptiun,you should WATIiR SYSTHM/fRR VHNG
h , become suhjacl to her,Campcnssaien prow,ions of The Labur Cade,you nate( S :h
Wfonhwhh comply with such provisions or this nannit shall he dermad revoked. WATER S17RVICF
Q
C
U zCONSTRUCTION LENDING AGENCY NEW RUSH)EN'TIAI,PLMB, SQ.FII P )
I hereby ulfrm that there is x amstmminn lending agency for the perfonnanec of [)ate Receipt a
(J. Na work for which this Portrait is issued(Sec.307,Civ.C.)
C) Lender's Name �77BDL: 0
LUA Leaders Address HPIAL:
y I codify That 1 have read Wix application and xmte that the rhove Im ormatlnn is BUILDING IT-
correct l agrca to comply with all city and county ordinances undsmte laws relating to QTY. MECHANICAL PERMIT FEB
(C27 4
C.) 'j7. building construction.and hereby arsize reprcsenwtives of this city it)enter upon The SEI SMIC( i. 0 O
above-mentioned property for inspection prapascs. 1'17RMIT ISSUANCE:
(We)a,.,.save.indemnify and face,harmless the City of Cupcnino agmen IH.F.0 ICT .
Imbilities,judErints.costs and expenses wh ohtney inmy w.y.ceme against said City '
AI.THRORADD'I'OMECII. 12-.20
nscyucnce nl Ne gmmin
Out Permit PI.IJ EF. Z
APPLICA,' UNDEkST IS )WILL COMPLY WI'TIi ALL NON-POINT pili HANDLING UNI'I'fl'O 10,001007M) 7
S(lI1PO < GOLAI'ION MSCI CAIJEE C..
/ AIR HANDLING UNIT(OVER B)(NN)CPM) CONS ION'TAX
.'g bramApplican Contractor Uatc BXHAUSTHOOD(W/DUCT') HOUSING MITIGATION THE
HAZARDOUS MAI'(TRIALS DISCLOSURE I�r ��
V"'"a
furore building occupant store or handle louromus material HEATING UNIT(TO 100,00 RI U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
Ctdc,Seatin 125532(.)9 HEATING UNIT(OVER 100,000 BTIH
❑Yes 0 N , VENTILATION FA N(S INGLE ROS ID) (0 . 10 PAID
14
Date rat p
Will I,commcaur nrfmure building occupantuseAre.
Air
rent atQualit Managemch
ent
BOILER-COMP(7HPOR IW,WBTU)
it hararJous air cnmanTinams as Jef red by The 11ey Arca Air Quality Mana6emenl T
uric!! F
❑Yes ON. BOILER-COMP(OVIiR 11y1,IHX1 BIG)
I have read the hamrdousmaterials J AIR CONDITIONER V
requirements under Chapter rsta of the Cali ISSUANCE UA'I///F.�)y
fnmia Hea1T Salny Qde,Sea s 25505,255 7]OTOL15534.1 understand that If The NEW Rf SIDIiNE IAL MECH. SQ.Itn r•- ?,...- e./ 0
hailding rat purrcn0y have: n t,than' y rasgmslbility to notify the occupam I
,,fine IT smarts which must t rit . ....ceof an yf_Occupant
rUrunthomedageV Me(�� TOTATL' D., ISSUED BY:
OFFICE
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