S 1674 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUDDING-ELECTRICAL PEST T No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �J 1674
BUILDING PROJECT IDEN'1'IPICATION
BUILDING ADDRESS: SANITARY NO. APPLICAI'IONSUBMITTAL DAT Ii
22 $ LU /SVG— ul I n CA X50 lQ � < �`t g
OW '1511:SNA II: I'IIUN:: C TR ACTOR'S Nr�f41l: LIC NO:
D —� �j�[ r ,.2-3 NIC CvDvNTROLp
P CIII :Cf/I:NGINC_ „1''1' 2_2-%2
�1-11 N� ;" c0( ao3a 2 / J �S4 MI J010
❑
CONTACT. SS ( l PHONE: UI APPlicanl(Initial) BLDG ELECT ING I IMD
mc, c� (��)t92-vtol nsulranl Fees Paid by MECH
�DJc\
IJCENSED CONTRACT'OR'S DECLARATION TY. 1?LECTRIC PI?RMIT FEE
I hereby affirm that m
E am licensed under provisions of chapter 9 momencins - JOB DESCRIPTION
MaZ with Section of Division 3ofma Basinasand Pmfesxiens Code.anA my license is �IDf TIAI;
W 00 1'IERMI'1'ISSUANCE F
[-UF Licnlsc Cmsand
Jcffcat. Lic.q rl'DWI ❑pLumniN REMODEL
Fab D.na. Contmanr AI'I'LIANCES-RESIUEN'I'IAI. ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECrs DECLARATION INNEIS ❑MUI:1"1-UNIT [D STRUCTURAL
z I mrstastana my plans shallM asW as public records UI'102fXInMI'S MODIFICATION
OZ- El INTERIOR �CHIMNfEY REPAIR
I.icensal l'rorcnsimud 201-10XI0AMI'S IMI'ROVEMFN'I E]SWIMMING POOLS
OWNER BUILDER DECLARATION
[L W Q I hereby affum that 1 con exempt Gum the Crinaador's License Law fee do. VI?R 1(00 AMPS [I BAT] RI?MODCIJNEPAIR DEMOLITION
52xOyJ following rea
son,(Section]031.5,Business and Professions CWO
Chile Any city or county ti1GNS LlaXE' IGAL I❑farBER
W 3
W1- which marirns it permit to con.mucl,alter,improve,rich loll,or repair any awetme
F.�fOfnnd prior 10its ksum,ce,olsoreyuims the applicant f"orsmch pcouil topic it signal aa¢mnn 51'IECIALCIRCUIT/MISC.
that he is licensed Imitator,to the provisions of the Conlmctors License Luse(Chapter 9
W�a0 (eommeneingwith Section70fRo or Division 3of,he Business and Pmfeaions Code)... Itic '.METIIR OR POLE INS'L COMMBRCIAL:
G d e C Thal he is exempt Ihcrefmm and the basis fur me alleged emor,hom.Any violation of ❑NF.W BLDG/ADDITION ❑DEMOLITION
X m 4LL.
Scot n 19031.5 by wry applienot fir a person.ablest,the nppliwnt m u civil penally of WER Df?V 'S ❑TENANT' ❑FOOD SLItVICE
W >1 nil marc than live hundred dollar,F- >1
1.a, n',urns In xes with wa en au their sole com tion, SWI )UL 'L1iCfIt IC 01 HER IMPROVEMENT
S=2 ❑ pmpe ) yemp y g Isms
F- will do the work,and the someone is not intended or offered for sale(Sec TH4,Business ❑GI HER
W 3 m and Profession,Cndn:The Contractor's License Law Jere not apply ti an owner of OU' S-If 1 HES-I'IX'I URES
propchy who hollds or improves thercon, erl who does such work hltnsclf or Ihrnagli
his own employees,provitlul that such improvements arc nil intended ser oBercd I'or N1IW RES .N'1'IAL iCIR SQ IT.
xale.IL howuee the huilding nrimprovemenl issold withinins yea Of ennmittion,thel�X�^ SQ.FI'.FLUOR AREA S/SQ.FT.
owner-builder will have the human of proving that he did not build or improve for put- � kip{,.
