S 0089 .:APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING.ELECI'RICA], PERMIT NO. n
RUILDING'DIVISION APPLICATIONIPERMIT PI.UMBING.MECHANICAL
'BUILDING PItOJRC'PIDRNFIFICA'FION, '
BUILDINGADDRHSS, 7SANIEAAIVVLICAIssION SUHM ITFAL PATIlig
OW ERS NAME: I'fl E: CONTRACIY11t;S-NA is a NO� ` A ONI'It01.#
ARC111'I ELTIENGINEIiR; LIC NO: ADDRESS:
y
pNTACp; PHONE: • BUILDING PERMIT INFCI
❑ Consultant Fees Paid by Applicant(Initial) _ BLDG . U1.ECI' PLUMB MliCll
do
LICENSED CONTRACTORS DTCIARATIONt
ELECT RIC PERM71' - FEE -.
1 hereby B' that I um IimnseJ J provisions f Chapter 9(commencing QTY SOD DF$CRIPTION '
�aZ isithSection 7m)0) tDv on 9ollhe Bts sandledai,iomC Ice m yheensa s RESIDENTIAI:
LLT pI'PIiMI I ISSUANCI:
F+w� ln l'll( a.ndefEd ❑SI'UWI. ❑KI'ICIIEN RhMIIDI?I.
TUU Lice. CI s e# APPLIANCES RESIDENTIAL ❑ADDITION ❑VLOMBING RE-PIPE
Fzw Date Commit.,
t/a46 ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATIO
Fpv' PANELS MODIFICATION
C -Z 0 UI'TO 2W AMPS ❑
I understand my plant shall ba mcJ as public records
CZ-.,0 IN'I'HI210R El CHIMNEY REPAIR
I".n W Licensed l'mlesstornl - 201-10(MAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATRE ❑
ION OVER 11MK1AMPS - C3BAT'IT MODEL/REPAIR DEMOLITION
-,W, 1 hereby affirm that I am exempt from the Commana's Lateral,Law for the ❑OTIf!}t-
°�d'o a U following rcasou.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECT RICA],
W30 which requires p tt 'I i aft p Jt I h p ).t cure _ 1
1CC'� ant I '.. hrequiresth applicant tf chp 11 fl .b Jltcncnt - SPECIAL CIRCUIT/MISE. •' T
2�}
than Icensed Pursu n thep 't t fth C t tr Lic I lChepnr9 COMMERCIAL:
�aap (rnm ens ng 'th Sect ]fIq) fD 3 fine Bu'n ss dP fie ' vCalc)or 1 CMP.METER OR('OLE INST.
LL y C that hes cumpt therefrom and the basis for the alleged exemption.Any violation of - ❑NEW IHDG/ADDTI'ION ❑DUNIOIA DON
LLXI p• Section 11131.5 by any upplicant for a petaitaubjmis theapplicinnoo civil Family of POWER DEVICES [1TgNANT ❑FOOD SERVICE
>y
at nom han Eva lnmAruldollars($500).
S� ❑Las owner of me pn,peny.or my anployees with wages us their sole compensation, SWIMMING PDO[Ii1PCTRIC IMPROVEMENT
EJOTIII:R
L will dome work,mad Plenrucame is a,,,mandate,oHe,ed for sole(Sao.]IY14,Businci '
and PFofeeaimin Code:The Coutmmors License law docs not apply m an owner of OUTLETS-SWITCIMS-FTKTUR1i5
me,arty who builds m improves thereon,and who docs such work hire or thinugh
his own cmployeres.provided that such irommatn ots are not(mended n offend for NI?W RIISIDEN'MAL ELECTR 5 P.
svleJL howeven the building or impose cot exam wiihiroacywrnl'a rill etirny me SQ.I PI/pA S/SQ.Pf
,ser-huilder will have the burden of proving that he did not build or improve for par- ~
)
(]1 f the pro,pcmy son exclusively contracting with licensed commatim,to TOTAL.
con 1 11h p ]cl(S 7044 B .. and Pr f. C—..The Contmmr ....
