S 1570APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO IRUILDING - ELECTRICAL
RUILnINC nI VISION APPIACATION/PFRNIFP PLUMBING - MECHANICAL
I BUILDING PRO.HiCT IDENTIFICATION
I'EF�\]IT NO 1570
kJ
ILDING ADUHESS'. ) `
SANITARY NO.
APPLICATION SUBMITTAL ONE [I
o�oZ/SSG% e. ,ln• ��Cx-+TI nf7
✓
� 2
VNER:S NAME: N
OZ_ JPO asp
Q
CONTRACTOR'S NAME. LIC NO'.
NIC
❑
rsfkCONITRRROLIT
/ V�
( e
ARCH1TECr/HNG;ER: LIC NO:
R:CAa_d Hiek TOhn a
ADDRESS:
ONTACr: PHONE:
BUILDINCPEIiMI'1'INPD
WaWal
F��
W-+
<-U
F Q 6
t Dm
z0anzI
az=o
F4ttrl
�dY2;
a a Q
a o, U
W 3 a F*
1L O`er
Q,
i
❑ CnnSBltanl Fees Paid by Applicant (Initial)
131.DG'1{� IiC'1' _ PLUMB MECH
A _VJ'[-, ❑ ❑
LICENSED CONTRACTOR'S DEi LARATION
I hereby arnnfl mal I .m, ba7rsed ander prayIscon+ of Chapter I) Ic KlIammins
with t0(10O)ol Division 3of the Rmina+smad Podassiana Cade, and our license is
in full mmcind effect
License Cla» Limp
Date Cen,.,,,,
ARCHII'FC`S DECLARATION
understand myplansehal III as Public ,.,ads
QTY ELIeCTRIC PERMPI' Il?T:
JOB DESCRIPTION
RESIDENTIAL '
❑SI'UWI, [I KITCHEN REMODEL
)ITION El PLUMBING RE -PIPE.
MULTI -UNIT EI STRUCTURAL
MODIFICATION
❑INTFRIOR ❑CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
❑ BATH REMODF.LIRE1AIR ❑DEMOLITION
Ol'I{I7k
I'IiHMI'1'I$$IIANCh
APPLIANCF_C- RESIDENTIAL
PANELS
UP TO 200 AMPS
lie,awd f ol'c,i( al
OWNER -BUILDER DECLARA'130N
I hereby amen that l am ucmpf from me Contrncmra Livuase law far be
followingmmom (Section 0031 5, Business and PmEssions Code: An cit t
which requires a t m construct alter, im demolish, or repair an ruucture
9 R p P Y'
poo t t ,s - ld rc Rac.,licandfor such permit file a signed statement
201-1000AMPS
OVER IfNN)AMI'S
ti1GN5 ELEC1'R1CAI.
SPECIAL CIRCU I'VMISC.
'n
adE
M y o a
LLXI Isy
H Z �•
Q
� �
tail �'
a
that he Ircel,rd pursuant tthe summons of the Coal t License 1' (Chnpler9
(,aroma a. all w't h Selina 70(hr 11)'v'aia. 3ofthelb+au,a W lr l e'' 'Gda)or
r me alleged exemption. Any vinhninn of
that he i+cxunipt therefroand the hoes. foegeex
m
Section M1ymryapplicant Earn permil,ami is thoapplicam m a civil Niully of
of more loan Five hundred dollars 1$500).
❑Las ew of ndfle, solvently. or nrycnsployee.wim Bredwagesfastheirsele 0-14, Business
dos of apply to an o ax, is
will dmbe sion4 and the he Cont is hot tors Lndede Law
and Rnfesin, h Cute: The Contractors License l,aw docs not apply m h . owner of
progeny who bn'es, lar impnrvcn Ihcram, and who Anes bah im hltn,dl' llemd f..
m of urn, for
his awn employees, pnrviJnl mat inch imprnvmnonw are nal iycle of
sale, If. however . the building or ltnprovemem is+old within one year of completion, the
PIMP. MP"THR OR POLE INS' r.
COMMERCIAL:
❑ NFW BLDG/ADDI❑'110N DEMOLITION
❑'117NANT ❑ FOOD SERVICE
IMPROVEMENT
❑TTI III?k
POWE DEVICEti
SWIMMING POOL ELECTRIC
OU'TLE'TS -S WITCIIliS-FIX'fURGS
NI1W kB31D1:N'I'IAI. I?LECTR SQ PT.
SQ. Fin FLOOR AREA
4/SV. 1'P
rvhuilAer will have be burden of placing that he did no build to improve for pol,
poseeofsale.).
❑ 1, as owner of the property, am exclusively countering with licensed contractors to
O
construct the project (See. 1044. Business and Profemions Cod, The Contractar'e Li-
-
1se Law dale mat apply Enron owneri property who htdlds cr imprnvea nmmon, and
QTY. PLUMBING PERMIT FEE
whoeommclef ranch pr jests wllhncnnwemr(s) licenrcJprommann The(: .... ms
Liceae law
lam exmnpt der Sec , B & P C fa,hi, reason
L]un
I
PERMIT ISSUANCEA
mer nate
ALTER -DRAIN & VENT- WATER (EA)
VALUATION
A
BACK FLOW PRM ECI'. DEVICE
WORKER'S COMPENSATION DECLARATION
A
1 hammy amort awnr penalty of ge iaD ane arnte launwbt6 acehtmdonx.