p,.,e E2 vik Uf
I,asr ol'the property,n ,cxcluxlvely eonur,un,with IiccnsW en uractor,o, )
ro,struct the project(Sec.7044,Business and 1'ndesvions Cmde)'UN Chroacu's[.I. /k
cense Luw a«suns applyman ownendpropeny sono builds ririmprovez thereon,and QTY, PLUMBING PERMITCIV
FEE 1\CwJ
who commas forsuch projects with a comornmod)licensed purman RI the Contractors
loernec I., PERMIT ISSUANCE I
❑ Imo,nm csen"Iunder Sunder Sec. .B&P C or this reason
is — ACrER-DRAIN&VENT-WAT ( VALUATION
OwnDan
WORKERS CO DECLARATION BACK FLOW PROTECT.DEVICEI D
I berchy notion under paused y If perjury one of @e kolowing Jcdan,liuns: b
❑ Ihtnx and will anuinmin aCcnificme nl Cnmcm msclf-insane for Worker's Cnmpcm DRAINS nVEA,CO
serum,as provided for by Section 37M of the Labor Ca
Chile.for the performance of the STORIES TYNE CONR'rltlJCT10N
work for which this perit is issued. FIXTURE
❑I have and will mainmin Worker's Compensation Insurance,as required by Section
7100of(he].no Code, 0Ihcerfmmm�ceafthe wink fur wbleM1 calx rislnsned. GAR.Nf .y,'I'I .I:NL. OU'I',E'1"
1 pem,i I, n UCC GROUP APN
/
My Worker's Compensation lnsumnec carticnmd Policy nnmhu art: ♦. v J
Cartier. Policy No.: GAS FATslHM%IG (EAJ1
CF.RTIFICA'l 1I OF EXEMPT ION FRONI WORKERS' r si
COMPENSATION INSURANCEGREA' TI'I WASTII INTERCIiPIOR
BLI ]VISION PF.P.3
(TIis section need nil Iso cumpletca iHlic permit is fat nuc hundred Jnllors(511111)
or if
less.) CIt IEA. A PLANCIIEC '13
I reNfymm intheperforomnceofthe week forwhielidd,peri,is issued,10mil SEWER S ARI'-S'IOR.
nil employ any person in any manner se as to become subject to the Workers'Compcho ENEHGY IEE
z sation Luwsof California Dan WA'I'IiR F oN'1'l1IhlEC'1'R
O GRADING FEE
z Q Applicant
NUI.piss becourCE TOAPPLICANT;the WorkIf,after Chrmaking This Ceimmofall of,Labor ion.dyoushould WATER SVS'11IM/fkF.ATING
a ' become subject R,the Workers Crimpensaiis p iniaiuns of the Ichor Cute,you must SOUS 19iE
W
Forthwith comply with such Pmvienns.,,his permit shall M,AeemeJ revoked. WATER SERVICE
Q
G CONS'I'ItIJCTION LENDING AGENCY NEW RESIUIZN'I'IAL PURI, SG,Pg PAID
'7 Z 1 hereby affix that hem is a construction lending agency for the permonanm of Date -2111
11
the work for which this permit is issued(Sec.3197.Civ.C.)
lonirn,Name �,. TOT
C V Lcndcr's Address
I certify Thal I have read this application and state that 0e above infbratien is BullITLIE5
Va) cmacn.I agree to comply,ith all city and county ordinances and scare laws relating to QTY, MECHANICAL.PERMIT FEE
building cnnmmction,and hereby authnrixrepresentatives nflhivcity mentorugmthe SEI. IC r7
anomou emioned Properly for inspwtion putloms.
(We)agree to save,Indemnify and ksvp bonnie,,,the City If Cgenlno against I'IIRMI'I ISSUANCE EL . .I1EE
liunili,ice,jntlgnmms.crisis and ca,roc,whichmay in any w'ayaccme against said City ALTER OR ADD TO MEC11. �
in conmqucnceef We mining ofdd,penman, 1'WA1 INC,PEE CIA
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN1AIR HANDLING UNIT(To I0.1tl0 CFNH
SOURCE REGULATIONS. M' HANICAL FETE
r / sl�1 y AI R HAN DLI NG UNIT(OVER 10.000 CPM) CON. 'R UCTION TAX
Signe eofAppicanUCmnr car 1im (EXHAUST HO(N)OV/DUCT) HOUSING MITIGATION FEE Vl�
HAZAI )GUS MATERIALS DISCLOSURE
Will the uppli,.chlulatrehuild'nag necupum score...'hadlehnrnfduusnmlmiul I(HATING UNI'I'M 100,1100 BTU)
ns JetineJ by the Cupeni ,Municipal Core,Chapter 9,12,and the I IM11,and Soon,
Calc.Section 25532Gd? HEATING ON]'I'(OVER B0,000 BTU)
�Ya �� VENTILATION FAN(SINGLE RP,SIDI PAID
Date Receipt Is
Will the applicant or kuhre huilding occupant use c,mpmun nr devices which
Ivoig hardous air contaminants as defined by the Bay Arca Air Quality Monagemem BOILER-COMPD11POR 100.000➢'1'U) f, L
District?
❑Yes kA ❑OILLR-COMI'(OVER 11X1.!00 B'fU)
AIR C<NDTHUNER
I have read the mmndim,owe els rcquiane funder Chvpmr f.95 ofthc Coli- pSS1A CH DATE
fomiu Health&Safety Code,Sections 25505,25533..,125534.1 understand Ihul if,hc NEW RESIDENTIAL MECH. SQ.I7.
building docs not cumenny have a mnam.Ibat it is my m p 1 lity m m,tify me roartantlity m notify the occupant
of the reymremena which man,be metmam bC con Prior lI,, ;titicam if(kcapancynf(kcupancy.
Owner nr aamorircd egem I).,. ISSUED BY:
OFFICE