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sit CANTTO nI I w wcnou ennu wrtsRlN APO 1 INPa _ IISF BALL POINT PEN ONLY
CITY OF CUPERTINO '. BUILDING- CLECTRICAL
BUILDING DIVISION APPI,ICA'FION/PERA717• PLUMBING - MECHANICAL -
r(' :, "IIUILDINC i'ROJECC IDSM'IFICATION
PrSIITNO.0896
21. ADI S. �
SANITARY NO.
AI'i'h�TI �SI�TIAL DATE
\
OWNER'S NAME: PHONE:
CONTRACTOR'S NAME: LIC NO
NIC
CONTROLp
❑
�♦ 1`
�ARCHIrfECf/ENGINFIER: LIC NO
ADDRESS:
.CONTACT: PHONE:
a
BUILDING I'ERMI'I' INFO '
m.nG ELECT PLO MECH
❑ Consultant Fccs Paid by Applicant (Initial)
TrY`
LICENSED CONTRACTORS DECLARATION
I hereby arena mat 1 ata licensed under provl+bas of chapter v (commencing
�J�,..
r; t ELECTRICIIERMD•ls't
- _ _
t'I'HE
E
JOB DESCRIP'T'ION
'
I'ERMI I ISSUANCE
wnh Seeno,nrnun of obhion3nnho nmxine.., ttw rrorest I, Cree,.tmdttty ECemea
� in full fnree end effect. .
RESIDENTIAL
❑SPDWL El KITCHEN REMODEL
APPLIANCES - RESIDENI'IAh
License Class LIc.M
Dent- Cnn
DDITION L3 PLUMBING RIiPiPli
MULTI -UNIT ❑ STKUCI O
CHIMN CATION
❑IN'I'IiRIOk ❑CHIMNEY RIT'AIR
I.NII'ROVEMENT E]SWIMMING I'DOIS
ARATION
ARCHITECT'S DECLARATION DECL
nndersmnd my plain,M1nll he used as pu0lic recoNs
'
1 Licensed l'nde"i'sol -
INNELS
lll'T0200AMI'S
201- 1(XXIAMPS
OWNER - BUILDER DECLAItAI]ON
i hereby affirm that I am exempt from the Contractors License Low for the
❑ BA'I�RH� O[E.16EPAIR 0DEMOLITION
q r Q
OVER INX)AMPS
SIGNS I!LECI'NICAI.
t follawi ng reaam. (Section ]031.5. Haaaw,s and Pmfoxskm, Cade: Any city or county
R
which rewires a permit to continual, after, improve. demolish, or repair any stucauc
SPECIAL CIRCUTDMISC.
A1, {S'•
1r._
3 prior to its issuance, also requires the applicant for such Perot to file a signed smmment
dam hnlslicensedpar,mor In the pro,ino.,ofine Contractor, Llconee Law (Chapter 9
-
(commencing with SectionIng)) of Division 3 afore BUSiae,sund Pad esslon+Qwle7o
that he is exempt tbcrefram and the look for the alleged exemption. Any violation of
' Section] 031.5 by eny ti,iicunl for a permit the applicant n) u civil penally of
or man- than five hundred dollars (95m0.
1I]Lu,awnerofthe property, army employees with wages its thcirsole mmpersation.
will de the work, and the xwcmrc is not intended or oflered fin sale (Sec. 7144, Business
'TEMP. METEN OR INIhli INS'I'.
COMMERCIAl
bt
(.u�s'ItW``B,,'L'DG /ADDITION ❑ DEMOLITION
❑Ttmvr,I iflu ❑I'OOD SERVICE
GRItOVIiMEN9'
❑ O'fH1iR
_ _ _ - _
POWER DEVICES
_
SWIMMING POOL ELECTRIC
-
OUTLIi IS - SWITCHES - FIXTURP_S
i and Professions Code: 1Ev Contractor's License Law does not apply to an owner of
pmpety whit Luilds in Improves thereon, and who dxs such work himselt ur Enough
his awn employees, provided that such improvements are nor intended in oliemd for
sale. IT. however, the huildingor improvement ix sold within one yearafcomplenion the
NEW RESIDENTIAL FLEC, R SQ FI'.
'
SQ. FI'. MOOR AREA
S/SQ. PL
erhuilder will have the burden of proving but he did Bat build nr improve fur pa,
,ae of u.). /
1
n 1, as owner of the properly, am cxclUSively contracting wfh li,e,,d cobbo l to
cnnswcl the I rojat a. ](Wt, Business tad Pmfcssinn +QodeJ'Ilac Convannr', Li-
censel.awd sman ymano ertdpntpen'to bit fkc or improves thereon, and
who nmtmns 'n nJectsw'hlnconlr nr(Olicen tlpuraunnne lha Cnmmemr's
^ I+
!w
.QTY. PLUMBING PERMIT
's
FER
PERMIT ISSUANCE
License law.