JUN. '✓K
�close Law d l m"l,It,an milac,itfn pa, 1 ld-aimprtves marear,and QTV F{ 4 '•PI�UMNINa TCR I" 'fJii t i CCC, ���'''�WWV
who mmet fm,ochpnijact,wll nuctano licensed pursam(to the Contractors CI 'PUL
Lic Low. PERMIT f ISSUANCE -�_Vf �k/1 `Hr'NO
❑Iamexemptinder Sec, B&1'Cordthreason
AUTHR-DRAIN S,VENT-WATER(EA) < VALUATION
Owner Dale
WORKER'S COMI'IiNSAT1ON DIiCLNtA'IION BACK FLOWPROI'ECT.DEVICii
I herebyaW under penalty of perjury one of the fallowing Jeclamtions:
- Thane end will mmnsam aCenifcateaf Consent mselbinsure for Warker's Compen- DRAINS-FLOOR,ROOEAREA,COND' STORIES '1'1'I'ECONS'1'RlICF1Ob
tion,us provided for by Section 371X)of the Lahr Code,for the performance of the
wok for which This permit is issued. FIXTURES-PER TRAP '
1 have and will mainwin Worker's Contpensmion Insurance,ns myuimal by See ilon -
1JWnftheLabor CoJgfor the performance of the work for which this Permit is issued. CAS-IiA.SYSTIiM-I INC.40U'ILIiTS '• OCC.GROUP - MIN
My Worlones Compensation Insurance carrier and Policy number Ire: -
Cmur,: Policy Na: GAS-HA.SYSTI7M OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS OR HASE/INDUSTRL WASTE INT 13RCEPTOR
- COMPENSA'FI ON INSU RANCE BUILDING DIVISION FEES
(I his section need not be completed ifine permit is for ore hanJreddollam($100) GRHASETRAP s
or less.) PLANCIIIiCK FEE
Icenifydadjuthe pedormantt of the work for whichthispermit isissued,Ishall SEWER-SANITARY-STORM ESA.20D FT
not employ any Person in any manner so its to become subject to the Workers'Compete ENERGY GEE
Z $anion Laws of Calihr t.Dote WA'I'lilt HEATER WIVIiNT/F;hliCl'I<
Z Q Applicmn ' - GRADING IEE
NOTICE TO APPL ANT:IL a er nm:ing this Ce Trane mf Enemplinn,you should WA'T'ER SYSTLMII'RIiATING
a ; became subject m the Workers Compensation. .ions of the Labor Cole,you stn, SOILS PEE
W forthwith comply with such provisions or this not shall be deemed revoked. WAVER SERVICE
Q
CONSTRUC'T'ION LENDINC,AGENCY NEW kESIDENT'IAI.I'IA1H. SQ.PI'. PAID
U z I hembyaFnn Plot mere k liconsuuction lenJlny agency fonbe performance of )ale, liceeipl#
U 0 the work forwhich this permit is issued(Sec.3197,Civ.C.)
U Lari Name TI.
OTA
lad AddressTOTAL:
certifyt tIh mdm: 1plein J.II mai me abncinlnnni KTI.AL
'f?E
� correct. b I ply Pl II city I Ir Tt aa,d rot rte caws;ell bl •QTy t _.MECIiANICAL PER MII �Pf E�}'
U z bold g instmcbnn utidberebyaum ri p ventaavesolthracitymenteruFanlhe' , P.aMve.manaoned property for inspection Impose'. PERMIT ISSUANCE(We)aures,tosave,indemnify and keep hamdess the City of Cupertino againstFEEliabilities.judgments,cnts and expenses which may in any wayicetucagoinst said City AldHR OR ADD TO MECH.in rcquenac of me grnnl ing of this pennil. FEF.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING ONIT(TO 10,000CFNG AL /EESOURCE R ALATIONS. ,� AIR HANDLING ONI'T(OVER ULON)CPM) T NTAXSignam. ll Appllca,a nlramm Dvte EXHAUST HOODfW/DUCT) " TIGNI'[ON FAHI IAVARDOUS MAI'F.R ALS DISCLOSURE
Will the applicamorfuture handing accmamt,i mciahtedlchmmalousmmmlal HF.ATINGUNI'1'TO 100,W0UTU)as defined by the Cupertino Municipal Cole,Chapter 9,12,and the Health and Safely
Code,Sectio 25532m)! HEA'T'ING UNIT(OVER 100,000 H'I'U)
❑Yes ❑Nn VRNI'ILA'ITONI'AN(SINGI.IiRESID) --
Dale Receipt#
Will the applicant er Futuro building ocwpunl use equipment or devices which BOILER-COMP OHP OR'100,0 0 R'I'D)
tit haeatdous air conaminarrs as defned by me Play Area Air Quality Management 'OTAL:
one, BOILER-COMP(OVER 100.000 BTI)
❑Yes F7 No
(have re:ul the huanrdous muteriuln ruluinnrenu ander Chaplcr M1JS of he Cali- AIR CONDITIONER ISSL NCE DRDi
mmiv I{ealth&Safety Cade,Sections 25505.25533 and 23534.1 undcownd mat it'he NI?W RESIDENTIAL MECIL SQ.FI'.
building Jres not currently have a team,that it is my responsibility to notify use occupant
of me requirements which must he met prior to issuance of o Cenificam al Occupancy,
Owner nr authonzeJ agent
Data TOTAL: ISS,,,)I1Y:
OFFICE.