99120070 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY _ L
CITY OF CUPERTINO BU07
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BUILDING DIVISION APPLICATION/PERMIT PLUMBING-h11!CIIANICAh
IIUILDINO 1'ItD.IRC'I'IUI?N'I'IfIG\'('ION'
BUILDING ADDRLSS: ^5A R APPLICACONSIlip1111JI'ALD61
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NI!R' AMT:;IrSMA I i'1{ONE: C( A N'S NAMG; LIC NO:
N/C CONTk01.X
RCH TT iNGI EIiR: AC NO: "S: ❑
CONTACT. \, tA;; pq{C - PHONE BUILDING PERMIT INFO
WI'\`C"GIJf, ❑ Consultant Fees Paid by Applicant(Initial) BLUG ELECT PLUMB MFCH
Ertl - Z d ❑ ❑ ❑
LICE ilfD COMHACTOR;S CLARATION QTY ELECFRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that I am liccnvvl under provisiaa of Chapter 9(commencing
==ZO with Seaiun700suaf Division 3 ofthe Husincss and Professions Cale.and my lkensei PERMIT ISSUANCE RESIDENTIAL'
i-__
a__ in full force and effect. OSFDWI. OKITCI{EN RI!M011lil.
QUU hmenm Class LION APPLIANCCS-RE!SIDENTIAL ❑AUDITION OPLUMBING RE-PII'li
VF1 Q L hale rI),tlrn
ANCHITIiCES UhiC A ON PANELS OM1IULTI-UNIT OSTRII(TURAI.
~ti Z 1 undcraand my plans shall be used as Public rcasNs MODIFICATION
Z Oy,,, UP TO 300 AMPS ❑INTERIOR OCHIMNBY RHPAIR
O,y,,,f„W Licensed Professional 201-HuM1AMPS IMPROVEMENT C]SWIMMING POOLS
�11 � OWNI7R.I1UILDPR DECLARATION OVER lkX)AMPS O BATH REMODEURHPAIR ODEMOLI'rION
C Q I hereby al3lim that I um esentpl fnnn the Contractor's License Law for the
O 0.0 following reason.(Section 9131.5.HnsineV and Prafosinns Code:Any city or county SIGNS 17LECTRICALEct ❑OTHER
h.H which require.Ih permil to construct.after,inlprove,demolish.or rc olr any structure
C primtons alio y 'r., h misoon l 'h pc in a IIc.,i,ncdttmert S PECIAL Cl RCO II'/MISC.
of (hath l mouninI lie powi,is In C ancou,I -c L (Chapter 9 COMMERCIAL:
��� (ton 6 IhS ui 7fNN1) ID 'knhl It Bsiess d1 f :Cdc)or TEM P MCIEROH i'Ol.li IN51'.
y y o y that h e l t d do I II bell I Ih ll g d exempt Any ton o[ 0,,..,,NIi��W BLDG/ADDITION O DIiM(ILITION
X__4. Section 70315 by fury upplmnnt tear a pen nt annluts the a pieunt w.uivil penny of POW LN DI:VICL yyR;NANT ❑POOD SI!NYIGIi
to amour than live humnsidellart($Amb
IAIPROVF,MHN'I'
ODl.as nwncnff the pmpery,or my mnployce,with wages as theta vole compensation. SWIM M INC,POOL I?LCCIt IC
f+ will do 0e work,and tilesuucture is not i mended or offcrul fa sale[See.7(Ia4.Business El OTHER
63 m
and 1'nq'of t,Code:The C...I.cmr'c License Law,does not apply hs an owner of OUTLITS-tiedI'I'CIII!S-P%'IVRES
property who builds ear Improves thereon,and who docs such work himself or through
his own employees,provided Ism such improvements arc not inlendeJ or offered,for NHW RESIDI:NT1AL BE I!C'TR SQ FI'.
sale.If,however,the building or improvement is sold within one year of complefion.the SQ.Fr FLOOR Ak1iA ASU,I•I'.
ownerhuilder will have the burden of proving that he did not build or improve for pur-
pose of sale.). '101AL:
1,a%owner of the propety,out exclusively contracting with licensed contractors to
construct the project(Sec 7044,Husincss and Pmlessions Gde:)The Conuvcturs
cense lawdoe%not apply to an owner of property wno builds or improves themon.and QTY. PLUMBING PF,RMIT FEE
who contracts for such projects with a concurrent)licensed pursuant to the Cmmmemts
License Law. PERMIT ISSUANCH
O I am esem,a under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(IIA) VALUATION
cora Dan.
