S1519 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF.C'1'RICA I. PF. IIT NO
BUILDING DIVISION APPLICKI'ION/PERMIT PLUMBING-MECHANICAL — 1519
BUILDING PROJECT[13ESIN IFICATION
RPU ILDING ADDRESS SANITARYNO. APPLICATION SUBMI PIAL DATE
jo3S' LA95PA.LF- A&R,
OWNEk'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO.
C• �. LS•�— g> NIc covrkoLd
'ARC]l l'I'ECDENGNEER; LIC NO: ADDRESS. ❑-T
' CONTACT': PHONE: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
Np
LICENSED CONTRACTOR'S DECLARA'HON QTY ELECTRIC PERMIT FEE ❑ ) ❑
I hereby affirm this I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
Z with Section]n00)ofDivpaon3 ofine Business and Rofessiam Cude.andmy licemeis RPSIDENTIAI,
61 O p P13kAt1'T ISSUANCI!
F�.-. in full farce and effect. ❑SFDWL ❑KITCHEN REMODEL
aUV License Clns. Lied APPLIANCES-RHSIUENTIAL ❑ADDITION ❑PLUMBI6G RE PIPE
hQ W Date Contractor
S.Dm ARCHITECTS DECLARATION1'ANIi1S ❑MULTI-UNIT' ❑STRUCTURAL.
zbr z I undcrstandmy Nam shrllbe"sedaspubremcmdz MODIFICATIONOZ y^ UI'10200AMPS [I INTERIOR OCHIMNEY REPAIR
f¢vn t:V, Licensed Professional 201-I000ANPS \`�'IMPROVEMENT [D SWIMMING POOLS
Xs 77 OWNER-BUILDER DHCLARA'1'ION OVIiR IGIN)AMI'S ATH RF;MODHIARFPAIR El DEMOLITION
yyard 11 by ff Iran pu a Centimeters L err the
JC�6WAV
fallowing .(S B 9031.5 B IProfession,- Code:Any IY cuunY SIGNS II,F.CTRICAI. L�GTf1ER
L•134� xhih respire,.pecou1 treat,war, P theraili,lb, ,,repair ).t stare
F I!-OQ prof to its issuance.also requires the applicant for such Permian file asgned staenem SPECIAL-CIRCUI'PIMISC.
that he s licensedP - antt the previsions ofth C t t r License f (Chapter9
�ap0 (commencing `th Section 7000)ofD al t he Business d ProfirssmarsCore)or TI.MP METER OR POLE INST COMMERCIAL:
0.0.o that lie is eIcir,dremoranaral❑he thin... he a II b J Pt A ) I'I' t l ❑NEW BLDGIADDI'1'ION ❑DEMOLITION
Section 7031.5 by any applicant lore pennlsubjccts the eppl catuo.civil Penalty of POWER DEVICES
u•-N Ic deRive hundml dollars(5500). ❑I PROV El FOOD SERVICE
FZY nal uwnerof the r,arra employees with saes a their sok compensation, SWIMMING POOL ELE IC OTHER IMPROVEMENT _
= Prnpm > YcrnP g Penn
�(..O Ill do the wok.and dre ewemre is not intended or offered for sale(Sec.]OSJ.Busines. ❑OTHER
tiW and Professions Cade:'The Cantmcons Licence Law docs not apply to an none,of OUTLETS-SWI- ?S-FIXTURES
4'
property who hould,or injou-stM1 1 who does: h weak1' If through
tis van can,byee,pavvidedrl t. h'mp C reenol alandealnuodcredlet NEW RESIDENT I.EI.-' R SQ FE
sale If him ever.the building p e ) t is sold within are year ofc PI tion the SQ.fly, RARF.A S/SQ.FF.
