S 1304 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CIJPERTINO IIUILDING-INALLT'R1CAL PLI8IT NO. 1304
BUILDING DIVISION APPLICATION/PERMI,P 1'hI1A1111NG-MI!CIIANICAL l\�
BUILDING PROIFILI'LDEN'I IFICATION
IIIt II,DINis ADPRES£ SANITARY NO. APPLICA'T'ION SUBMITI'AI.DAF
20 _ 8.
OWNER'S NAM13 PHONE: CONTRAGTOR:S NAME: LIC NO.
�Sfl--f4'.1� ^�-. QN7Q (N kl�N�sliOle�N NEC caurl(ul.a
RCI{I'fliCf/ENGINEER: LIC;VO: ADDRESS: ❑
RACHARD t4A'RO v
CONTACT: PHONE: BUILDING PERMIT'r1NFO
d*If—+1 Q Q ElConsullanl Fees Paid by Applicant(Initial) {}LUG EL PL MECII
LICF;NSED CONTRACTORS UECLANATION Q� QTY ELECTRIC PERMIT FEE TMJ
1 Hereby unina that I an FELL under provisions of Chapter 9(cmnmereing JOB DESCRIPTION
MWZ with Sr oum7flmO)ol Divisin I3ol,hcBusims,end Ptofcaslons Cude.mndmy l ire.se 1. RESIDENTIAL:
W 0O PERMIT ISSUANCIi
F W 2 in full lease and eft O SFDWL O KI'1'CHIiN REMODEL
aVU Liceme Class Lic.# APPLIANCES-RESIDENTIAL AUDITION OPLUMBINGRL'-PIPE
Q 1 Datc Ce.tmclor
ARCIUTECI'S DF,CIARATION1'AN[LS MULTI-UNIT' OS"rRUMURAL
ZpyZ Idersandmyplans shall beusedis publiccond, MODIhICATION
un
0ZUP TO NXI AMPS C1 INTERIOR O CLUMSILY REPAIR
Fh.�.W Licensed Profeseinnal 201-IOWAMPS IMPROVEMENT0$WIMMING POOLS
YE OWNEROBUILDER DECIARAI'IONOVER 10NIAMPS ❑BATH REA1ODEIJR1i1'AIR 0UP OLITION
ry,C{��Q I hereby affirm that I um cin mpl from the Cnmmmar's Luciano,Law for @e ❑OTHER
x 3 C U billowing I'cunon.(See ion 7031.5.lhouse and Prolcvvione Code:Any city or lowly SIGNS ELECTRICAL
W o', which requires a femi)rIn construct,alter,improve,demolish,or repair any structure
F�OJ prier t, wwaa,.LoNvEv,mm,awE,,ficmEtf hpe id to file r,tioned,coamumm SPECIAL.CIRCUEUMISC.
999Nydual ac 1,1 utansedt oe to I he pnovikin.,ofI c n Int License I,.(Clantne,9 COMMERCIAI;
ap0lcon g 'ahSect 70X0 fll i,i T III B: con dl I :: ,n,Codr)m II.MV 11 HR OR I'OLC.INS'I'.
a a e C Ina he is exempt themfrom and the basis for the alleged esemptinn.Any violation of ❑NI'W BLDGIADDITION E]DEMOLI'1ION
X.n¢. Section 7011.5 by any applicant for a permit subjects the applicant In a cm3 pvicity of POWER DEVICES
W y w ElTENANTSERVICEOOD SERVICE
m mmv Ih:m five Imndred dollars($500) IMPROVEMENT
=Q O Lasovsithe pml,cny.o my cmpinyces with wages a,their sole crou"o-tiara. SWIMMING POOL ILI.ECEIR;
F ❑OTHER
will do the work.and the,memo is not intended or offered hawk,(Sec.act Busirri
a w and Pn duct-,Code:The Comrdetnr'e Liters,Law docs an,reply to as nwncr of OUTLETS-SWITCIIES-FIXTURES
A. property who builds or improves thereon,and who dxs.such work bllnn.It ar dnough
his own onplayees,provided that such improvemcnn am not intended m ofikrcJ for NEW RI31DIiNT1Ah[LEC'IR SQ Il'. �
.sale It,however.the building or improvement is sold within one year of completion.the SQ.IT.F1 OUR ARE SISQ Irl'.
