S 0608 ARPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
(JTYOFCUPFRTINO Bull PLUMBING-MFCHAICAI, Prunnrrvo.
BUILDING DIVISION APPIACATION/PERMIT PING PRNC. T IDENTIFIC S 0608
BUILDING PROJECO'IDENTIN'ICA'1'IUN N
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIF
;( 1 '7,31 SJ}N'rA 8ELLp. pLAGL" q--72PL "7
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
}evFn iNNJNE �51- 71Sg NIc CIINIRGI.p
�ARCHTIT"CT/CNGINEER: LIC NO: ADORF_SS: ❑
CONTACT: PHONH: BUILDING PERMIIINFO -
❑ Consultant Fees Paid by Applicant(Initial) BLllj; HLP,CT PLUMB MF�GH
/rC�r�`�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PHRMIT FEE
1 hereby alum that I am licensed time,provisions of chapter 9(cnmmeneing JOB DESCRIPTION
QRZ with Section 70001 of Di vision 3 of the Business and Prnfession.s Cade,anlmy license is RESIDENTIAL
Flog nfull force inJ effect. PI!RMI'I'ISSUANCF.
p. ❑SPDWI. El KITCHEN kF.MODIiI:
�UU License Class lar.W APPLIANCES-RESIDI!N'HAL ❑AUDITION ❑111.1-MEINGREd'IPH
h;j W Date Contractor
aA G6 ❑MULTI-UNIT ❑STRUCTURAL
ARCHITFCFS DECLARATION
Fpm PANUS MODIFICATION
`zZ 1 understand my plans shell he used as public rttnrA
—Q UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F� W Licensed Professional 201-1000AMPS IMPROVFMLNT C]SWIMMING POOLS
OWNERSBUIIAER DECLARATION
P C a I hetnhy Efrm that I um exempt terrible Cont..won,s License Loss,rnr Ilio OVER 10111AMPS ATH RIiMODI!WR PAIR BPMOI. N
ip5, 4U followingn.,re,(Section 70315,Businessand Pmtr,aama Curb:Any citynrcnud, SIGNS ELECTRICAL OTHEk
to 3 t+•y which myubes u permit to con me ei,mler.improve,demnlisn,or repair any strun am
F'�•�� priorm its issuance,alsomtorea the applicant(orsuch penult ,I eleasignedstatemint SPECIAL CIRCUD'IMISC.
CyQfthat hmiislicensed pursuant to the provisions ofthe Contrvcrars license law IChupm19
W�GO (con cmgwith Section 7")of Division 3ofew Husimessand Professions Code)or 'ITMEP.MIH'ER OR POI.Ii BEST COMMERCIAL
W c C that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION ❑DI?MOLITION
Section 7031.5 by any applicant fore perndt subjema the appllcum m a civil penally of POWHR UHVICES ❑TENANT ❑FOOD SERVICE
> not more than live hundred doll,:s($500). IMPROVFMI!NT
�F6 Las owner oftbe property.orm,cnlployees with wages as their side compensation, SWIMMING POOL FLFCfRIC -27
C sur do the work,and the Suriname is not intended or offeml for Sale(See7044.Business .E]OTHER
ad and Praf ...Code:The Comoutnrs License Law does not apply to an owner of OETTLIN S-SWITCHIS-FIXTURES
property whit build,,,,,improves Inc.,.,and who dues Such work himself or through '
his own anployees,provided that such improvements am not intended mattered for NEW RESIDENTIAL ELECTR SQ lel'.
.]I,If,hovesta.me bulldingor lmProvnmant issodd within our yeast completion,the SQ, FLOOR AREA S/SQ.Ff.
owner-builder will have the burden oI prevhtg that he did not build or improve for par- �� �[�
pose of sale.). 111.IJa�
1,vs owner of the property am exclusively mntmning with licensed contrucmts to T(TIAI"'
onstme,the project(Sec.70cW,Business and Professions Code:)The Commc urs,Li.
cense lawdvvs not apply to an ownerofproporty who hiild.cor improves thermm,and QTY. PLUMBING PERMIT FF,E 1D�f ur• Vurth I INO
who contracts forsuchpmjeets with a commercial licensed pursuant o the Contractor's
License Luw. PERMIT ISSUANCE
•.[ 0I lamexempt n r. c. ,BdcPC for this reason//- e .Date DEVICE
� I9 .� All'I!R-DRAIN Ya VIiN'1'-WATER(EA) VALUATION
O
WC KFR'S COMPIiN$ATION DECLARATION I BACK(LOW PROTECT.
