S 1710 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
f{UI LUBNC-RhN:CTRIC.\I. PET'N(J.
CITY OF CUPERTINO [%Oil'l{TNG-M1LC7ERIC L 1710
Ill]je',DINC DIVISION APPI,ICA'FION/PF.RMIT PLUNBUILDING PROJECTIDENTIFICATION -
# BUILDING ADDRESS. nn SANITARY NO. APPLICATION SUBMITTAL ONE
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O 'SNA ?: PHONE: _ CON'IRAC" IiS1�AhB:., IICNO'
Gini 6 Z5 Gl y J8`T 74 xl7i'S E ou123965 NrC CON TROL#
�CHIIIECfIHNGINEER'. LIC NO ADDRESS' ❑
d s- '��?�!a 1' e'i yti A'I✓L
CONTACT: PHONE;: (I pp p S- BBILDING PERMIT INFO
❑
COT nsullan Fres Paid by Applicant(Initial) tlDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION Q3y, ELECFRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
OZ with Sectionraal of Division 3 of me Business and Professions,Coal,and my license is � RESIDENTIAL:
p PF.RMI'I'ISSUANCE
F+ly Ialulll'ovicenitd affo, ❑SFDWI, ❑KITCHEN REMODEL
<UV Liupnsc Class Lie. APPLIANCES-RESIDENTIAL ❑ADD ITION C1 PLUMBING REPIPE
h Z a Dam Corme or
ARCIIITECI"ti DECLARKI'ION ❑MULL-UNIT ❑SIRUCI'URAL
Z O V,Z I undetshnsd my plea shall ha rroeil os public records PANELS MODIFICATION
OZ--O UI"IU 200AMPS ❑INTERIOR ❑CHIMN17Y REPAIR
F4tW Licensed l'ndexsiotol 201-ItNNIANIPS IMPROVEMENT []SWI.VIM ING POOLS
W 002.1 OWNER-BUILDER DECLARATION OVER III(1(IAMI'S ❑BATH REMODFLJREPAIR ❑DEMOLITION
u '�� 1 hereby affirm th.e I um m
exept frmothe Cnoclnr's ntrLicense Law for the y U following maer,n,(Secton
i9031.5,Bovine,and Pin1'eoianx Cod,Any oily or nm^IY SIGNS ELECfRICAI, ❑0'I'I IER
LL E- which requiine a nasion in construct.alter,improve,demolish.or repair any structure
F u•OQ prior to its issuance,also inquires the applicant fnrsuchpemtitlnflcasigned.natmnent SPECIALCIRCIII'TTMJSC.
ymail beislicenxedpursuunnn the provision of the Comrrtmrs l.ianxe Law lChaper9
60 Innnnsncing with Secrlon]OUtpof Divisinn3ofrha ltuxinexs and l'mfexeiansCodc)ar TEMP METER OR POLE.INSI'.
IL d o yy that he is Oxman,bacchant and the ht,sk for Iha alleged cxenmrion.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
x^N Section 7031.5 by any applicant for a pcmtit auipiN the applicant nn civil leva0y of POWER DEVICUS ❑TENANT ❑FOOD SERVICE
g-xd not more than rive hundred dollars(5500). IMPROVEMENT
I,au owneroftha prolan
y,y,nr my employees with wages as their role mmpc.wrinn, SWIMMING PIXIE.ELECI'RIC�pS.A will dothe work,undrhastmaumisnol lnlmWcd ornl'l rilbrnuI (Sec.]M4.Itnsine.s ❑G'I'11IiR
nal anJ 1'rnfes+inns Code:The Contraclore Limnse Luw rices.nf apply to an owner of011'I'LI;TS-SWI'I CfIES-FIX'I'11RF.S
�'3•' property whit huiWs or improves thereon,and who uses such work himself or through
his own employees,provided that such impmvemery sere not intended or entered for NEW RESIDENTIAL ELECfR SQ ET.
,a],11.h...vuq l he building nr impmvcomnl is sold within oncycur olcamilpeion,the SQ.FT.FLUOR AREA LSQ.FT.
oar-builder will have Ilia harden.1 proving that he did not build or improve Iia per-
Psse of sale.).
