B 0401 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ]III I[.DING-1'LELI RICAL PERMIT N fi 0401
BUILDING DIVISION APPLICATIONMERMIT PLUMPING-MECHANICAL. S0001
BUILDING PROJECT IDFYI'IF'ICAI'ION
SANITARY NO. APPMCAI'ION SU13MI'PIAL DAI
I3U LUINOG AI)I)RIitiS:
ON'N R'S NA E. /JY)�� CONTRACTOR'S NAME: LIC NO'. J` -
�LV NIC C�ONNTROL#n
t BI CrIEN'INEE ADDRESS: ❑ { JF
CONTACT I)N BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) ❑LUG ELECT PLaaB MITCH
I-ICENS17D CONTRACT ORS DECL Rr UON QTY. ELECTRIC PERMIT FEE JOB DESCRIPTION
1 herehy uftinn that 1 ten licensed miler pmviein l of Chapter 9(commencing
OCZ with Section7ism)dDivleion3uf the Bnsinaas and Pn le,rim,Code,andnty l Ou,c is R .NTF TAI_
H0O lull farce and 01 co. 1'IiltMl'I'ISSUANCIi ,DWI- ❑KITCHEN REMODEL
QUU Licen.0 CLas Tic.# APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RI7_PIPE
�Z, Dan—COntracmr
it. ARCHITECPS DECLARATION PANELS ❑MULI'6UNIT N40DCCATIO
'D.
a,tz I unJcrsmnd my Plans%hall M u.ad as public records MODIFlCATION
ZO � Oil 10 AMPS ❑INTERIOR OCHIMNEYREPAIR
OZ_—C
d4y�W-1 LiccnscA Prnfeseionul 201-HNXFAMPS IMPROVI:MF,NT (]SWIMMING POOLS
Q I M1orehy nlf nn that 1 em exempt from the ContLION OV17R I(NNIAMPS ❑BAim REMODEL/REPAIR DI?M(]LITION
OWNER-RUL I.UER DEGLANA
C seracum's License Law for the ❑OTHER
X 3d U fallowing roan.IScdion 7031.5,Business and pinfesdon%Cde:Any City or county SIGNS ELECTRICAL.
ad LL which requires a permit m construct,altar.improve,acmalish.or repon any stmaurc
F'RN'O.' anonuits iacuance.aLo requirestheapplwmn for tech . m File a dgned atatimern SPECIAL CIRCUIT/MISE.
f W> mpursuant at he is licensed pursuano the provnions of the Contractors license Law(Chapter 9 COMMERCIAL:
WQC) (commencing with Section 70)(Bd Dlvisian 3 of the Business and Profession,CoE)"I 'I'hN11'.METER OR PULP INST.
IL6�(�a�.' that he is cxmnpt Ihereftmn and the husis tar e mv11ugM vienapnon.Any violation of F1 NEW BLUG/ADDITION ❑U13MOL1'f10N
Www
Section 7031.5 by any applicant for a Fiord subjects the lapplilnt m a civil lxoully of POWER DEVICES ❑I'ENANf [I FOOD SERVICIi
not more than five hundred dollars(M50p). IMPROVEMENT
SSG01.as Ownerofthe property,or my employees with welts ustheir sole cnmpenation, SWIMMINGPOOLELLMRIC
will dome work.and the cwmurc is oat imm�deJ oroRered 4t ale(Sec.7014.Business ❑OTHLR
H OUTLETS-SWITCHIS-FIXTU G
W 3 m Fwd Note,ors Cade The Contractor's License Law Moe•not apply m an mvncr of
progeny who builds or improve.%mercan.and who does such work himself or through NEW RESIDENTIAL ELECTR S
hi. andb yees,provided Ihat etch impm eras u tet mmrded o nllemd lar SQ.17L FLOOR AREA SISp,FI'.