• 1 hereby alBnn under penalty of perjury one of the following deelemilmmc
❑(have and will maintain aCertificate of Consent m.self-inwm for Workers Compcn- DRAINS-FLOOR,ROOF,ARRA.GOND. STORIESTYPE CONSTRUCTION
Station,as provided for by Section 3700 of the Labor Code.for the performvnce of the OL
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurancn,as required by Satins
37M ofthe Lubar Code,for the perlimnnmcc of the work for which this permit IS issued, GAS-IIA.SYSTF,M�I INC.4()Of LETS OCC.GROUP APN
My Wmkcrs Compensation Insurance carie,and Policy interactive:
Carrier. Policy Nn: GAS-EA.SYSTEM OVFR 4(EA)
CFRTIFFCATR OF HXHMPTION FROM WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE: BUILDING DIVISION FT:PS
(Thissetno.need net the completed if the permit is krone hundred dollars 1$10) GR HASE TRAP or less.) PLANCHPAK PIiF
I cerci by,het In the Ewdooneare of the work fill which l III x permit is i„trd,I'hall SEWFN-SAN ITARY-SEE ORM EA.200 FI',
not employ any person In any acture,,;as m become object m the Worties Compete RNERGY FEH
,Z virion Laws of OOifnmia.Date WATER HEATER W/VHNT/FLHCTR
ZO Applicant t GRADING Elil?
III) NOTICE TO APPLICANT:IL after making this Certificure of Exemption,you Should WATFN SYSTEMRRFATINCr
a become subject to the Workers Compensation proonto
of the Labor Code,you to SOILS PCE
forthwith comply with such provisions or this permit xhal l hedeemed revoked. WATCR SERVICE
Q
=s CONSTRUC'I']ON LENDING AOIiNCY NFW It B.SIDENTIAI,PI.MB SQ.]it PAID
V 01 hereby effirn Nat thereismetuational lendingogency for the perfornmmv of Dew IpI
the work for which this percent is issued(See 3097,Civ.C.)
�' I••r OI'AL:
Lenders Name
O W Lender's Addes,s TOTAL:
U4 certify that 1 have read this application and state that the above information is BUILDING PGP
h enmec,l agree to comply with all eit,..deounry announce.,and state law,relating In QTY. MECHANICAL PERMIT FEE
V funding ennshnction,and herchy authrnim wpoeseloniveS illINS city mentor upon the SHFSMIC FEN
move-mentioned propeny for inspection Emrposes PERMIT ISSUANCE
(We)agree m rove,indemnify and keep hamdas,the City of Cupertino against FI.F"CTRIC PHI:
liabilities,judgmems,costs and expense'which may in any way accrue against said City ALTER OR ADD TO MCCH.
PLUMPING Plili
inconsequence ofthe N thispermit.
APPLICANT UNDERSTANDS AND WELL COMPLY WITH ALL NON-POINT ALR HANDLING UNIT(TO 10.000 CFM)
MECIIANICAI. iE
SOURCE REGULATIONS.
AIR IIANULINO 11NIT'(OVIiR 10,01(1 CFM) GONSTRHGTIO
Signature of AppliciWCconewmr Doc HXHAOST HOOD(W/DUCT) IOUSINGMI'NGATION tt
HAZARDOUS MATERIALS DISCLOSURE
Willtheapitheant o,fmum builiingeecupant eeaeorhvadlefoaaNna,mmenol HFATTNG UNIT(11)10L00l BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sectio 2.5532(a)? HPATING UNIT(OVER 100.010 BTU)
❑Yu \Nn VLN'1'I LATION FAN(SINGLERF"SID) PAID Dale ReceNl 11
Will the applicant or fmurc building occupant use equipment or devices which
emit hiveNaus iirsxmtaminumbas defined by the Bay Arca Air Quality Management ❑OILEk-COMP(3HI'OR IIN),INN)BTU) ;TOTAL.
( Distnm? \�,
❑Yes x�Nn NOILCR-COMP(OVIiR FINI,IMNI BTU) _ n.
F hive read he haaardom mainals rcyuimmentxunler Chapter 6.95 of the Cali- AIRCONDUIONER ISSUANCE DATE
ramie Hcul@ k 5 fc C onions 25505,2553?and 25534,I understand that i1'the NEW RPSIDENTIAL MFCIL SQ.14.
building 1, mol n emdv natenunl,That it is my restio,ibirtvmnodlYth ire m,e(
of the r•, nidi mtM met pnnnnissr -enircateor ypnl y.
Owner ammo Magent Date TOTAE ISSUED BY:
OFFICE
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