50885APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUHAINC - HLDCTRICAI.
BUII,Ui DIVISION APPLICATION/PERMIT PLUMR NO. MECHANICAL,
RUIIDINC I'ROJI?CI' IIIUNTIFTCAIHON
:NMIT NO.
BUII.DING ADDS lL")
SANITARY NO
AI'PLICAf IONSUURMITI'AI.DATE
_ �•
OW/-HONEON!
J
CO IDSNAMI7xu.s RLIC NO'
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CON'I'k01.9
❑
ARCHITECT/ENGINEER: LIC NO:
ADDRESS:
COM'ACT: PHONE:
IJUILDIN(i PERMIT INFO
,(J
El Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
O
C O :i
❑ ❑ g;—/ ❑
LICENSED CONTRAC'I()ItS DECLARAHON
I hereby at tom I ran licensed under provixinnx of Cirpler 9lmamnencing
with Section]gMoof DivisinnJoflhe Business and Proft Cope, it ••liceneeis
in full Force and cqR CCCCpp
Liron..v,PJa _ J Lic.p
QTY EI.L'CTRIC IIFRMIT FEE
WOZO
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PUV
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Fpm
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JOB DESCRIPTION
RESIDENTIAL:
❑SpUWL ❑KI'TCHENREMODEL
❑ADDITION ❑PLUMBING RE ]'Hit;
❑MULTI-IJNIT ❑STItUC'LIRAI,
MODIFICATION
❑INTERIOR [I Cl UMNEY REPAIR
IMPROVEMENT 0SWIMMING POOIS
❑ BATH REMODEL/REPAIR ❑OFMQLITION
❑OTHER
pERMiTISSUANCE
APTUANCES-RI!51DEN'HM,
ANCIIIiEC'TS D!CI.ARATION
IundemanJ my plans shall MusW en public records
PANFI.$
UP'1'0200AMPS
Licensed Professional
OWNI!R-ItU1LDfat UT:CI,AHA'fIUN
1 hereby uffrm that I ant exempt from the Cout...on', License I-aw for the
following reason. (Seaton 7031.5, Business and Professions Cala: Any city nr county
which requires a permimpose, it to construct, alter, impve, demolish, or repair aaure trey sau
prior in its issuance. ahorequlres the apphrz Ilorsneh pennino) fie
20I.1000AMPS
OVER I000AMIS
SIGNS EITCfRICAI.
SPI7CIA1,CIRCUI OMISC,
Ing
a q e C
^LL
q_<
2 p
F
a 3
Ilan be is licensed pursuaut... LIE e ..... won,nl'Ihu Contractors Liceaue l.nw(chttpicr9
(commencing with Section7(Xhuuf Division 3ofthe Bu,incs,and Profession, Code) or
that he i, exempt Ihercfrom and the basis for the allege) aen+ption. any violation of
Seninn]031.5 by any applicant fora .cant,xuhjecmthe applicantia�
no.ean rise to t6vil Paulneof
uuthan blo,ridolris S5IX).
Q Lae owner nl'the pnspmy, nr my.mPlnyees whh wages us their sole cumpemmi.n,
w+IlJmhc work, unJ themm�um is nolimendufmoHc¢J for sale t$cc.l6W. Bueinus
and G+Je: The Cnmracmrs License Ww Jaz not apply to if owner of
propeny who builds or imposes thereon, and who does such work himself or through
property who
his ..wr employees, prnvid,d Owl Inch in+provemcall am not immured uu offered is,,
We. ILhnwevor, Ilm building.., improvement ismid withinoneycvv of aimplei lon,Ihc
TEMP. MITER OR POI.E INST.
COMMERCIAL'
❑NEW BLDG/ADDITION ❑ DEMOLITION
AMf FOOD SERVICE IMI'ROVI:MI!NT
❑OTHER
POWI!R DEVICES
SWIMMING POOL. 17hECTItIC
OI1TLIfS-S\41'1'CI1ES-FIXTURES
NI7W R1i$IDEN'I'IAL ELEC'!'k SQ PI'.
SQ. FC FLOOR AREA
$/SQ. P1'.
mrbuilder will have the burden of passing that he did sol bu1W m improve for pur-
poxe of sale.).
❑ 1, owner of the propeny, tan cxat,, oly Counseling with licensed .ronaoctor, u+
'll)TAL:
.. ur.pi Cudc:)'mmCs
Pracno
mslr..clthepmjcm(geno..
hercur.%Lb
sin,oeanod
Wi thereon.and
ilharomorchrox whosedprs itnt
QTY. PLUMBING PHRMIT FEF.
afro ciaweoeemnapplyman
tothe
who convects fneueh projects with a conwamis) licensed pursuant m the C..mmemr's
Liccnm Law.
❑ lam exempt Linder iler Sec. .D&PC this, reason
PERMH ISSUANCE 3
Dare
&VIiN'1'-WAI'I!R EA)
VALUATION
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK PLOW PROTECT. DEVICE
�Ow'nc
1 hereby aff..L antler penally of perjury one of the following declarations
(have and will inumtmn aCenlficate of Convennosel Finutrc for W.rker, Rnnpom
a...... d for by $eclinu 3Jl10 of lM1u Lubar Cade, fur the perfnnmtnce of the
workhnwhichthiepermitisiesued.
