S 0809 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITY BUILDING-ELECTRICAL _ I'ERMII'NO.
CI
BUILDING DIVISION APPLICATION/PERMIT. 1'Lu (RING-MECHANICAL O 0809 8 O C1
IIUIL INUINR IJECI'IDENTIFICATION S 9
SANITARY NO. APPLICATION SUBMITTAL DATh
BUILDING ADDRESS:
OWNER1 NAME: ^ PI ONE: CON'I'RCfORS It EJC NO',� NIC (ION R LN
❑
,�ANCIIIT Cr/EN INIiF.R�. LIC NO: ADDRESS: `
CONTACT: PHONE: BUILDING PERMIT INFO
S kvF ❑ Consultant Fees Paid by Applicant(initial) BLDG ELEGT' PLUMB MECH
LICENSED CONI'RACTOR:S DECLARATION QTY, r f �! . ELECTRIC PERMIT I•-EE
I nanny amrm Inas I ant Rice"d none,polimors nr Ch,doc,9(�mnne cin, r JOB DFSCRIPTION
Dat w'th Section llNNl nl'DivisionJ of the liusinesv )Professions Cnde,andtny banal.+ RPSIDFNTIAU
'0 a ) PRRMI'1'ISSUANCE
F O full force un�eR ❑SPD WL ❑KITCHEN REh1(lD1iL
a,WjF Livens I+eQS# —Lic.p V ��33.fY .
G U AI'PhInNCES-NF,SIDIiM'IAh ❑ADDITION El PLUMBING RE-PIPE
FZW Date Commcun
m<L / X�� ❑MULTI-UNIT - El STRUCTURAL
Fly AHCHI'1'F:CTS DECLANAI'ION PANF.1.5
I andersmnd my plias nball II used ns public records CHIMNEY
REPAIR OSL-� IIPTU 21XtAMl'S El INTERIOR ❑CHIMNEY RfiPNlt
t-� ul Licensed l'odewional 201-10(1)AMPS - IMPROVEMP„NT 0SWIMSIINGPDOIS
�.j ; Oat I me a.clipa fr UEthe RATION OVER 11X1(1 AMT'S 1BA'I'I{kE DEIJNI'I'AI ❑1 'MOLjI„ f1'ION
d C W Q E hereby affirm that 11S exempt farm the CommashectorsCvdaLicense Law for the Oft{EH r �
X d U following reason.ISeamn 111)15,Business and Professions Cnde:Any city or county SIGNS ELECTRICAL n +�
1+13 LL y which requires a penny m consmuca,.,her,lnhprnvc,Acinellnh,or aupnn any svaanm° V
og prionoi0.iouance,also reyuircslhe applicvnt for mdh permilm file.signedsmtamant SPHCIALCIRCUIDMISC. 1
I,N1y} In.,he is iiccmedonruanrto the provisions ofthe Cdtmanr's License Law(Chapter 9 I
a00 I...... ncingwith Sewion 101N)nf Division9nrthc Rosiness and Professions Cede)m TEM II MSTBH OR POL5INS'll COMMERCIAL, ❑DIiMOLI'I,ON
C,L e thin he Is exempt Ih...br in and the hast,for the alleged exemption.Any violation of El BLDG/ADDI ZION
Xy Section 10)1.5 by any applicant for a permitsubjecls the.pplicanun.civil lknally of POWER DEVICES ❑TRNANT ❑FOOD SERVICE
at
n more thin rive hundred dollars(551X). IMPROVEMENT'
=O 01.as owner of the property,or my employers with wages a+Ibeirsole compensation, SWIMMINGPOOLELECTIRIC `
y�F• will do the work,and the structure is not intended or offered for s:de(Sec.TD,E Business ❑0'I'HI?R
Izl-' and Professions Cndc.The Cent.mgor.Liemue Law Joel nal apply m nn owned of OUT,,I!'I'S-SWITCIII35-PI%TUHI!.
6'3 property won builds or improves thereon,and who does such work himself er through his own employees,provided that such improvements am not intended or lotted for NEW RESIDENTIAL ELECT R SQ
.It.IL however,the huildboo,improvement is sold wdintIone y"carol coordel4o,the SQ.Fr.IgAOH AREA SIBQ.Fri.
cr-builder will have the bodam of proving that he did not build d improve In,par- p
ove of sale.,. TOl'Ald AL D
❑ 1,as owner oftnr property,am exclusively contracting with licensed conduct—it,
consumer Ib project(S c 1(Di Business and Prof:. Code)The Cemmmafs Id --. , - .
c I I t pplrl fp pang n b ldxor lmpmvcs dolls and QTY PI,UMBING'PERMI'I HE r�
wl onncolsf hprIll, 'Ihacantu.lr(:)ntsnsedpurwunuulhaCnnacho i8
License low. PERSEFISSUANCE w a
❑ I am¢smolt under Sec. ,B&1'C for this rcnvan
ALTDRAIN&VNT-WAER(HA)
Owner Uma CI7Y ULVI PT LIQp
WORKER'S COMPENSX1 ION
aymn DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby alt ori under Penally of perjury one of the following dcd.rescou
❑Ihaveandw111 I...bynection 3cnte of Conmmua sof-in sure for Wmkdv Compel- DRAINS-IT.(R)H,ROOF,AREA.COND. STpR{ES TYI'[C(INSI'NUCTION
wor a,Provided liar by Section]11X1 cruse IaMn Qtr,lin Thr prrEannnnce of the
,arti ran damn this pem,it is i.,nea, Flxrukcs-rlat Tan, .