,at..If.hao,ov,I he landii ng nr lmprovIonmi aenld widilm nnc year of amnplv-tinn,the /�
wnerhuildcr will have the burden of proving that he did not build or improve For put-
arose#f ale.). TtifAL. t
of the pmpeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7M4,Businc%%and Professions Code:)The Contractors 1
verve
q
cense law does not apply to on owner of pmpeny who hwlds or improves thereon.and QTY. PLUMBING PERMIT FEE 14 X1 2Y S
who umvucN for such pmjmta with n conuacbt(O licensed pur..am m the Cnnirunor', J
Liccneu Law. 1'IiRMfP ISSUANCE
Iten exen.in ander S¢. ,Ii k PCl Poi%reavan
1n �O ACD!R- 'VP T-W'AI'F (EA) V�AXLl1AIl�UN�r�,�
p WOI KWS COA EN. TION I :CLARATION� F BACK FLO
I hereby alfrm under penalty of perjury ane of the following Jeclamtinn (/
I have ary wi llmninmin a Certificate of Consent self-insure for Workers Compen- DRAINS-PLO )F R O D. STORIES TYPE CONS'I'RUCTIG
scion,us ni. n,J f r by Seen 13]1X1 aF'me Labor Cade,for the petfannuale of the
work for which Fhis pumnit Is issued. Fl8'L'URES-PCR TRA'
I M1avc rod will maintain Workers Compunction In.surancc in required by Section GAS-IiA.SYS LEI'S
3]lq of me lalxmCNcfof the performanceof me walk for which this permit is issued. OCC.. ROUP A'N
My N'arkefs Compemauon low mance artier and Policy numhcr ate: GAS-EA.$YSTEbt-O
Cartier; Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' GKIiASUINOUSTRL WASTE INTERCEP1 OR
COMPBNSAIION INSURANCEBUILDING DIVISION RTES
(I'hbswtian asualt be compktcd if he gaunt is Tato,handfed Balham Is 1 W) GREASE*1'RAP PL.ANCI IEC 'B O '�
or Icsc.) y�
Icenify thatbribein permnnnceoDhe bee for whichmis theNorth W.kos'Od.Co sM1ull SCWIik-SANITARY-STORM EA.21X1 Flt F.NfRG1 'f p ��
not employ any parson in any manncno.11-became object tome Wolters'Compete
Z anion laws of Culifumiu.Date WAI'IiR HEATER WNEKfrELECTR GRAD C19':
O O Applicant l
Zy NOTET-TO APPLICANT:It,after making this Cenlfcute of Emmption,you should WATER SYSTEMITIMIXF'ING G( L, if
F become object to the Worker,Gmi,no oa pnovislonc al the Luhor Coda You.,all
Wforthwith aontply wiihwch prnvisionnor this pemnit nhull M decmedrevolorl WA'1BR SERVICIi
IL Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB, tip.f4. PAID Dale Receipt#
UV p ffi
Ihereby arm that there is a construction lending agency for the performance of
F the work for which this permit is issued(See 3097,Civ.C.) I -I:
O U Lender's Natnc TOTAL:
Isnder'n Ad urT, BUILDIN FELT �C7C
G I eenit'y that 1 have rend dr,itsPinwion ate;old statill the above imbn"Inas I,c
tot cored l agree it)comply with all city and county ordinances and.%tate laws relating In QTY. MECHANICAL PERMIT L'I'E SEISMIC Il111 n
U Z building construction.and hereby radiative representatives of this city menrcrupm the #
abnve-mentioned progeny for inspection purposes. KAIT ISSUANCE ELECT' 'Flit:
(We)agree w save,inacmnily and keep harmless the City of Cupertino against
liabiIda,, prbaentn,enst undex)ensc%which may inunywayaccoac.n itwl said CityR OR ADD TO MITCH, PLUM
n%cquOnce of the granting o1'Ink permit.
APPLICANT UNUEItS'1'ANDS AND WILT.COMPLY WI'rll AL1,NUN-1')INT HANDLING UNI'I'('10 IIL(NXICFM) MEC e.'1 AL FEE, r S
SOURCE REGULATIONS.
/� d HANDLING UNII'(OVER 10.1#X1 CFMl Co.S H Cl SON
A
T61—.1
nature of Ap c an racm I Jane aUST FOOD(WNUCD HOUS GMrrIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fumrc building occupant stare mar handle hii,ird nrenalNG UNIT(IO 1(X1.000 BTU)
ax defined by me Capenla a Municipal Code.Chapter 9,12,and the Ilealth and Safety TESTING UNI TOWER 11X1,000111'Off
Cadc,Section 25532(,):'
❑Yes FINo TLATLON PAN(SINGLE RESLD) PAID
Date Racim#Will the applicant or future building eccupant use equipment or devices whichER-COMP(3HP OR 10BBBB HIO).nit hzeanlnu,air cnnwmiunJefnN by me Hay Arca Air Quality ManagemntDismicC ER-COMP(OVER 100.000 H'I'UIE]Ye, ONDITIONER ;SLANCE DATE
1 ham rend me huenrdoisInan.255 rcqui 533 ms under Chapter f95 of the Cali-
b ildi Bcahh,@ Safely CMe.Sectionsl.Bar 25533 and8534.I understandmm ifthe RESIDEM'IAh MLCH. SP FLbuilding d«enot ars, Ii haveatanant,dunpItsiOmficure11Vt mcuPant
ftherequilemenu :t et pct 10.3 sofa Certificate o[t upuyti TOTAL: ISSUPO By I
Ow awhnri'md O,mc
OFFICE