S 2563 - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OI'C PERTINO RIALOING.ELBC'IRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAi. S 2563
BUILDING PROJECT D)ENTIFICRI'ION 4-
BUILDINGADDRRESS: SANITARY NO. APPLICATION SUBMITI'A.DATE;
(IW ER N G: N/
r+ PHONE: C I'RACr ITS NAME: LIC NO: _ ^
1 _ C CONI'ROLN
�.ARCHI'ITLT/ENCI EER: LIC NO: ADDRISS: ❑
wa
CONTACT: PDONE: .BUILDING PERMIT INFO
Z ❑ Consultant Fees Paid by Applicant(Initial) HG ELLE 1' PLUMB MKCH
LICENSED CDN'I'RAC'I OR'S DECLAlt61'ION (/
I lately amr:n mal l am all l ander provisions of Chapter 9 leam:n awinQPY IiLGCTRIC PERMIT; FEE s JOB DESCRIPTION
OceZ rh Setion]BIXhaIDIVIFlOm2 ofine liuxinesx nt "in;n Code d Ile, is RESIDENTIAL:
PI Op w' FERMI'I'ISSUANCE
m11 mruf and t.
9.41E '" 'LQ ro _ ❑SI+DWI. [:1 KITCHEN REMODEL
<UU Lice eClaxs Llek APPLIANCES-RESIDI:NIIAL
i--ZW 11 - Commcmr []ADDITION ❑PWMBINGRE-PIPE
ARCI UTEC I'S DECLA RATION It CMUI.TI.IINI'f ElSTRECI'URAL
Z Or'g'q� I and erstand my plans shall hat ns public reusNs CHIMNEY
TION
REP
UP'I'(12(XIAMPS
O Z'O El INTERIOR ❑CHIMNI:Y REPAIR
F En Licensed Protest III - 201d101AM1'S _ IMPROVEMENT
C ❑ [I SWIMMING M)OIS
SF.r, OWNI!H"BUILDER DCCLAHAIV' )N OVER 1000AMPS BATH REMODEL/Rlil AIIt CDEMOI.IPI
' ON
a,
I Thereby tectum on 1 um esenym Prom the Contractor's C s License Law for 3:0w<U IMlowing reason.Section 7031.5.Business and I'ndessinnz Gdc Any city or county SIGNS EL[CI'RICAL C1 OTHER
W a W y which.....mesa permit n;nn,I stry,obr,im lix4 or eauve,mon repair any lora...
�� .prim In its m,alxoreyaires the uppliant for such pern;it In lileas'i shmen;am SPECIAL CIRCUIT'1'/MI.SC.
� } Ihat he is licenwdaromm,lnmepmvisiomnf We Contractor's Liccnu law(Chapter9
�E50� (utmmencingwim Scctimr7RKdmLrvision Joflhc llasinessand Praeonm Ctdu)ar L:
TEMP.METER OR POLE INST. COMMERCIA
M y o rG mm he is exempt IheretroT and me huxix lot me n11ogM exemption.Any viol aiun of C NEW BLDG/ADDI'T'ION C DEMOLITION
N
I+- Scdion]IUIS by any applicnnl for a pei at subjects me applicantm a civil penultyof POWIiR DEVICES
i-44 ❑IIMPROV El Fool)SERVICE
not marc man Eve hundred ty,terdollars,y enalpJ.
U wi l[,ax..c vonk. adhepeny,nr I, nnplayees with wagexustheirsule 044, asalion. SWIMMING POOL ELECTRIC IMPROVE ih1ENT
22..p.. will dnlbe,mas Cachi sw Cola.tone:dors :censeadod Lawddl wot apply o44,(Sunroof ❑0'I'HER
63m and Proliwhob CN or The ContmeLicense Lowsocanotapply toan
or
of OUTLIRS-SWIIICIES-FIX'1'UHIiS
property who hailsE or improves thereon.such and who als are n work hlmsd(m mnmgh
his own ovivereee,pnrvldal.hal such Impmvmold w ore nal attracted nr offered for NEW R85IDI3NTIAI.ELI3CTR Sp FF.
ownccOr
Lbower will
buildineorimpmvcment ithat
hedJ wiid nom wild or;improve For
'.VLGGI3 AREA 5/SIJ.PF.