I have uad will mitran W'orkce,Compensation insurance,as required by Section
3900 of oho Labor Cade,for the pertinounccof the work for which thiapermil is issued. GAS-EA.SYSTEM.I INC,d OUTLET'S OCC.GROUT' AI'N
My Workers Compensation Insurance carrier and Policy dormer are: - -
Camer: Policy No.: GAS-EA.SYSTEM GVER i EPA)
CHRTIPICAM OF HXEM P`1 ION FROM WORKERS' GRE SIJINDUSTREWAST'Ii NTcra',I'TOu
COMP12NSATION INSURANCE BUILDING DIVISION PEES
[Thi,,¢Jinn need not be cmidamdiflhe,. hit is for one handled dol airs S 1(X11 GREASE THAI'
nr lest) PLANCHLCK PEE
Iccnify,h fame, nkfn. hid,aloe icided is issued,I thin SEWER-SANITARY-S'FORM EA.200 Fr.
n Iem y in �nrnrw1ita ¢µpe�u 't oche Workers Compel- ENERGY PBii
z x ' nLnwx n( .Dote l WA'I'HR HHAI'ER W/VEN'I'ddAiCTR GRADING FEE
O Ar
NOTICE TO A ,afmr makin,this Cambeae of Exemption,you ehoulA WgT'1!R SYSTEMRRI!ATING
a; Ixe.,.a mhjcel I c s Cnmpensmaon Individuals of the Lona.Coda,you must - SOILS FEF.
tri > fon6with cnmpl,with such pmvi+i.n...or this panni,shall be deemed revoked. WATER SERVICE
p" CONSTRUCTION LENDING AGENCY NEW HESIDI!NTIAI.I'LMN. 50.hT. PAID do R. X
VQ Iherebyaffimt that is a mnstmelion lending agency far the performance of
W the work for which thispermil is issued(Sed.3097.Civ.C.)
UTOTAL.
Lenders Name
{tI Lenders Address TOIAL:
1 ern fy that 1 have read this application and stale that the h e information is BUILDING
Vaj ¢omen lagree ,comply wan.Ilcty and cdnyommmac d stat I....cl Ingle Q'Fy; i MECHANICAL construction,
i- iFGF,a SEISMIC FPI?
building consetion,and hereby amhowe representatives of this city m enter upon the '
amove-owntion ul property far inspection pmynses. PERMIT ISSUANCE
(We)agree to I...indemnify and keep harmless the City of Cupertino against ELSC'IItIC PI!13
liahiiiaies,judgmemx,costs and expenses which may in any way accme against said City' ALTHR OR ADD TO MFCIL PLUMBING FIE
in eonscgamme of the grunting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ABR HANDLING UNIT QO 10.0111 CPM) MECHANIC
SOURCE!REGULATIONS.
AIR IIANDI.ENC UNI'f(OVER 10.000 CPM) CONS I'RUC'I'ION TA
Signamrcal ApplicanflCnmmna, Date EXHAUSTHOOD Iw/DUCD HOUSING MEFIGATIONF
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle menrdous maaerial HEXING ON 11(TO I O(IAfO RTU)
as deMcd by the Calamine Municipal Code.Chapter 9.12,.ad the Health and Safety
Code,Seclinn 25532(a)'1 HEATING ONE(OVER 100,000 RTU)
❑Yes [I No LAN N(SINGLE RF_SID) PAID .-
Ouse Rdci X
will the..Phe..,or future huilding rwcupunl ave cynipmenl or devices which BOILER-COMP
OR OR IIq,INNI
mit hazardous air corna
ua nts as defined by the Bay Area Air Qaalily Management TCIPAL:
Yes Distad^ BOILER-COME(OVER 100,000 13 1 U)
❑No
_ Ihave rcuJ the hvzurdous materials requirements under Cnapmr h95 of the Culi- AIRCONDITIONER ISSUANCF:DATE
forma Health&Safely Cattle,Sections 25505,25533 ad 255W.1 anddsmnd Thal if the NEW RESIDIiNT1A14 MECH SQ.FF.
building dins nal rumen ly have.mann,that itis my.Fora biliry umouty the racupat
,,fine arimmmencs which muss be and prior to ssuance of.Cenifiaatc of Occuface,
Owner nr authomnl agrnt Data IGTAL ISSUED BY:
OFFICE