owner-builder wall have the burden of proving that he did not build or manure for pur-
pas f: I 1
E] 1 f the pro,terty, exclusively contractingwith licensed comes, is or TOTAL: /�
onI tire nproject(s 744 Basic— n 1 c l :)ln c t r- - APR
c t J I apply it) fp ly n old. I , b d QTY. PLUMBING PERMIT FEE
sense
ImcNfor such p jectswthacont Inns)licensed pursuant m Contractors 0/n''1
License law. PERMIT ISSUANCE --vr LUr
❑I am smar,o order See. .H,c P C far this reason rKIIN
�. 1, ` _ AMER-DRAIN AA,VENT-WATER EA) VALUATION
WO K HR S COM PENS A'I'ION UECI.ARA'I I ON BACK PLOW I'HfYfI:CI',DEVICE
I� have
and waflum under Penalcam of Consent
onfollowing Workery Co ` 1
El and will for by Section 37M of Conwrno sell-ire"refer Worker'seocof b- DRAINS-FLOOR.ROOBAREA.POND' STORIES TYPE CONSTRUCTION
ration.as hick this
for by lection 3](N)of the Irbur Code.for the per(ortnanee of the
work have
which this Pemni ix ieorker FIX Yl1RF5-Plik TRAY
❑ 1 have nnJ will maintain Worker's CnntPensuminn Insurance,as required M1y SttIion
370B0of t he LalrrCode Gn the pednmresentilic work fla which this penned,issued. GAS-PA.SYS'rl?M41NC.40U'I'IJ?T9 OCG,GROUP MIN
My Worker's Compensation Insurance canner and Policy number arc:
Carrier: Policy No.: GAS-EA.SYSTHM-OVER 4(EA)
CERTIFICNI'I,,OF EXEMYI'ION FROM WORKERS' GREASFANDUS'1'RL WASTE.INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
(9Tisaamn accrual becomplIdit the permiticfnnmehandreiddlopsSIIIO) CREASE'I'RAP or IcsxJ PLANCHHCK IPE -
Icenip,mal in fleperfonnunceofere so,kforwhich this ponsil is mrd,isleallSEWER-SANITARY-S'CORM ICA.200 FT.
not employ any Person in any manner so as to become subject to the Workers Comport- ICNERGY FEE
O Z satinn Lows of Cam .DWATER HEATER WIVENTIELECFR GRADING FELT
lifoeam
Z C) Applicant '
NOTICE 10 APPLICANT:If,after making this Ceaifienm oI'Exemption,you should WA'TE'R SYSTEMA REAPING
f'^ bemire-..bjeo to the Workers ConaTematiun prior sicns nftle Luhor Cale,yon inuxt SOILS FEE
a forthwith unmply with such Provisions or his permit.shall be deenlvJ revoked, WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAT.PLMB. NQ.FT PAID
V 0 l hereby affirm that is a construction lending agency for performance of Dal` pfd
D, f'+ the work for which this pcmtit is issued(Sec.3099.Civ.C-) 'AI
C) ULender'.,Namne
W Lenders AAArc.ss TO3'AI.:
Ctim i cerify That I have rend this aPNiemiun and sole that the above informnmiun ms BEH-DING FEE
F' tn career l agree t.comply withal]city and county ordinancesrnd stale laws relaiag to QTY. MECHANICAL PERMIT FEE
U Z buildingconsmumion.and hereby authorize mpreoonaves of this city to enter urym the SBISMICFEE
above-mentioned property for iu,ection purposes. FERMI l'ISSUANCE
(We)agree to save.indemnify and keep harmless the City of Capone,,against IH,ECI'NIC FEE
habilitims.iudpmen¢,crxlx nnA cxPenvex which miry in any way umcmc againa suiA CiIY AI:FICR OR ADD 10 MICCH.
PLUMBING 17];
seyuc of 6roming rl ibis Pe."I"
APPLICANT UN I STANDS AND WILL COMPLY WI'H ALL NON POINT AIR HANDLING UNIT(TO IqXNI CLAD(
MECHANICAL LEI.
SOURCE REGUL T NS.
•yS AIR HANDLING UNIT HOVER 101100 CFNI) CONSTRUCI'IONB'AX
.ignuum •oi'A IiumJCnnmm¢ntr Date EXHAUST 11001)CIIDUCT) HOUSING MI'I IGAI 101 FEE
HALAItDOUS MATORIAI.S DISCLOSURE
Will the upplievm refulnrehuildingtrc ,parm,mrc in handle h;verdousneledal HHATING UNIT(10100,00 HPU)
as defined by the Capetian Municipal Cole.Chapter 9.12,and the Health and Safety
Code.Senior 25532ord? HEAPING UNIT(OVER 100.000 if put
E]Yes ❑NoPAID
VICNfI1,A'fIONiAN(SINGLE RC9ID) Date Receipt#
e Will the eppheant to fuorm building occupam use myai,n cam or devhes which
mit hamNoux air conuunmmlr5 as trainedum by the DoY ArAir Qrrltry Marigm taB)
n IILI:R-COMP(311P OR I0FkX011'1'U)
TOTAL
p YN; ❑No BOILER IMARY) 'PU) :
I huvm read the hanndenx materials rttlrirements under Chapter(Ins of0m Cali- AIR CONDITIONER ISSUANCE DATE,
fanner IInJIh At Safety Coda See llnns 2550.5,255]3 rind 25534.11 ii—Lard Ihm if We NI?W IZ17SID17,N I Al.MECH. SQ.Pr. '
building does not cvneally have retain mEX it is toy as,va siladay to notify the pecri and
of the n mmtnam,which moa M ren price m issuance of a Certificate.f OceupureY
(Owner or aumomed agentDam TOTAL: ISBUIiU BY:
OFFICE