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S 1405APPLICANTTO FILL IN'INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY CITY OF CUPERTINO EMITTING -ELECI'RICA C BUILDING DIVISION APPLICATIONA°ERMIT PLUMBING-MFICIIANICAL BUILDING PROJECT IUBN'rIFft:ATION PE 1'1'NO 1405 UILDINGADDRESS: ate© iE AFi t SANI'I'ARVNO. APPLICATION SUBMITTAL, DATE 'SN MF q PHONE: T 2'O o O COMRACIOR'S NAME: IAC NO. NIC ❑ CONTROI.4 kCHITECTIENGINEIER: LIC NO: ADDRESS'. CONTACT: PHONE: ❑ Consultant Pcles Paid by Applicant (Initial) BUILDING PERMIT INFO BLDG ELECT PLUMB MECH ❑ ❑ ❑ LICCNSEDn IreanRACTOR'S DECLAnisio- A'IION 1 hereby ufaraAA mm I rOn urelmsed under pts Fret Chapter v ¢A ins with Section]IN(lefOivinion 3rfthe Bmin... and It fi_olons Code and ory lwerse is .'..full force and effect. j License Class dr Dive on¢ C enur QTY. IiLECTKIC PEKMI'I' 1sliF: JOB DESCRIFfION RESIDENTIAL: ❑SFDW'I. OjjTCHIzN REMODI;I, 'ION MNGRE-PIPIT ❑ADDI'TBI ❑MUTA UNIT ❑STRUCTURAL, MODIFICATION L1 INTERIOR ❑CHIMNIEV REPAIR IMPROVEMENT ❑SWIMMING POOLS ❑ RAIH REM( - 1 ENl El 01 \ 1 L{ PERMIT ISSUANCE APPLIANCES - RESTUIENTIAI. ARCHTI ETC 'I"S DECLARATION 1 Tamer, and my plans.hall be used as public records I'ANEIS UPTO o_INl AMPS hiecmWT'mfcesinnel m CLARA'HON t nWNiim es,crupt from I nanny moon that 1 am eBusipl from the Comms Co License law cot the following retina. Rei o ]IULA Business and Professions Code: Any city or county 1 which any smmmm j which I requi u Irorm Amuse, uiteq imp,. c, h Earner t e a signed jthat heslieundpursant tote provisinsapplicant for sucCommnnlrm semi, gnud.wmmcm Thur he lnding and pursuant to the provision. or the CnaVatass ur Prof LuW (Chapter 0 (commanding with Section IIXX))ofDivi.ionJof the Businnsand Pmfessinns Coda or that he is cscmpl fineefrom and 0e b:uis I the alleged esenpnien. Any violicam It S,T,lem 9031.5 by anyapplicmlfora,anuit subjects IM1e applicam IT, ncivill'ennityor not intimater live hundred delta,, ($510). X 01. as owner of the propcny, or my employee. with wages as their sok compenwion, will do the work, and Ihesnunure is nut immrided molbered for sale (Ste. ]OIC Business and Prfcmions Code: The Commit— Licum. Law dI apply to un owner ar property who builds toimprn es them., uad who due, . uch work himself or though his own employer., provided that such improvenmme am nor intended or offered for nale.rhaildeveoll havelthe burdenof1mvinn ieseld norimprvedon,the pµe-hullder will have the humen of proving dim he did nm build or improve for pur- ee m nalel. ❑ L m owner of the pmpcny, am exdasively enmraming with licensed emvaaor. to nnoua Inc project (Sec. ]BM, Brains, and Professions 0.10 The Commuter, Li- property who baikk or impve rhemommm nol,aw does nor apply it) an owner of ro wen cona..1, rot suint pmiecm wen u cnnnamor(e) licensed Pursuant o the Commcmrs I.icense taw. ❑ I am eacmlunder Sec. ,B&PC otitic r 201-IINN)AMPS OVER 1000AMPS SIGNS ELECTRICAL SI'ECIALCIRCUI'1'/MISC. TIEME METER OR M)LG INSE COMMERCIAL: ❑ NEW BLIJG/ADDI'LEON ❑ DEMOU LION ❑TENANT ❑ FOOD SERVICE IMPROVEMENT ❑ OTHER POWER DEVICES SWIMMING POOL ELECTRIC OU I'].I, I S - SWITCHIES -I1XI HIGHS NIEW RESIDENTIAL FIX=R Q tiQ. IT. Fl1)ORARF,A 66 •T , MAR 25 ANS'D $ISQ. FI'. T(YfAL: QTY. PI.,UMBING PERMIT FEF. P12RMIT ISSUANCE ACI ER - DRAIN Fr V IiN'I- WATER (EA) 'WORKERS COMPENSATION DECLARATION 1 hereby affect under penahy of perjury one at the following declarations: ❑ I have and will maintain a Cenifcmc of Consenno self insure ter Workers Comen- 6ivinn, as provided fm by