S 0379 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUILDING-RLEC'I'RICAL I PHRMITNO. -
BUILDING D[vISION APPLICATION/PERMIT PLUMBING.MECHANICAL S 0379
- ... BUILDING PROJECT IDENTIFICATION d,' rr; I ;"1
BUILDING ADDRESS, �! SANI TARN NO APPLICATION SUBMI FIAT.DATE
OWNEI S I' PHONE ONTRA OR'S NAME LIC NO '
M//yl � NIC CONTHOLN
-µ�I E I/LNGIIINI:H ��y/ IC NO ODRESSS•�� �
�I�fr F�JX/Y /OLL7G/✓✓ 1� //LL L' �xiG�7/N�
COISTf7<'Cf �N�;F1 / // //� .BUILDING PER INFO ,
❑ Consultant Fees Paid by Applicant Initial / nhDr hlr.L' PLOM M1;a1
LICBNSED CONTRACTOR S DECLARXI'ION QTY. ELGCTRIC PERhtI'I'� ', FEE',
I ncreby utfimt Ihm 1 air hccmed Onset pmvlstons of Chapter 9(commencing I r• r ... I JOB DESCRIPTION
MCZO xah Seninn TN(0o1❑IVisionanfihc HUSUms.aW l'Inlesannn��yyNc,an my bcen.c 1. 11 I'13kM1'I'ISSUANCIi RIEZIDENTIAL;
CI~ in full force nail o fect �Q/4 1 ,IrpN'L ❑KITCHEN kfiMODIiL
U License CFn La p
rFQa ];am Contractor APPLIANCES-REST DEN'I'IAL I ❑ADDITION ❑PLUMBING RE-PIPE,
CHITTGTS DECLARATIO ❑Af U1.Tl-UNIJ' El STRUCTURAL
E:.D 0 PANELS
z p l undemmnd my plan.Shall M:u.eJ US public record. CHIMNEN RE N
b � UPTONM)AMT'S ❑INTERIOR ❑CHIMNE\'HI?PAllt
a�„I"J ul Lmen.ed Piece...cast 201-ITTMAMPS IMPROVEMENT DSWIMMING POOLS
p:Y;•.1 OWNUR-BUILDER DECLARATION
, OVER IIIf0AMPS I ❑13A'I'H REMODEUREI'AIR ❑DENIOLHION
C Q I hrmhy anon That 1 am exempt from the Contmcmr's Laen.e l.ow fur the
ip5,�6U loflrwmg remon,(Section 70115.Hu.Inc..unit Profe.smtw Code Any coy nruluntY SIGNSDLECI'RICAL El OTHER
lit 3 LL y which requires a permit to consumer,alter,improve,demolish or repmr any amemr-
t�0Q prortoin...ma are,also bNares the applicant tor.mchpennn m file astgned,tdtement SPECIAL CIRCUTUMISC
hot he is icensed pnnurint.mc pmvis..mot he Contractor'.Laem.c Law(Chapter 9
W�C� (commencing with Sectoon]00)of Dn.smn J of he Business nd Profession Carlo)or TEMP.MET ER OR MOLE INST. COMMERCIAL:
dq rG Ibm he i,exempt thmdmIn and he basis Ind the.diesel!exemption'Any cola ale n, ❑N17W BLDG/ADDITION ❑DEMOLITION
X m tN Section 7131 5 by any upphum far a gene omect,he applaan.Io a uvll penally nl POWER DEVICES
YYII r more than live hundred dollars SIR) ❑TENANT �FOOU SERVICE
ROVEMENT
=Q �hnowner of the pmpenY•or my employees with wogs.x.then sole cninpen:einn, SWIMMING i'DOI.ELECT RIC
WF.m wJldothe work.andtheamewre snrn mantled or offered fnI late(Sec](144,BUSinm, 'f HER '
a,R and PnResaons Code The Comrannr's Lmcme Law Joen nor apply m Ira nx ncr of OUTLIfI'S-SWI"1 rIIE5-PIXTIIHCS "-
propeny who budds or.mpmve.thereon,and who Joe,such work himaclf at thnmg.. y IS 1
his own employees,gambled that such improvements am one or oRercA far NEW RESIDENTIAL ELECTR SQ PI'. 1/ '
sale.It.however,the building(,I Improvement is sold within one ye,rafcompleuun,the • SQ FI'FLOORARF.A ASQ.FT.
xner-budder will have he hoiden of proving hat he alit not buJa or Improve for pot- � �� Iy� ^� t �. ^O y�
prow of sale) � ill I`
❑I,as owner nl he protect,n ndusrvely contractors wnh licensed comracmr,m TOTAL:
I constimot the project(Sec.7014,Business and Pndnsions Code.)The Coolmnols Lt- I, ) r• �5 �
reme Law dues not apply man uwnernfpn1lmny who budds onn.pnnea hereon,unA QTY'.•' .PLUMBING PERhIIT�t•
moss Lamm.er mob ply to as owner of prof orf.l licenmJ pursu oproves Ceres,m. -�f
011 exe PERMI"f ISSUANCE 49 / Sr.
❑lam exempt under Sec .Ps@YClnr this reason /
Owner I'm I ALTER-DRAIN&VEM'-N'ATER FGA) VALUATION
I homby effirORKdder Per COMPENSATION
cal,of SAS one of he following dedsommus. HACK PLOW PROTEC)'.
