S 1803 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Y I I
CITY OF CUPERTINO Bull ;.PLEC'I RICA rr
PE NO
BUILDING DIVISION APPLICATION/ MIT 1'LOh1111NG-MF.CIIANICAE � 1803
BUILDING.PNQIEC'F IDENI'IVICA'1'ION II1111.U�INGA/DDHAIi$LS; I�1L SANITARY NO. API'LICAl10N SUBM1I I'rIAh UAI'li
I.IC (1'. l L9
f/ ��N��pp���� <�A /�.��kk per'y Q NIC C(1N'I'HtI`LyIN/
�A III'11;C1'/I:NGINI:I:R: pm&I. 'N ADDRIiSSI VVtl�Z •�) �•�I� - 151,1 _❑
CONTACT: {a�{- I'H�I{�yG. Y RU ILDING PERMIT INTO
/ b 6L c l0 W 1�6 El Consultant Fees Paid by Applicant(Initiap Hl.l�i ELECT PLUMB
/ MECII
U^L� L7 I� L_
LICHNS171)CON'FRACI ORIS DECLARATIONQTY EJLEC1'R IC PERMIT FEE y
1 hereby affirm that I am licensed under provisions of Chapmr 9lemmnen,eng JOB DESCRII PION
❑a 2 Ih Section 70 Xb of Ibvj,i....)of me Batumi,and Prnfevciooc Cade,and my license is RI°SIDFNTIAL'
µ)Op wl I I'IiRMI'I'ISSUANCIi
CSF in force and c(fca. ❑SFUWL ❑KI"1'CIIEN RIib10D11,
QUU License Class Lica APPLIANCES-RESIDENT IAL ❑ADDITION ❑PLUMBING RE-PIPE
FZlal Oulc Cunua"'
yQ4 ❑MUCI'I-UNIT ❑S'1'RUCTUHN.
ARCHITECTS DE11All, 'I N TAME ti
OZ`�z lue,termand lay plunxxhal he used as pnhlicrecards 1 PANELS1XIAa1Ps MOME[CAI'ION
UP INTERIOR ❑CHIMNEY REPAIR
xE 4L, Lue.nW Professional 211-I00XIAMPS IMPROVEMENT C]SWIMMING POOIS
7..1j OWNER-JUILDIIR DECLARAI[ON j�I
s{fuyt�1 Q 1 hereby affml that I am excmpl Prom the Commnor's License Law for the IIVL'R RxH1AM1'S ❑BA'FII HBMODEI EPA(ILy DFyf1 IN
4pGU fflowi,m +n.(ticelinn]Nasi Hec+nes nJ I'n+f,ions Codc:A l rami ❑OTHER iJ ui�
nyay nY SIGNS ELEC'IRICAI.
3 4
which rey..ims a perms n,conatmet.ahesimprare,demolish.m mpmt any 9roaare
pa 'bath I E. m ppm if hp.. bill ic g nlm,,,,9 ereanl,clRcurrmnsc.
a
'bar he licensed p xu II theP Itl L I,r'sl 1 fChapar9 R •I
1+1�Cp (con 6 with Sect: 7000) fDivisionJ fth business JP f.:' ns CWc)or r'N METER OR POLE INlI'.
4 4 C The,nc,,..acinic IhereGom and the k+sis For Inc alleged exengalon.Any violation of [IN .DO/, )ETI ❑ 101.1 0
W^m Section]tills by any epplicanl for a permit subjects the applicanno a civil penally of POWIJt DEVICES
❑'T 'I' ❑FOOD Sir:
anoese In,,Lee Inn dreddellern($5IX1. ♦ 1 SpVE.❑Laxnwncro(thcPmperty.ormyentplayeeswishwakesuctheirsolecmnpcmatnn. SWIMMINGI'OOI.IILEC'TRIC ❑O' ilt 1998
F.. will Jo the work,and the structure is not intendedor offered for sale(SecJULI.Business
W and Proles.......Co 1, 'rim Contractor', Icenie Law Jon not apply to in mvner of OUTLETS-SWI" -I' 1 L
pmperty who bailor m improves atercon,and who docs seen work himself onhn'egh
his own employee.,provided Inns such improvements em not intended ur offered for NEW RESID'- .:CTR c ` IT
sde.R.however.the building or imp mvemm.It is wid.thin one Yea".1 emnplmlon,the T
erbWlder will have the burden of proving that he did nor build or improve for puts
Iroseot sale.),
n I,ac owner of the property am exclusively counting with licensed contractors to
m,In,eI the I jeer Ser.7094.Business end professions CndcOThe Commetnix L i-
sc law does bol apply ,I an owner of propery who huildnor inq....,Fherc..I.and Q'rY. PLUMBING PI AT FEE
who contracts for such stores with u enmme....OF licensed pmsoam,,he Contractor's `` J(J
I.iccn.w Law, PERMH ISSUANCE
n 1 um c,mnpt under Sm. .R A P C(or this reason I
ATTER-DRNNk V' f- 'rl?K(EA) VALUATION
O sm, Dam
WORKER'S COMPENSATION DECLARATION BACK PLOW PROF E ICF �J DO OOO
. I hereby affair under penally of lmrjuD enol the following Jccluretious:
❑Ince.and will mainrainaCenilicme of Consem molt-inwmfur Worker's Compen- DRAINS-FLOOR.ROOP,,, N, ND, STORII?S TYPE CONS]RUCI'ION
,anion,us pmceird for by Salon37(X)or ate labor Odc.for the,,crfo iemceofthe
work for which dr,permil is iswN. IgXTURGs-I'EH'1'HAI
❑ 1 heve and will mainmia Worker',Cnlna nvalinn Insurance,as required by Sectio
i]IXIOOhclann Gde.f nhc perli+mmncc of lhcwnrk(a which thix hcnnit slssucd. GAS-En.SYSTNM-I INC.4ULIIIN a. FICC,GROUP AVN
My eiders Compensation Insurance currier and Policy number am: GASB EA.SYSTEINI.OVI7R 411iA)
Currier Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' ,REA51%INDUSTRI.WASTE INTERCEPTORCOMPENSKI']ON INSURANCE BUILDING DIVISION ITIS
1'ILis oreionnndumnecompinW ifthcpennit:,rooms Hundred Jullun 1511X11 GREASE'I'RAP m l 4s.) I'LANCI IHCK Illi r
I certify that in thc perh,nnuncc of lh.w, V;Iinwhich this permil is ivwcd,l she]] SEWIIH-SANITARY-S'IY)RMIiA.21NIPl'. ,
not eatploy any person es any manner s. {y� Ict"t to the Workers Compete- HNE-HGY 119?
