S 1357 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEWFINO BUILDING-ELECTRICAL. 1'E ITNO
BUILDING DIVISION APPLICATIONIPERMIT IPLUNIFUNG-MECHANIC L 1357
RUlld)ING PROJECT'IDEINTIFICNTION
BUILDING ADDRESS: � NANITAKY NO. AI'I'LICAI'ION SUBMITTAL DAH?
_
OWNER'S C E: �.V�'L IL7%f TOR'.SS1NANT.: .S I.IC N0 `V
i./i// NIC CON'IkOLk
.RCIII'O?C'I'fENGINFER: LIC NO. ADDRIHSS: // ❑
s, S
CONTACT: PHONE:
'') r--� .'k 6DILDING PERMI FINFO
pyus /YICtSbnf '�/ / /��o� ❑ Consultant Fees Paid by Applicant(Initial) BI,I)gr EL?CT PLGMH MECE
,meq/ ❑ ❑ ❑
LICENSED CONTRACTOR'S DCCLARAI'ION qrY (ELECTRIC IaIiRMIT FliE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
X00 with Section 7")of Division Soflhe Businessand Pmfcxxione Gde,andmylicenmis PERMITISSUANCE RESIDENTIAL
+{LOO
F�.. in full flute and of I p /O�a-9 ❑SPDWI. ❑KI'I'CfIF,N kGMODEh
�VU I.iccnsc Clw, I E APPLIANCES-WISIDEN'GAI. ❑ADDI'UON El PLUMPING RE-PIPE
y z 6i Dale Ate.
Fly ARCHITECTS DECLARATION PANELS'Don El STRUCTURAL
z OinZ Iundersmndlnyplansshall bcuudaxpublic records MODIFICATION
Oz-Q I1PT0200AMPS DEN'ITiREGR El CHIMNEY REPAIR
Z il,, Licensed 11 f, nomal 211-I"AMPS IMPROVEMENT E]SWIMMING POOLS
G�
OWNER BUILDER DECLARATION OVER 11NX1AMl'S ❑HA'I'TI R1:410D1?IJItI?('AIR ODI?MOLI'I'ION
Zi
YeL7 Q 1 homby nffna that I am exen"a rroul The Cmmravmr'x 1 iters,Law far the
0.O 0.V following reason.(Section 703 IS.Basin—and Professions Code:Any city or,auday SIGNS HLFC'I'RICAL D OILIER
3 U.ywhich reym cs a permit m cnnstric,aher,improve,demolish,or repair any svudure
FLLO¢ prorto its issuance.also requires the applicant for such pemtit to file a signed statement SPECIAL CIRCUIT/MISC.
E;!lyJ Ihm he is licensed purxuumin the to-kimsof Te mm
hCoraer's License Law(Chapter 9
�' QDa (cnnnnrnclo,with Scctlun90mdut`Divieinr3sflhu Business and Pro@ssions Cbdc)or 'TEMP MET ER OR POLI INS'('. COMMP.RCIAI:
0. o LL that hu is coaa,1 0emfrnln and(be hasis Rt The alleged corupdon.Any violation of D NEW RI.DG/ADDI'I'ION D DEMOLITION
y Section 01131.5 by anyappllcinl for a permit subjects the applicant to a civillwnnity of POWER DEVICES OTENANT ElFOOD SERVICE.
not mom than five hundred dollars(3500).
OTHERVIEMENT
I� Q Lasbew is,
and
property,mmyct incendeswitheand fox Thei flute c°mpcn..... SWIMMING POOL ELECI'RI
S� will dolhewna,ando she Cosa is act icensernf dor,rx:I n,ly.,, no whereof OGTELER
and property
whops ilds or imp Gus there
s,.lams Law Asea am apply m wt r thio of nU'I'LETS-SWI9'CHES-PIX' R
properly who hurl,,or improves that
thsuchn,and Who does such tints himself of through
his ownowever.are pmvideJ Thatsuch menti sold w main
nm intendedorattendfar NEN'RF_SIUIiN'I'IAI.ELGC'.'H
sale.IL however,the building or improvement is sold wiwin one yea of completion.the SO.FT FLOOR AREA $/SO,ley
owner-builder will have the burden of proving that he did not build or improve for pur-
pose"I"ale
I,as ow net of the property,am exclusively convector,win:Incensed c°mmmor,to 1'
o..met the project(Se,.71144,Badness rand Profeviom Code.)The Contractors Li-
cease Law cars
i-ceaseLawdae.s not apply to an owner of property who builds or improves thereon,and Q'fY. PLUMBING PER MIT
who contacts for such projects war o commands)licensed pursuant to the Contrac ue, S
License Law. PERMIT ISSUANCE 's
El Ism exempt under Sec .B&P C for This reason
Owner Dae
ALTER-DRAIN&VENT'-W61'P.R(EA) V
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT..DEVICE 4 .1 CSC -00
(hereby alEm:undcr,raalty of,crjuD one ofthe following declaration, 1X 1•rJ C!