.Q(have nail will mumlom uCCnifmtcof Cnnsenl In sell-mwrelnr WOAer's Cungxn- DRAINS-MOOR,RUDE ( -
snuon,as provided fit by Secbnn YEW of he Labor Code,fonhe performance of th. STORIES / TYI'li CONSTRIIC I ION
nkie,whchihnpcoonl.—oral FIXTURES-PER TRAP �C(S •f C �(�(17
(]1 have and will maintnm Worker's Comrym.atinn Innm ice,m oNtemd by Section _EC -$I 09 _
37M of do Labor Code,lot tire performance of the work forwh¢h this pemnusl...Id
GAS S\'STF.h1-I INC.tOtTT1.ErS OCC GROUP APN
Ca Worker's G.mpenah�m lnwranre caniereld IN, nninhnne GAS-G SYSTEM-OVER btfjys--
Carrier PION FR — _.l -
CF.R9'll>ICC OF EXEMPTION FROM WORRIiRS' GREASEANDUSTRI,WAS.-L.(I,ns.IntA< f
COMPENSATI(1N INSURANCE
(Thissection need not becompleted lfihe Permit tsoo nchandreddolDrs ISIT101 I BUILDING DIVISION•''ISEIiS -
orle...l GREASE TRAP PLANCHECK FEE I ,.� � /e 2 .�
Iverrythat In theperfommnceofthework lorwhahihn permi.is Issued,I shall ) SEWER-SANITARY-ST ORM HA 201 FT (ENERGY PEE 9; 70
not employ any permm m awn manner no as m N. , ablcn to Ibe WorAcrs'Gnnpen-
Z cetmn laws of Caldnprlla Dfil �f_�� WATER HEATER WIVEM IELECTR
t_ LL GRADING.(1'.�
Z ti NOT L TO APPLICA ficr nmki us Cenit1 no of Eulhpboll,Y"u sM1nulA WAT17R SYSTEMoREAI INC /1
I-" become subject to the nmpe nun ors of he Labor Cade,you must I SOILS FF.Ii 1
forthwith comply with such pmvntomor this p[mut.hall be deemed revoked WATER S17RVICE
Q
� z CONSTRUCTION LENDING AGENCY I NEW RESIDIiMIALPLSIB SQ 14 PAID
V p Iherchymfirmt1lherelwcomve,oyU.Crag agency for the performance of 1 Date Recapta _he work for which this 1.11,Is 3ly)].Cm C) 1 G Y-0
0 W Lcndcrs Nam• ` / 1' _ -
r Ixnder'.cermyt /I �A:
L1•I 1 certify lira I lime real his application and ma¢that the above infomtauon m �I�7 �BUILDING I�E //, ))) 1
.Fi fA iormo lace to comply with uu rely and ramnry oximances and.rate lawI T[Imtug w QTY. � ' MECHANICAL PERMIT 0 FEE 1' /
V Z building[onametion.and botchy awbonre reprecemauvnofhn city norm,upm the - MaNBCl
abovem[ntooned progeny for Inspection purposes PERMIT IgSUANCIi
(We)us.to save,Indemnity unit seep bundle..he Cdy ul Clgemm,ngaiitsi ELFi R 'E 1
ti Ilablilties.Judgme.ns,cons and expenses which may In any wayaccmcagmiml.ad City ALTER OR ADD TO MECH /
PLI/MBIN( E f
mcmnequencc of the stunting of this permit ! _
APPLICANT UNDERSTANDS AND WILL COMPLY WII'It ALL NON-POINT AIR IANDLING UNIT 1'10 I TINS CFM) (- �c/1
SOURCE REGULA )) hiliC11AN1GAl.19iE Vn
/ 7 /•�� AIR HANDLING UNITIOVER III,Bf(ICPM) CONSfRUCOONTAX -
Signature of Ap canVCo a R//�`////�� Dam EXHAUST fi00DIW/DUCq HOUSING MITIGATIONS
I cOUSMATERIA DISCLOSE, li _
Willlbc apphcam or Ohre huildingl gam score nr hankie h...nE uso,dearl HEAPING UNIT ILO IfN),IN10 B'i U)
as defined by the Cupermn, I I,Chame,9,12,and the Ilcuhh and Safely. _
Code.Seclinn 25532mr? HEA'T'ING UNIT LOVER 110,0X1 B I'TO
C]Yes E]No PAID Al �...
VI7N'l1LAT10N PAN ISINGLE RIi51U1 Reeclpt#
Will the applicant or future building occupant use cgmpmenl mr devices which - l -
ema hnmTduu.aircontannnant.its defined by the Bay Area Air Quality Man.IgementI BOILER-COME'LEHP OR 1(18.001 BTU) TOTAL
D...III BOILER-COATI'(OVER 101,1X()BTU) (p-/—�(Vl 6 ts I No
Ihave read the hvnNous materials mgmamenu tinder Chapter 695 of the Cali. AIR CONDITIONER 'I Vr 1,A(ANCE DATE
forma ILaid,•9 Safety Cndc,so,( o,25505,25511 and 25534,1 undemmnd hat If the I ��r h
building does not current have a tenant.that It is hiln In nolif Ihmuau t NIiW RESIDENTIAL A11iCll SQ.PT Q
g Y Y respmsl Y Y pan I /N )
of the mquimnmms whsh nma be mm pour m....once of n CeniBcaR of(kcupancy. ffy1
Owner nr euthnnad ogem Dam ,T'1f 1, +� ISSUED BI':
OFFICE _ 's