1,as owner of the property,a exclusively contracting with licensed contractors m
nnstruct the p jeer(Sec.7044,Bneine,and Pmfussi..m Cadw)'Ilre Commmcrs LL-
ccne,Law a ws not apply as an ownendpropcny win cauldx m Ilnpmves thereon,and QTy. PLUMBING PERMIT FEE
who contra.for such pnsjecis with a rentmnor(s)licensed prouam m the Condi ernls p�
License Law. PERMIT ISSUANCE i� RR
I am exempt tinder Sec. ,B&P C for this remon S-
AIIfER-DRAIN&VENT'-WA'f' ( ) V (JAI[ON
woes Dale MAY 2g ANS'
WORKERS COMPENSATION DECLARATION NAC,PL OW 1'R(..E.CT.DIiVICL
I hereby about under penalty of lm,a,one of the following declaration
\] I havoand will maintain a CerOGcwe al'Cori tosclf-in.u:e for Worker#C'ompen- DRAINS-FLOOR,ROOF,AREA,COND. V STORIES TYPE CONSTRUCT ION
anion,as pmvlded ser try Scoion J]00 of the Luber Codc,fm the perfonnuna of the 1 1
Ur UUf GTA I BVV
wank for which anis permil k isxom. FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3)I0eflhe Lnb..r Codo,tar the rfimnanca nfthe work for which t4his pandrilsis i..w-end. GAS-EA.SYS'I EM-I INC.4 DO FLEE (ICC CROUP APN
my
CurrierrklrF nrCOMPENSA'f10N1NSUNPolicy .: fVi'- e ~ + CAS-1?A.SYS,HIM-OVER 4 f liA)
C Pol
CHIGIfIC E OF EXEMPTION FROM WORKERS'
INSURANCE GRHASMNDUS'1'RE.WAST H INTERCEPTOR BUILDING DIVISION FRES
(Un-actin r outdoor he uemplcrrJ i r the ptrmi(is on, hndoddul hill S1UP) GREASETRAP
nr Ices.) PLANCI BECK PEE
Ironifythat inthe perforreareefthe wmr),aawhich in,art[is issued.Idell SEWER-SANITARY-STORM EA.200 F-K
nor employ any pe,.a in any manner sit as m tsenmc subjauo the N'orkeri Gmpen- ENERGY FEE
Z naliar Laws el California.Dam WA'1'HIt HP TEIt WNEN1'117LACI'R
OO Applicant GRADING FEE
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y
NOTICE IT)APPLICANT':If,afmr making this Certificate of Iixemption,you should WAI ER SYSTEMG`REATING
F' become aubjaa to the Workers Conitica m.provisions of the Labor Code,you mus, Solis FIiE
Cat1 r'�i fonhwirh comply with such pmvisinns...this pemnirshall W deemedo curd. WWI 17R SERVICE;
Q
7z CflNSTRUC'I']ON LENDING AGENCY NEW RF:SIDIiN'I']AL PLAID. SQ. ?. PAID Date
evel
U O Iherehy aR:m tbn there iso cmxtmainn lending agency lia,he perf..nnance of
,he work for which this permh is issued see.3097.civ.C.)
0 F' Leadvi,Name 'QTAL:
LU lender'.AJAcaa I(TTAL. BUILDING FEE
I Certify that 1 have read this application and sone Na,the above infi namomr,
Fy Correct,l Ogre nComPly with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U ,Z hndiingc..nmmmioq and hembyualanir.a mpmorv.tivas ef,his city t,,.terup..n the SEISMIC FEE
triose-reamonamd pmporty fur inpccllon purposes, PERMITISSUANCE;
(We)agree n nave,indemnify and keep harmless he City of Cupertino against ELIiC'I'It1C FEE
iahili,ies,judgments.cows and expenses which may in anywayacemeagalnnt said City ALT RR OR ADI)TO MECH.
in PLUMBING FEEasequence of the granting of this permit.
AI'I'LICAN'I'UNDERSTANDS A d)WILT.COMPLY WI'fl{ALL NON-POINT AIR HANDLING UNIT('I'O IO,1Nq CFM]
SOURQ- ULATIONS. c MP,CI IANICAI.FI
AIR HANDLING UNIT(OVER 10.000 CFM) CONS'I'kUCTION']AN
Sigdnw IAppliamd/C...union, Dun 17XI MUST HOOD(WDUCT) HOUSING MITIGA'T'ION FI i
HA9,ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building ncuupanr store or handle haianlous mmceial HEATI NG UN IT fro 1000D H'I'U)
as defined by the Colin..Municipal Cade,Chapter 9.12.and ilia Health and Safety
Code,Section 25532(..)] HEATING UNIT((EVER 100,000 BTU)
❑Yes ❑Nu PAID
VHN'I'ILATION VAN(SINGLE RESIDE Dulc Rcaipr
Will the applicant or future Wilding accu{.tm use equipment or devices which
nit hazardous air commnm
inasmdefined by, rea hc 13,AAir Quality Munugemem BOILER-COME JHP OR]BELOW JET
TO AL:
[)[,to"? BOILER-COMP(OVER HX)q(E0 Bf131
E)Y" Fl No
I have most the mlrardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health h Safely Gala,Sermon,25505,25533 and 255341 understand Iha,drhe NEW RESIDENTIAL NIECE I. SQ.PT.
of
ngdocsout cunendyhave ntmretE Ibsen Ismyucof Cali mleofythatrvarcy. n
of the requirenmms which roust M mo prior m issuance of a Cenilicnte of Occupancy.
Owner or awherized agent Dam TOTAL: ISSUED BY:
OFFICE
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