eol"aldcr will haw the burden of proving Ik t he did not build or intpmve for par-
le
] 1.ii circ of dm Fmpony,a xdtwively Conmwting with 11®nwd c mlmauts m ,•,�.� TOTAL:
....te the project(Sec.7W4,Imola,sad Poses:.:..Code:)The Cmmacnds Li- t
cemse Low does out apply it)an owner of property who builds or improves thereon,and QTY. ,PLUMB r ERM FEE
who lvntmcls Tnnnch pmjCClx with a nmaamnr(s)Becnsod pra,mal to the Cmancstnrn -
LicenxcLaw.. PERMIT ISSUANCE 1
❑I an,c,cri under Sec. ,B&P C for this reason
REFER-DRAIN&VE WAT!2(H)FI
VALUATION
Owner Dale
WORKER'S COMPENSATION DFCLAIIATION BAC K FLOW pact i'1'. VIC1
I hereby alma.under penally of perjury one of the insure or Worker's
C x:
�-ti n.as and will mammy coenilicnmof de Labor
Code,insure far Wotk[t's Cnmpcn- DRAINS-FLOOR,ROoh A�Y.sminn,us pmviJnl for by Serlinn y)IIIIof We Luhrt CnJc,lo;'the perlbrmm�m nl the STORIES '1'YI'I!CONSTRUCTION
work for which Iis permit is issued. FIX'I'USES-PER TRAP
❑I hate and will maintain Workers Compensation Insurance,as required by Sermon
My ofk Arum ndglm'the dive mneeormauwrk f}n�;wnich lnylpurmlt' hand. GAS-0ASVS'rEM-I INC.401f (ICC.GROUP APN
r':plfannryEtsygll nee cutrl Gy� •I1 /�/b (l fit- GAS-EA.SYS"EM"OVIiH4([?ACIiRFIFICA'IEOFEXBtsIPT10Npt OhCGMPEN$A'F1GN INSfl1C/s '. Gltl!ASE/INIRIS'FRL WASTE IN'flbis archon ncad not be completed ifthe pemat k far onehundred dollars($100) BiJI1.DIN0 DIVISION 1931_;5or less.) GR GSETRAP PLANCHECK FEE
I cetlify lhut in an,atnmmccuf the work bnhicb This permit ix issued,I diall SHWHII-SANITARY-S'FORM 1
not employ any person In any numner so as to hnome subject to the W�rkers'Conijen- RNI!ItOY I:EI?
Z ,Z, motion Lws of Colifamis.Date WATER HEATER WNENT/ELECIR
Applicant I GRADING 191.1:
rI
NOTICE TO APPLICAN'1':ll;afernwking nils CeniBe;ea of 5xmunion,you nha:ld WAI'BIL SYSI M/1 THAI INC.
a , become snhjmt to the Worker,Compensmion provisions of the Labor Code,you must SOILS FEIi
;..,,
carbonic comply,:.beach pmvisions...this permitxhall he deenaal poked. WAITER SERVICE
0.
5 z Lha work hereby
which that the isacerlNLENDINGAOENCY NI:W ItEHIDI?N'I'IAI.I'I,MIi. SQ.pf I'NU D. e Rerei 14
CONS'I'RUC'FIU
or
ns
nnic
is
U O thereby affirm that there isacnnory FN NO AGENCY
agency far peUamr:ume of P
W (Ser.3097,Cu,C.)
O U Lender's Nana - TOTAL:
r U tender's Address TUI'AL,
I cenify that 1 have I this application and axle that The M information - - BUILDING Il.
IF-I V correct Iagree fit comply wi In all 'ry and county orch ounces and state laws reladIII,to Ur y. - MECHANICAL PERMIT FEIi
V z build' 6vn ssmtit shady rtht'`e. pnsv .na"c'tfd'xciyl cIe.try. Bc SEISMIC THE
'-' above menlionedprop:ny forinsperetion purposes. ,'
(W'e)..gree m wee,indemnify and keep harmless the Ciry of Cupeninn against PERMIT ISSUANCE IiLECIRIC hI!E
iuhilitiex,judgments,rnts and espI whwnmry in any way acerae ngainslsaid City AM 17R OR AT)[)IN)MI3CH.
yomnceof lnegrunt i flhis permit. 1'I,IIMItINO TEE
APIyypp.1 INT fINDERSTA U'AN WILL COMPLY WITH ALL NON-POINT AIR I IANDI.ING UND'fFO IgIXXl CFM7 O
SOIIRCI REGUI.AI'IONS. MECHANICALPTiE
ll AIH IIANDI:ING UNI T(OVER IIIIN 11\ ,IIIIB CFM) CONSTRUC'TON'TAX
-
gnaupcn AppheanUCnnlmlar Eric EXT IAUST HOOD(N'/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAU DISCLOSURE Q
Will the upplicanl or h;mm huilti ng oca;pant sbte of h:mdle humnfeux ntawriul 1113A'1'ING IINI'1'(1'0 100,000 B'I'U)
as dcr,md by the Cupertino Aiunicipal Ced Chapter 9.12,anJ the IIculm and Safety
Cede,Section 25582(0)] I W^/'/ HEATING UNIT(OVER 1000 XI IITU)
❑Yet VEN'DLA'1'ION IAN(SINGLE HESID) PAID _-
]lane Receipt R
�I WII We applicnnl or fmate building tkcupam use eyuipmenl..r Jevims which BOILER-COMPLHPOR IW,000BTU)
vndt Imnudous air cumvminunLs as def neJ by the Ray Amu Air Quulhy Mnnugcmem
UisiricF! /
Clvs :4t"/ B(111.EN-C(IMP(OVI!It IINI,gNI i{'N)
h:rvc real the bazunlous nmtcriuls re a unJcr Ch'v ter G.95 of the Cnli- AIR CONDD IONER ISSUANCE DATE
motel
fom'a I Icahh&Splay Ic,tiedinne 255115.25511 and 25514.I understand Wal Illhe NEW ItESIDiiN'I'IAI,MI!CI{. SO.I"1'. /
Tsui]l; does currtn y calenam.Wm it ix lay tespo:sdhilitymnolify thearupant57
ofd cots wnic m .Inemcipdonoixsu:;nceory Cenircateof( capuncy. -
am neell agent Dae TOT ISSUED It Y:
OFFICE