Von I an extra In le A ,B &P fn hi'
W et Dale
•\ ORKEN:S COMPF I IN Of Cl It
ALTER - DRAIN & VIiNT- WATEIR (GA)
HACK I'hOW I'ROI'IiCT ❑1!VICE
VALUATION
I hereby affirm under penally pe'ryone ofthe l"Iam ing Jalameam:
`
I�,_Irl have and will muinmin aCenitica¢of ocenvuself- insurefnr Workers Campen-
section, as provided for by Secuch 3700 of the Labor Cade, or the performance of he
DRAINS - FLOOR, ROOF, AREA. CONE).
STORIES
'TYPE CONSTRUCT ION
work for which this permit is issued.
FIXTURES - PER TRAP
-
1 have and will maintain Worker's Compensation Insurance, as required by Section
37W ofthe lalbin Code. for the performance ofmc work for which this pcnutis ixwed.
GAS - HA. SYSTEM - I INC. 4 Oil I LETS
Or GROUT'
AI'N
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.:
GAS - EA SYSTEM OVER 4 (EA)
GREASITINDUSTRI. WASTE INI'I!RCIT'IOk
CERTIFICA'T'E OF E %EMPTION M OM WORKIiRS'
COMPENSATION INSURANCE
RUH NG D SIGN FRES
TIN section need not IN completed if the wribil is for one hundred dollars (S1 W)
nr less,
GRP.ASHTRAP
1'LANCIIECK FE �
�
SEWER- SANITARY- S'fORM 1?A. 200 FT.
ENERGY FITS jr
Ueemly that In rheperfoammccoflhe work torwhich this permit lx issued, Iball
not employ any person in any manner so as m become subject to the Workers' Contpcn-
WATER HEATI!R W /VENT /ELF.CfR
WATER SYSTEMG REATING
GRAVING Ili
' ,mien laws of California . Date
1 Applicant 1
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
hroans, aub oa to the Wndcr, Con,wo, alien provisions of the Labor Cn le, you must
' forthwith comply with such provisions or this permit shall be deemed revoked.
WATER SERVICE!
I CONS'TRUC'TION LENDING AGENCY
I herebyaRmt that here isacorarbo;m lending agency ficamepetfonearn,of
NEW RESIDENTIAI, PLMB, SO, Flt
PAID
vi' Ih<cipt4
TOTAL:
the work for which this permit is issued (Sec, 3097, Clv. C.)
' Lenders Name
TO 1..
11.
Lender's Address
er
information
BUILDING 1!E
I etouly that I hove read this applicalina and atom ohm the above is
1 council. E agree it) comply with all city andcounty ordinance, ' d t how, rclting in
bolting construction. and hereby mahonce representatives fm: city to enter upon me
t a- s
QTY ':MECHANICALPERMIT.' a
n. s
FEE;.,
SEISMIC
iE,
0
PERMIT ISSUANCE
ELEC'i'HI
IgiG'
+ above mentioned pmpeny for inspection purposes.
We agree at save, indemnify and keep harmless the City of Cupertino against
PLUMBING P,
llabilbl s,jufi�,, assnsandexpcnses%hiehmayinnny Way acerwagainstnaid City
in our, e
APPLE( NRS NDSA icl COMPLY WITH ALI N N -POINT
SOURC RI 0 / ,�
1 1 I J
AU1'17ROR ADDTO MECH.
AIR HANDLING UNIT(TO 10,000 CFM)
NICTION
_
AIR HANDLING UNIT (OVER I(L(XIO CIrM)
CONSI
CONS'IBUCTION'1'A
RiMurre of App] ca -1 r Dine
EXHAOS: HOOD(WTUCI')
HOUSING A11,1(IAII(l 1'1711
HAZARI U: TT:R S ISCLOSURIi
I IEA'IINGUNIT (TO 10(1,(XNI BTU)
Willlbeappllatm nrfmtre h'ding tee u slorcar hunAlo M1aaunlnm mwcriul
as defined by the Cupertino Municipal Cade pier 9.12, and the Health and Safety
Code. Section 255325)?
HEATING lIN1'F(OVER 10,000 BTU)
VENTILATION RAN (SINGLE RESID)
-.• El W, El No
PAB)
Dam Receipt a
BOILeR - COMP (311P OR 100,x10 BTU)
/oii Emendnus air comaminann as defined by maday Area Air Quality Management
ll�l win the applicant nr ftmre building occupant use equip rent or devieas which
- 'IYJTAL:
BOILER - COMP(OVER BXI,mNI BTU)
-
grict?
❑Yes No
AIR CONDI'f10NER
I have read the hownaro,narnmal,n ems under Choler h95of the Cali-
w553 p
ISSUANCE DATE
NEW RFSIDGNTIAi. MECH. SQ, PT,
fomiagdoesn Safeydyhaea tenas25505, and 25534. notsynd tlan[ lithe
is my to
building duesnotcurrency have atenant that o ismyrespomsCWfi toamity the re
Ily.
of the n•quiramentx which mu,l be mcI prior m Issuance nl n Cenilieule of Oreupuncy.
ISSUED 11
T
Owner a, initiation] ugenl Dam
OFFICE