crbr ildor will bine the barren of proving that he d lJ not but lJ or i mprovo tor put- '� 1 ��
fw v af.h,.O Il
0 L as owner of the pn,pecty,am exclusively contracting with licensed contractors to
construct the project(Sec.91114,Bo,lnuna and I'adesoor,Cede:)The Gnalmaor'S Li- /---�
c o,Law Joe not apply loan owner no'property who tai Ids or improves then"..and QTY, PLUM II I NC PERM I'1' FEE R,,�J
who contacts for such projects with u contracmds)Iicemed pursuant In the Contractor's
License law. PERMIT ISSUANCE
n I and ectnpt uric,Seo .B C I'C fur lois reason
ACrER-DRAIN&VI?NT-WATER fns) VALUA'I'IUN
Owner Date
WORKER COMPENSATION DECLARATION HACK FLOW PR(lTl!LT DEVICE
1 hereby al ire under penally rl perjury one at the Ibllawing declarations:
n Ihave and will maintain a Certificate of Conwal to self-iniac for Worker's Conifer DRAINS-FLOOR,ROOF.AREA.COND. S"I ORIES 'I"YPE CONSIRDCrI,ON
,.tion,as provided fur by Section 3710 of the Labor Cede,factor,performance of the
work fur which This peon"is i,nucd, 14XTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as required by Section
37(IHoftnc Latx,rCWe.for lheperformanccofthe work forwhich this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTIXIS OCC.GROUT' ALIN
My Worker's G,nq,ensalan Insurance canner i i Policy number ore:
Cartier: Policy No.: CAS-IiA.SVSTF.M-OVER J IIiA7
CCRTIPICA'I E OF PXEMPr10N FROM WORKERS' A II
GREASEIINDUS"TRh WASTE INTERCEPTOR COMPENSATION INSURANCE1 ILDING DIVISION PEES
fUnisnutinnnreJnnl hewmpletcdd,Icpermil'n for chundnrrdollar,610) GREASE I'RAI'
� or
less) PLANCIII!C 1:
lh
I rectify that incperformwnr
ancenfthck forwhich pe
0iardO,issuW.],baR SEWER-SANITARY-STORM EA.200 P1'.
i employ any prison r any asarwr o,as to hecume sublect m the Warkurs'Cumpem ENERGY
O ,z nation Law,cl California.Dam WR'I'ER IIEAT17R WNENIIIiI.EC'I R GRADIN( FL
z Applicant
H NOI'ICH TO APPLICANT:If,after making this Certificate of E ausn, on
d you should WRIER SYSTEM/1 RCATWC SOILS Ili
a >
hucunm suby,l lo the Worker's Conlpcnsa I Prnvi,'innx n(mc huM,r Gnc,You mawr. forthwith comply with....h pnrvisia.sor this�rmit,hall be,deemed revoked WA'ITR SERVICE
:Z) H,z CONSTRUCIIONLENUINGAGENCY NEW SQ.IT. PAID Das Retell
U O l nereny ars m anal tome ry a conamenon m.dins asmny In,the pan'om,lmae al
D. 2 the work for which this penal is issued(Sec.3107,Civ.C.)
'I O
O Leader's Name TAL:
r {U Lvrd,,,Address BUILDING FTI,
y I cenifY Thal I have mad this application and mate that the above information is
stn coot"lagmctocmnply with all cityanJ cnumynrrinanccsanJ sem laws relating u, QTY MECHANICAL PERMIT FEE SEISMIC FIi
U z huilLa chromenor,sal herenylmdmdze reprewmmiveaafthi,cityo,vater apo.the
above-nn.tioned properly 1'ar inspection pup,oecc PERMIT'ISSUANCE EIJiCI'RI' 1:1 2
(We)allose m save,imita fy and keep factories,the City of Cupeninn against
Rahili,ic,,judgnuenla,costs and eeperses which may in any way accrue against aid City AUTER OR ADD10 MECII. PLUMBING I.E.
xc4uercc el the grunting aI psis actual.
APPLICANTUNDERSTANDS AND WILL COMPLY Wll'1I ALL NON-POINT AIR HANDLING UNIT CTD 10,001 CPM) MECHA AL FEE
SOURCE REGULATIONS.
NHI{gNDLING UNIT(OVER IO.INXICPM) C(INSTRUC UN TAN
Signammof Applicanl/Comractnr Date EXI{AUS'f HOOT) W/OUC1) HOUMNG NUI ATION ITC
HA%ARDOUS MATERIALS DISCLOSURE
Will ILc IgRlirnm rr hnurc lir,ilJingovv'llpnm mul'u or M1mullc harurrouenenenal HEATING UNU('1010.000HTI)
a,JefinW by the Cupenina Municipal Code.Chapter 9.12.and In,Heath and Sale" HEATING UNIT(OVER I(NL(NIB B'I U)
CWc.Section 25532(,)!
O Ye, E]No V ENTI LATION FA N IS INGLIi REST U) PAID
Uwc Rcceipl#
Will the applicant nr fdure hailding occupant use equipment ar devises which HOILER—CO.111'(JHPOR I01.B0TU)
mil haiallou,uir cm.amiraas as defined by the Bay Area Air Quality Maa100.000 RTi
District^ 13OIhIIIt—COMB'(OVER I01,IXIU Il'rU)
❑Yes 0N
I have rcud the hlvuNouv nmtends rctl.i temente under Chapter 6.95at the Cali- AIR CONDITIONER ISSUANCE DATE
famia llcalm So Safely Cede.Sections 25505.5533 and 25534.1 unJedmW,hal d the NEW RESIDEN'UAL MECII, SQ,FT.
huili ing does not currently have a tenant,that it is my msrymsibiliry to ruddy Ile occupant
of lhercyuimnncmn which must be met poor missuance ora Certificate of(kcupancy.
Owner o .mb.riced agent Date ` ISSUED BY:
OFFICE ��