❑ Ihivcind will miiamina Certificate ofConxenu°self-inxmm far Wn k,,vCnmpen- DRAINS-FLUOR,ROOK AREA,CONDSTORIES TYPE CONSTRUCTION
satien,tea pmvrded far by Section 3700 of The Labor Core,for the pedomuuc,of the
work on which(his per and is issued. FIXTUIt HS-PEI I RAP
[31I iof mend will maintain Worker Caneaftheonrktor Insurance,which
nshis per by Scdinn
My of lvl+or sm"arop In performance ofthewnrk nu berarM1is permit is issued. GAS-EA.SVSTGM-1 INC.40UTLETS OCC GROUP APN
Ca Wnrkct Compenvtinp In mance carrier and Policy'1'71 7
Cnrtier.� " Policy No.;y9O�U' �D GAS-EA.SVSTGM1LOVF,NO(:A)
EiR'I'1 PICBI'li OF EXEMPT ION FROM WORKERS'
COMPENSAI ION INSURANCE GINEASIJINDIISTRL WASTE INTERCEP GIG
BUILDING DIVISION FI?Ii5
(r his section aced..I be,mr,bl,dd(he cots is Rmme hundred dolhtta(S I W)
or lass.)(I TItAI' F'LANCIIIiCK FEE
I certify that in the performance ofthe work for which this permit is issued,I shall SEN'ER-SANI'T'ARY-91(IBM IIA.200 FT.
not employ any person In any manner so us n become subject m the Workers'Compen- ENERGY FEE
,7.i anion aw.a of I forniu.I WATER HEA'DA WNHNTIId.IiC'I'R
Apph,inl GRADING IEE
y NOTICE 10 APPLICAN'E 11,after making this Centficatc of Haemplinn,you should WATER SYSTEM?RHA'I ING
H , become subject to me Worker's Compensation provisions of the Labor Code,you must SOILS IEE
forthwith comply with such provisions or pernitahill bedeemed revoked. WATER SERVICE
aQ
CONSTRUCTION acONIAtion AGENCY NfiW BESIDE UAL PLMIB sl).IT. PAID
Z" Iherehy ufOrm that lhmeix uennnmulinn lending agmmy lin Tho perfurmmucc of Dna Script If
V LLIthe work for which this permit is issued(Sec.3097.Civ.C.)
0 (•" L emdda Name TOTAL:
V Leadcr's Address TOTAL:
>+ Lkl BUILDING FEE
ante that l have rata This application and slam that nd.stme laws
is
�. T�/1 smites lagan to comply with all,iDmal annoy ominanmsundalnlelaws alining 1, Qty, MF:CHANICAI,PIiRMIT FEE
U � builJingennsvumion,nnA hcrchy aulhmriec leer,aemallvexnl Thiacitylo cnunlpnnthe - SEISMIC fNP.
abnvolnentinned turned,fm m,ler nn purpose, PERMIT ISSUANCE
(Ale)agree To save,indemnify and keep harmless the City of Culmina against GLECr RIC IEE
liabilities.judgments,costs and expenses which may in wry avenue against said Cay ALTER OR ADD"TO MECH.
in consequence of the granting of(his permit. PLUMBING FEF,
APPLICANT UNDERS'1'ANUS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('10 IB,BIN)CPM)
SOURCE RIiGULATIONS. MECHANICAL FEL?
/�A" 3���-9$ AIR HANDLING UNIT(OVI?R I(1,0fN)CPM7 CONS'I'RUCTION TAX
Signnure ofA,,Iw mK7 mac r Data EXHAUST HOOD(W/DUCT HOUSING NIITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the oprictm,or inure huilding accupant Mom or kindle hawtlla s Inmcrial I]EATING IINI'F(TO 100,000 BTU)
as delimcd by The Cupertino Municipal Cale,Chapter Q.12,and the Hea10 and Safety
Cala Section 25532(a)'I HEAPING UNIT(OVER I(N),(NX)B'FU)
E]Yet ONo VF.NTTLALION PAN(SINGLE RESID) PAID
Dale Rxeipte
Will the applicant truants
fume bur Wing by(he Buse Area
Air ural m Mnara which
emit hnualnlrnls iii wmluminnnls is defined by Tho Bay Asa Air Qualhy MunugninenT PUILEk-COMP(3HPOR I00.000BTU)
TOTALDistrict!
❑Yes ONo BOILER-COMP(OVER 100,NX)BTU)
N
I have read the hvmdnus materialsayuitemenu AIR CONDITIONER under Chapter b.95 of The Cali- ISSUANCE DATE
brain Health&Safety Code,Sections 25503,25533 and 25534.1 understand That lithe NEW RESIDENTIAL MSCI I. SU PI'.
huilding Anw nntcurrcnTly Love a Icnanl,mbar it ie my reslvmsihilily m nosily The......pant
of Ne ayurrements which must he and Prim or issuance of a Cendwer,of Occupancy.
Owner or authorized agent Dat, TOTAL: ISSUED BY:
OFFICE