C) ,Z cion l.uwx of f I�am lI � I__(-; I WA'I17R TEXTER WNENUELE(TR
GRADING FE
Z O Applicum Ii
= N(YFICI?TO APPhICAN'r:If.IJmr nwking Innme oa
[Exnpyo
uon, u should WAFER SYSTEhI/IREA'rING SOII S em'.
F•' ketone%dipper est the Workers Compen,atrnn pane onats of the Lrlv)r Cala y...Inwl
Ci .moi fnnhwith comply wits such pnrvixinn.lir this permit.churl be JeemeJ¢raked WAI'I7R SERVICE
4' CONSTRUCTION LIiNU1NG AGENCY NEW HIi.S1UliN1'IAh 1'Lh113/g" / SUIT. )
7 Z ^ Dam Rttxipl
UO Frwhi,lumi,pe thereixac..acwc.3097,On.egutmybnthe perfinmunccof Vso /
Lk� F., the work For whicnthis permit ix issued(Sec.3097,On.C.) 'I'OT'A h:
Lenders Name '[OF,L: a
LenJcls AddreztI11111.DIN(l Ig7p
0. 1 rem y that 1 have mad This application and stale that the anise information is
,E'. rq correct.Iago cctoeomplywith all city and coe,11yordlnmIcsandxanelaws mtnial... QTY. MECHANICAL PERMIT PFE SEISMIC FEE 30,
U beildingamamction,and hereby maloui'm were,crou e,of ditdlym enmrep.m the
'hove-nmntionclpropcny for lnxpedionpurposes. ' PERMIT ISSUANCE ELECTRIC PEE / 2�
(We)agree m cave,iadentudy and keep harries,Ina City of Copcnlnn aaanm
Ii abiline,judgmem...... andexpen,ec which may manywayaceme almoullsaid Cny AL'IHR OR AUDTO MECH. PLUMBING ITH
aqucna nl the gmnling of this po on.
APPLICANT IINDENS'PANDS AND WILL COMPLY WITH ALL NUN-POINT' -AIR HANDLING UNIT PTO IIIIXNI CPM) MECHANICAL PHI:
SOURCE REGULAI IONS. II`1 yy�I
AIR HANDLING ONE I(OVER I11.10k)CEM) CONS'IRUCFION'FAX ��S
SignulureoF'Appllcunl/Cmerucam Date , EXHAUST HOOD(W/MICG HOUSING MITIGAr10N PEE
IIAZARDOUS MATERIALS DISCLOSURE
wl]Ims,,,l'mznl or lerem huilding oceapum"I'm lir handle ha,ardnus mmenel HEATING UNIT PTO II0.000 IFTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and Fire Health ,It Safely HEATING ON]'I'(OVER 100.0U)
Code.Section 25532(ul'I
E]Yes F-]No VIWT[LA1'ION PAN IS INGLE RES IDI PAID
Dam Rcmlp a
e WIII Ino appbe,ml or homebrilda,o,,ap,,h use r,eipn+cm or device,which BOILER-COM it(JIIP OR 111111xd)IITU)
mit ImAndous air commmnants as defined by the InY Arca Air Greatly Management TUTA
OFseicfl BOILER-COMP(OVER Isfbi IfIB'rf)
C]yes No
I nnercud the humnloacmam...1,re I.under Chum"(195 of the Calm AIR CONDITIONER ISSUANCE DATE
25533 n
fnmio Health r Safety Crde,Sections 255115.155D and 25534.I understand h Ihm if tire NEW RESIUIiN'TIAI,h11iC11. �(y� .I W.PI'.
oftherg.wcvnmsm1nicyr,l atmwllLioEll it is111,uaceof;,Cerliyc"he noblyhe
nl the rcyuircltmnm which ln,nlM and Prinnn issuance bra Crnilicac of Uccapxncy. •/T/
Owner lir mmhnirtJ akent
Dane TOTAL: ISSUEI i
OFFICE