Secrion 3)Bfl m he I.ahor Code- lire are p -b.......... ¢ ol'the work tis. which this mon is i ... ed. ❑ I have and will maintain Worker's Compensation Insurance, as required by Section 37IN0 oflhe[,No CIA, for the perfoormare ofnce work for which this pcnnin.....reed. My iii CT persmio I I nomnfe rank, and Poli cy...... After are: Carrico Policy No.: CERTIFICATE OF MEbIPTION FROM WORKERS' COMPENSATION INSURANCE (ibis section need neer he mmplurnl iGnc permit ie for nmi .... most doll:,. IS I INP nr le".)CREASE Loy Troy not employ any person in any manner m a. m heunne nubjcel m IM1e Worker' Compen- in any johnnrof sInbekfur which this theIsaWlhl.s'Connl. n- satiun Low. of Cal ifomia. Doe Appl...I CID Ut QUrcHVINU" HACK FLOW PROTECT'. DEVICE DRAINS- FI,OOR, ROOF. AREA, CONED. S'fORIH5 'I'VPE CONSTRUCTION FIXTURES - PER TRAP GAS - EA. SYSTEM -I INC. 4 OUTIJ?TS OCC GROUT' APN GAS -EA, SYSIBM-OVIER 4 (EA) GRHASOINDURTRL WASTE HITIERCIEPTOR BUHJHNO DIVISION FE ITS l'RAP I'IANCHECK FEE SHWER- SANITARY -STORM En. 200 FT. ENERGY hili WAT7R IIRA 'I17R W/VEN"r/ELECT R GRADING PER. NOTICE TO APPLICANT': II, after making Nis Crniticam of Exemption. you should thse, ac,-subject,,theWorker'm sCep, W ensaion for, ofInc labor Calc, you musA fonhwimb comply with such prnvisiunsormis Penn, shall be dccnmdm,okM. CONSTRUCTION I.F,NDING AGENCY D nemhy affirm lbnune,.i.aconumnion RnJing agency fonhe perfnnnonce of the work for which this permit is issued (Sec. 309], Civ. CJ I.eaders Nit WATER SYSTEn1/IREtVF ING SOILS FEE WATEI(SERVICE PAID Dem R NEW RESIDENTIAL PLMB. SQ. FT. VIA L: I<n ler's Address I certify that 1 have read this applialion and smm Incl the aMve infonnaunn is cores. l agree o comply with all city and county ordinances and state mws relining it, fielding consmarinn, and bcehy ateman a mpneni,a ar ives of chis city m ente...... he rbo,v manliored pmEeny loot in 'Inas punas¢'. (we)agree to save, indemnify and keep harmless dm City of Cupenim, ..gains, liabiliries,judgmeals, costs and expenses which may in any way dame against. said City a. nwquunre of the groming nr This permit. APPI.ICAN'f UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT SOURC' !GULATIONS. $ AI: BUILDING FEE QTY. MECHANICAL PERMIT' PEE. SEISMIC PEE PERMIT ISSUANCE ELECTRIC ITT. AIAHRORAOD'IOMECH. PI,UMBING FEE AIR HANDLING UNIT CIO IO,BIXI CFM) MECHANICAL IT AIR I DANDLING UNIT(OVER 10,000 CFM) CONSTRUC'II( TAX Slgnuwrem ppliumVCortenaor Dao HAZARDOUS MATFRIAI S DISCLOSURE Will theapplirom er fuwrchuildin6 acupam score or handle hasallous mmerial ae defied by the Cipriano Municipal Calc, Chapmr 9.12, and the Health :u¢I Safety Calc Seaiun 25532(a):1 ❑Yes 0 N WiII me applicam or Earn,. building ocerEard tau equipmem or device. which Unit ha ardour air contest l noun as defined by the Bay Arca Air Quality Management Orsutell ❑Yes ON. I nave read IM1e hnrudnnsIii r e. a 533 an under . 1 tra r 695 uE IM1e if the Thalifthe Ibmia Health&Safety Cod,e a tens 25hati is and25534.1 to had the of air re dM. nen is whichmanly have h me, E, or to i, rr m.ptm.Certiy Irle of Int paincy aviation er tar requirements amen mA61 the me pdn. m ienaanre urn eemfenm eroeeApa..rr. EXHAUST GOOD(W/DUCT) HOUSING MITIGATI(IN EE HIEAINGUNI'TTO I00.00)BTU) HEATING UNIT (OVER 100,000 BTU) PAID Uam Re apt p VFN1'ILATION PAN RINGI.T: RESI D) BOIIJER -COMP QHP OR 10ST NNA II'I'U) BOILER- COVET (OVER 10(0.000 BTU) AIR CONDI'IIONI3R ISSUANCE DATE qqn ISSUED BY: NEW RESIDENTIAL MICA, SQ. Fr. Owner or aulhorued ager Dmc TOTAL: L)FFICE