WORK17S COMPHNSAHON DECLARATION BACK FLOW PROTECT.DEVICI:
1 hereby aRmt under penalty of perjury one of the following declarations:
I have andwill maintain Certifciaeof Conunuo self-insum for Worker's Compcn- DRAINS-FLOOR,ROOK ARCA.COND. STORIES TYPIiCONSTRIICTIf.
salon,as provided for by Scene.3000 of he Lahr Gde.for the performance of the
work for which this permit is issued. PI%TUR[S-PER TRAP
O 1 have and will maintain Worker's Compensation Insurance,as acquired by Satins
3700nflha Lmxa CmRe for the performmce ofthe work for which trispeamilni...ed. GAS-EA.SYSTI7M.I1NC.40UTLIffS OCC.GROUP
My Worker's Compensation Insurance carrier and Policy maher am: GAS UA SYSTBM-OVCR 4(HA) l/R sLJ
Corner Policy No.:
CEN HIOCATB OI'1iX1iMPTlON FROM WORKERS' GRLASFIINDUSTR ASIHIN'HRCHYIOR
CGMIgiNSA'HON INSURANCH HUILDINO DI VISIONIyiRS
(Tom ecdinn need not M:nnnplcmd It thea pennh 6'torero hundred dollars($I(NI)
PLANCHECK PI?li
orlets.)
(colt,thaini nan, as s,, as t work l newahr,,,o,hc it islssacoope - 1' lotion ENIiRGY FEE
mol employ Ivry�tun in any Innnncnnux to booms nubjcut w Ibu Wnrkerd Campcn-
Z ou I fCI'I' Or q? 1 DING ELL
z0 Ap11. ,
y NOI'ICI Is)Alll ILANI H.,olct lookingtl Ce,oli,inval Essrptnn yet should '1 SOILSihh
P ^ accolia,subject t the Worker's Ccaaf,no proojoureol he labor Codc you mom
forthwith,(nplywth Inch poolli-son,do,lemon hall be deemed revoked.
Q
G CONSTRUCTION L Ts DING AGENCY So FI', i'AID
U Z Da¢ Naccipt q
UQ Ihamhy ulEnnthnnhere isncnnstmdion lending agency fill perfoamancc of
t+ the work fm which this permit is issued(Sec.3097.Civ.CJ m pood for (30) TO'PAI,:
U Lenders Nair TOTAL:
B.) Lender's AJdmss BUILDING FEE
6. I ser ify that 1 have read this rml cairn and state In.,the dawe information is ��
nF.I (n correct,I ,uvo.comply with all city and county oNinancesand smtu laws mining m QFTam 'E NIL FF:E PEE
U Z Euildingconstmminn,and hereby amh...i,c rouescnlahivesof this city m enlerupen the
a nave-meminncd pmpcny no inspection pur{ehses. PERMIT ISSIIANC IC TEE
We)agree m save,indemnify and keep nannies%the City of Copious,against
Iiahilitics.judgmenu,costs and expenses which may in any way therueagainst.said City l PLUMBING FEE
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NONPOINT1 HANDL MI!CHANICAh FEE
SOU :GULAT )N..
/�J�� A H FU CONSTRUCTION TAX
_nature of Ap m1an to, )I[lur E%HAU%THOOD W/DUCT) HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store of handle humadnos material HEATING UNIT'LTO 100.000 BTU)
as define)by Ne Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVEN ItttgO BTU)
Code.Section 25532W)1
[-1 Yea 0 N VENTILATION PA N IS INGLP RLS(of PAID Date Receipt
Will the applicum nr future buildingsncupam use cyuipment or desires which BOILER-COMP(3HP OR I00,IM013'I U)
nit ha,allous air crnnaminvn s m donned by the]toy Area Air Quality Management 'i'(OAL:
sir iavi<fl BOILBR-COMP(GVER l00.1MM)It I of
�=
El Yet 7 N
NR CONUITIONI K ISSUANC1i DAT(?
I(have read tnr hue:udnus muaTiul,.reyuircmcnLs under Chapter,6.95 of the Csll-
fnmiu I1a11h&Solely C de,S,ctin t,25505,25 .hn 125534.1 understand that dthe NBW 111iSI1)EN'I']At,MI.C11. SO.FI'. /^ _ �r {,
1.11 ngA Ion tnmunt cone I P luiallly mnmifytne ccupea G /
ennr><•� hahtth i��tarty n � eentc� � �nf x :may.
rvmhori, gent Dale TOTAL: ISSUED BY:
OFFICE