S 2816Baal R`ANTT(] FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - FLFCI' RICA L
BUILDINC DIVISION . APPLICATIONMERMIT PLUMBING - MECHANICAL
IIIILDING 1'RO,IECI' IDICN'1'IFICA'I'ION
PERMIT NO
S 2816
IUILDINGADDRESS: i1�-
ii l
SANI'1'AkY NO,
APPLICAT IION SUBM/ FIAAFL])AAt1l.
OWNER'S NAMI7'. PI {ONE',
11 ^
11kCHT1'ECT /I? GINEER: 'T LIC NO:
CON 'IRACfOR S NAME LIC NO:
ATo
•ADDRESS:
NIL
❑
OIN'111OL#
CONTACT: - I'll 07
❑ Consultant Fees Paid by Applicant (Initial)
/ ,BUILDING PERMITINFO
BLDG ELECT PLUMB .MICA
❑ ❑ ❑Id
LICHNSED CONT'RACTOR'S OFCI.ARATION
I hereby dErm that I man licensed under provisions or chapter 9 (mmmeneing
with Scetinn)INN))ofDirio,m3ofWe BU.iihi and Professions Cde. and my license is
in mu rate and crcm.
r
Dane Cnntmcna
DateClass Coam
Q'fY.
.r,
ELECTRIC PERMIT'
EVE -
JOB DESCRLP'rION
R�ENLIAL .
❑SPDWh C1 KITCHEN REMODEL
❑ADDII']ON E:1 PLUMBING RE PIPE
❑MULTI -UNIT ❑S'TRUCTURAI.
MODIFICATION
❑INTERIOR ❑CHIMNEYREPAIR
IMPROVEMENT [:j SWIMMING POOLS
❑BATH RIiMOUF.IJREI'AIR (] DEMOLITION
❑ OTHER
pERM11T'ISSUANCE
APPLIANCES - RI!SIDHN I'IAI.
ARCHITECTS DECLARATION
E andcrstnnd my plans shalt IN nscd m puhli, vemN,
PANELS
UPTO 200AMPS
Licensed Pmte,ionel
Oat I OWNER- BURDGR DECLARATION the CoATEON
1 hereby aBimt than I am exempt from the Contractors License Law for the
Int,ra'mg mason. (Section 91131,5, Husdacss and Padesslnns Code: Any city ar cnunty
wlaeh reyaires n pennH m cunstmet, idler, imparve, demor.h. m 11pair any - snucm2
Priurtoits issuance. also requires the applicant forsuch permino the a signed statnnenl
that he is licensed pursuant to [lie provisions of the Contractors Licc wa Law (Chapter 9
(enonmenreng with Section 7000) of Gasoline 3of the Botanic, ad ficaions Cmle)or
than be is exempt thmefrom end the basis fur the alleged exemption. Any v.ola ion of
Section 71131.5 by any applicant for n pernit subject, the appllcam that revel penalty of
uranium, Wan live hundred dollars 6500)
I, as ownerofthe property, or myemployees with wages as their sole compenution.
will do the work, an] the om[tare i. tat imended or mTcned foruale(Sce 90,44, Imslness
and 11 rnfusiuns Code: The Gmmmmr -s IHcen,w Law Apes not apply man nwnvr of
,,,),By who bull], or improves Were m. and who does such work himself nr them jh
his own employees, provided that such improrensnts are not intended or offered for
sale. IL however, the building on mpmvencnt issold within one year nrcompletion,'hr
ow cr- 1mdd,r w l l Il'O lr, , I' prnvin at he did not bm� ur From" for par-
C
1 n of sale `` -
,g.�ls� )we,, !,he �y,am exc unively mntractingwitb ttmsed commemrsm
21'nsnuct the pmjmt (Sec. 9044. Business and Pmfexioni CWep'Ihe Comrumr's Li-
cause Law does not apply to an owncr of pmpeny who builds or mproves thereon, and
who nmlracts Lot such 11roy,1, with 0,1 tracmr(a)Ila;n,ad pursuant oWe Coauha,mh
I Law.
❑ I am esempt under Sec. ,13 Ar P C for this reason
201 -IINX) AMPS
OVER 10N0AM1PS
SIGNS ELECTRICAL
SPECIAL CIRCUII'/MISC.
TEMP.M LTER OR POLE DIST.
COMMERCIAL:
❑ NEW HI.OG /ADOI'HON ❑ DCMOLITION
❑'fCNANI ❑ POOD SERVICE
IMPROVE ENT
OTHER
1'OW Hlt DEVICES
SWIMMING POOL ELECTRIC
OU'I'1.13'E'S- SWI'f Class- FIXTURE
NEW RILSIUI3NTIAI. ELECTS 'Q p'.
,yV. Fr. FLOOR AREA
-
SISQ. FT
-
TUTAL:
-
QTY. PLUMBING PERMIT
PERMIT' ISSUANCE!
ALI'BR- DRAIN & VGNT- WATFR (EA)
Owl Dutn
VALUATION
WORnderP real 'I3NSjam, on Uf the ION
(hereby af�rm under pcwhy of perjury one of the following Aerkar', ...