DRAINS-FLDOIt,ItOOF,ARI!A.COND.
'
S'ffIRIES 1'YPI! CONS'I'IiIJC'I'ION
11X'I'URES-PEIt'I'RAP � Q
4-
❑ 1 have ami will maintain Workers Compensation Insurance, as required by Section
370d (if the Labor Cxle, for the perinrmance nfthe work lin which this pem+it ie issued.
My Wo i nranev ear P r�7C'
nv9d9�y J
Gtrrier 1Lfl'(ilieyrYF.:
- DCC, GROUP MfN
/�
®G�
CAS -EA. SYS TEM -1 INC. OLD LES
GAS-❑A.$VSTIM-0VHR4(FA)
CERTIFICATI? OP EXEMPl'ION FROM WORKERS'
COMPENSATION INSURANCE
GRHASDINDUS'1'RL WASTE IN'IERCF.PfOH
00
ItU1LDING DIVISION ITI3
('this section need not he completed it the permit for hundred dollars 1$I(p1
rt less.)
Gkl!nSE TRAP
SEWER-SANI'I'AItV -STORM EA. 2110Irl'.
Iccnhythatintheperllnnrumc of Nc work forwhich this permil Ls hwcJ, hull
nemploy any Person in any mourner so as m become subject to tire Workeri Compen-
*EE
I
WATER HEATER WNFNTrTJ,FCfR
,�m
Q
�h
a
LA
d n
z
U O
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stionhwsof Culifioin Dam
Applicant
In
GRADING FEE
(B.S FF A 1999
PAID
NOt Knit 10 API'LICANT:II;nrmr nm king t hie Cenifaucnf Es,arla..n, you _rloolJ
herons subject m the Workers Compensation provisions ..I the Labor Code, you must
forthwith comply with such pmvisimes.,,his Permit shall be deemedrevoked.
CONSTkisC1'IONLF.NDINGAGENCY
Ihereh flimuhnnhero i%u conetmwiun leWln for the wrfutmanm nF
yu ,C.) Y 1
ibe work for which this pennil is issuctl (Sec. LIY], Cie, C.)
Ecder's Name
I WATER SYSTEM/ BEATING
WATER SERVICH
NEW RESIUENI'IAI. PLMIi. SQ. ET-
Dow Rmci Ip
TOTAL:
Lenaders Address
T( 0
IIl11LDINO PIiE
I certify Ihul I have rend Ihiv application and plum Thal IM1e above inlianmtion is
cnrrca.l agree n+annply wiro all city and antnty nNinnncc%and xwtc land, relating v.
Wildingconsauaion. and hereby amhmiu primeomatisesoOd, city tocaterupnn the
QTY- MECHANICALPERMI'F FEE
SEISMICI-HE
PERMIT ISSUANCE(WO
FURCfRIC IEE
aMrvcmmmtioned propeny for inspection purposes'
agree to save, indemnify and keep harmless the City of Cupertino against
ACI' 1!R OR ADD'I'0 MHCH.
PLUMBING 113EOle
liuhili0e,,judgmm�rs, costs vndespouses which may in any way accrueugaind said City
in mn.cyuencc of Ill. grunting..Ruts permil.
AIR HANDLING ON IT(TO 10.NX)CFM)
APPI. CANT UNDERSTANDS AND WILT. COMPLY WITH ALL. NON -POINT
OU CF:REGU�\TION
AIECHANICNJLE
AIR HANDUNGUNR(OVEk 10.00fICPM)
CONSTRUCTION TAX
Z
Signauvc of Applin+m/Com. t r Dol
I=RI IJS MATERIA S DISCLOSURE
EXIIAl15T HOOU(WNOQ1)
IIOIJSING MI'fIGA'1lON VEE
IIEATING UNIT(TO Indian, I,rLD
Will theapplicam orfawn builiing+ecepant.lore or handle bazmJous nnmciA
is AcrincJ by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
l IFNI'INO UNIT (OVER IOn.s l BTU)
C..da, Section 25532(..)'! /
El Yes 11J n,+
PAID
VENT -1 LATION FAN (SI NCLE RF_SI Of
Date Rme' 1M
IiO11.ER-COMP(iHP OR IfM1,IXN1 B'IV)
'
Will the app onto in furore building by tiro B use equipment.. devices which
:ash hmord.us air contaminants undefnuf by the Buy Area Air Quality Mumgemem
DL%viny
�Yw
l'Al:
BOII.HIt- COMP(OVER 100.000 BTU)
AIR CONDITIONER
I have read the h:rsNoas material% requirements under Chooser 6,95 of the Cali-
ISSUANCE DATE
NEW I<HSIDENfIAI. MECH. SQ. R.
forma Ilealth & Surdy Cade, Sections 25505, 25533 and 25534. 1 understanA That a the
hldh+gdnes n,ournlly bavcalenam,lln+lu kury responsibilryto jushlyfle necnpam
—7 -/� g9
he
oflbe rvJyuircme whhi ustbe metprion once o(a CcZ hot 0,1Wncy.
g�g25/J{ / I
TOTAL^
ISSUED BY:
wncr..r aurhnnn, agent Dme
OFFICE