I haveand will autumn aCeniliam of Consent losell-imure for Worke-Canlpen-
satin, as provlda] for by Section 39(X1 of the Lahor Gale, to, perfarno nce of the
work for which this permit is issued,
UIiAINS-FLOOIt,kOOF.ARIiA,CONI)
er;E) 1(;S
yf tiVf• rrIIIN
TYPE CONSTRUC'I[ON
FIXTURES-1'13RTRAP
❑ I have on.I will maintain W..kelz Compensation Insurance, as reyuind by Section
3100 of the Labor Cele, for the perfornence of the wad(or which this permit is issued.
_
OCC. GROUP
APN
GAS - EA. SYSTEM -I INC. 4 OUTLETS
My Worker's Compensation Insurance anis and Policy number am
Cnrrien Polley
GAS - EA. SYSTEM -OVER 4 (GA)
GRH!ASFJINDIISI'ITT. WASTE IN'I'I!IiCI!PIOk
CIETTIFICNI V OFI?XEMPOON FROM WORKERS'
COI'
COMIiNSAT1ON INSURANCE
ILMI .DIVISION
PIidS
(Thixecction nced mat he annplmed i(me permit is forone hmndreddolhfrs(5100)
nr lass.)
GREASETRAI'
PLANCl117C
I certify that in the performance of the work for which this permit is issued, l shall
mot employ any person in any manner so as to twearm suhjee m the Workers Compen-
SEWER-SAMEARY- STORM HA. 2f N) IT.
ENERGY 17EE
O%
Z
h
I^ ?
Wforthwith
aQ
'7 z
�"' (•"
L)
.Fib
L)2
Indian Liwaof Califnrm, [)am
Applicant
WATER [WATER W/VI!NT/E1.13CTR
GRADING NHP. '
NOTICE' 11ll'APPLICANT: I1: u0cr making mss Cenilicme of EmmFlin c you Nadd
became subject to the Worker's Compensation pmvinlon, of the tabor Cat, you must
nnnply with such pmvisinns nr this pem)inhall he JeemeJ revoked
CO,Them RUCTIONLENDINGNGAGIiNCY
Iharahy ufdmlmm mere ixu aortwmainn lending agency car the perlixmenec of
mework In. who,(at, permitk Nunrd(SC, 3091, Civ. C.)
Lender',, NameFAL:
WATER SYSr,E /I HEATING
SOILS ItiE
WATER SERVICE
PAID
Uule kccci H
NEW RESIDENTIAL I'LMH, SQ, FL
Lender'+Addms.+
T(TI'AL:
BUILDING FEE
ge
1 certify that 1 have read this application and state that the above inlimmmum is
correct. l agree to comply with all city and amnfy ordinances andvme laws relanin"o,
mildia,comwclien, and herehy mnunice represemalives alibis city mcomr upm the
Ql'Y. MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
H TCI'ITIC FEB
above -mendoned progeny for Im,,c.on Purpose°'
(We) agree m save, Indemnify and kelp harmless The City of Cfgmrtino against
ALTER ORADD'10 MECH.
PLUMBING FE
liabilities, judgments, costs nd expenses which may in any way aecme against said City
in asequence,of the 'ronin' of bis permit
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT
SOURCE. REGULATIONS.
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCT [ON TAX
/ ` _!T�_
Sl mnac ol'APPlknnl/Cammnl Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST II00DOODUCI)
HOUSING MITIGATION FI!1!
H EDIfING USE FEE ) 100.00(1 BTU)
Will IM1eapplicant mfurore hoildingm'c.... ,Tom nr handle hamrdnafnuisrial
as Jefioed by IM1e Cupertino Municipal Cale. Chapter 9.12, and the IHealm trod Safety
Cod, Salion 25532(a)4
HEATING UNIT (OVER 100,000 II Fit)
Yes No
Willilwnl'Plicanl or fuauc huilJin6occuptunnse nry'andat m'Juviecs which
I it hmalous air cmnlamin us. a, defined by the Bay Arca Ail Qualify Maoagencm
Dislricl?
❑Yes ❑Nn
PAID [)air Rderiple
VINILAT10N PAN (SINGLE HI!SIU)
BOILER-COMP1311P OR IIMI,INN111'fU)
TOTAL:
B(111.ER-COA1P (OVER 100,0001111))
AIR CONDITIONER I
I have mad the hazardous tocammaLs requirements under Chapter 6,05 of be Cali-
ISSUANCE DATE"
NEW RESIDENTIAL MECH. SQ. FC
formal Health as Safety Calc, Sleflons 25505, 25531and 25534. 1 understand that if the
handingdocsnor currently haveamount, thatit is mryod, cihilitym mudy me nauparl
ofthe ma mmumnts which must rte the no, to iasaaaa of a Cetdfiate of (kaparc,
�AA
ISSUED BY:
TOTAL:
Owner or aumoriud agent Date
OFFICE