❑(have and will for by 37Ne ofCeLahor Code, far the Workers Cotnpen-
-- ,anon, a provided far hY Section 39!X1 of the labor code, fur one Pcrformunw afore
work mn wnitW red, pemnh i, laattul.
1 have and will maintain Worker's Connpenemion In.sumner, as rr,orcul by Section
3904 n( We laMsrCMe, Oonhc perfnnnancc nl We work fmwbich Wispcmtit Misted,
My Workers Com a,ioaona lnsumnce carrier and Policy numlwr emu
Cmricc Policy Nu.:
CCRTIFICA'I'E OF EX EMI, CON FROM WORKERS'
COMPENSA'I ION INSURANCE
(This mnion nevi nnl tw comple¢d ifthe pamdt is !Irani hundmldollars 151001
or less)
Ices Hy Wtno WC perfrnroanceolh,,,rk far which the - ,permits i ssucol, Wall
not employ any person in any mmeaarsn as m became stOb,rt to the Workers' Camlco-
cation laws of California. Dam
Applicant
BACK PLOW PR(YfEC'I'. DEVICE!
DRAINS -FLOG
-
RWEnRI ?n, - D.
S'TOkIF_S
TYPE CONS'IHUCTION
Flx'ru13HS -reR
'
N
GAS - EA. SYSTH
C.4 OUTLETS
OCC. GROUT'
AI'N
GAS -EA SYSTEI)VER
k
I.A
GREASIJINDUS "f
,WASTE IN'TI!HCF.PTf1R
BUILDING DIVES10N I$ES
GREASI TRAP
By
I'LANCHECK FEE
SBWHII - SANITARY - STORM I!A. 200 FI'.
17NFRGY THE
WATER HLAT[R W /VI3NT /ELL'CE'R
GRADING FEE
NOTICE TO APPLICANT: It, after making Ins Certificate of 17xcntptiov, you should
hcenme ,object to the W ..kcra Compnnmlon pmvisinrtc of Wo LaborCode, you ,a I
fnnhwida cmnply with such provisionsor this permit shall be]ecmcd revoked.
CONSTRUCTION LENDING AGENCY
I hereby arn. Watlhcne is acnnxlm ifan lnuhn,"cat, ror the p'I'arommol
the work for wnech this permil is e.m,d (Sec. 3091, Co. C.)
Lenders Name
WAr1iR SYSTEMfI'BEATING.
SOILS 1943
WATER SERVICE.
PAID
Date
NEW RESIDENTIAL I'I.MB. SQ. IT
TOTAL:
Lenders Address
TOTAL:
BUILDING DICE
1 emody that I have read this application and state that the above infornnmion is
touch. I agie m e:mply with all city and cnunty ordhamee, and crone Iowa rcluing m
building communion. and hereby aathmiec represca n ores of ous city to enter upon the
above- mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupetino against
liabilities,lodgntcnS,colh andcxpcnscs which may In any way mamcagainstsaid City
mseque¢c of the grunting of the, permil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITEI ALL NON -POINT
SOURCE REC.UI VFIONS.
QTY. MECHANICAL PERMIT
'f '' FEE f
SEISMIC ppE
PERMIT ISSUANCE
WJ
131.HCI'REC FEE
AI :I'1!It OR AIJU'lll Ml!CII.
PLUMBING FDA!
AIR HANDLING UNI'I'[TO 10,000 CFMJ
MECHANICAL.
AIR HANDLING UNIT (OVER 10.000CFM)
CONSTRUCHON Ix
: ignamre of ApphronuCninmmmr Disc
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicam or furore Buildinguccupantstow nr handle haamdousnmhen.1
nx deftne+l by the Cupar ion Municipal Code, Chapter 9.12, trod the l health and Safety
Code, Section 2.5532(a)
E] Yet C] No
WIII the applicant an furore building
ed by (1a, nt use ea An Quality or M; which
mtit icil s air trontmninunla os dcfnlul by the (lay Area An Vunlity Matntgcment
Dl.uria?
❑ YCS ❑Nn
m
I have,,ad the ha/wlkloo ath alsre a.ander Chapter 11195 of Om Cali-
builds Health .@ Esrey tly hi eaanaa 8505, 25533 and 25534.1 understand lbw it
building Accra not currently hmcamnanl. that it is my responsibility In nmily the owcupam
ofltmre ti I whichmu.��I metpnoY'1 sit me ofa Ceniheme of OcsvpancY.
f B�.o -a e''
GXIIAUST HOOD (WIDUCIB
HOUSING MITIGATION 17EE
HEATING UNIT (TO 100,004 111 (1)
HGA'I'ING UNIT (OVER 1001X)11 it I U)
PAID
VHN'HLATION FAN (SINGLE RISID)
Date !(emipt a
BOILER -COMD (311P OR IINI,INq I3TU)
f(1'1'A L:
BOILER - COMP(OVER IW,0p)BTU)
AIR CONDITIONER
O
ISSUANCE DATE
['3
L/[ . V
1SSUeD Hr.
NEW RI!SIDENI'IAI. MLCIL SQ. ITf.
-
ySZe
Owrcr rarmhmaNagna Dah:
,
- ")'rn .
D
OFFICE