S 1279 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERPINO BUILDING-FEEL I RICAL I'll IT N(1
BUILDING DIVISION APPLICATIONWERMIT PLUM DING-MECHANICAL 1279
BUILDING PROJECT IDE,N'I IFIC,ITION
BUILDING ADDRESS: SANITARY xO77pPEEcxrON SUBMITTAL DATr.
OWNER'S NAMII: PHONE CONTRACTORS NAME. U6 54 LIC NG'.
I. N/C CONTROL k
• ARCHITRCf/HNGINEER: , LIC HIT .ADDRESS: V III
�aAR4 ( p5Y5 ❑
CONTACT PHONE. . B UILDINOPERMITINFO '
Q ❑ Consultant Fees Paid by Applicant(initial) BLDG ELFCI' PLUMB MECH
O! ❑ ❑ X ❑
LICENSED CONTRACTORS HEAR f QTY. ELECTRICPERMIT 71SE :
n,enb to rm h l E •a 1 p t las 9 f ' b t,�, I DOB DESCRIPTION
Z wim Set m1900(oofD 3111 Businessand Pohsson,C le,auln,Tee alis t
O O PI RM I'1 ISSUANCE KPSI DM N I'LL
F in full fora vnJ I
IY W F ❑SI UWL i KI'fC111iN REMODEL
QUU I;cons us lieu r 7 -� I r t�p
y41/U9
AIILIAN(I,S-VESIUI'NTIAL It � �ADHIT10Ni 'r jj 1011'}LIMNNG BE PIPE
Dnl Co I yl f i, LIMBI
NG
PANELS 1 t€O_ El U�ITIII .4, STRUCFURAL
Z O y 7�. J -r ] y plan.sM1nll h umd p hl' ennds 1 7 N y E t j"( kMODII ICATION
O Z.-� UP'1'OESAMP4 1 4` ❑IN 1'I IRIOIi IIJ MIMNCY RFIIAIR
H Iv lace .1Rod.s. mol 201-IaOAMI'S LM I'ROVBMLN']'s Y
OWNER-BUILDER DECLARAHON E]SWIMMING POOLS
C ¢ I hatch,affirm(hid I um ewmpl your the Gnu...tor'u License 1101 for the OVER 1000AMPS ]RA'I'N RI!MODfillHlil'AIR DUE oLmoN
�a6�551�O C U following rcroon.(Seclinn 90315,iludineds and Pro(viom C,al,Any city or county SIGNS ELF.Cl
Iu4OmY^y0um• pta p g' lIfCutmhaepltumllt
SPECIAL CIRCRICA/DIISC.
]OI'I]UK
which require, 1 ter I lle I fih M y saucrue
nt t 1 y Il '011 tl Ip iu II
but l licensed 1 lI hetProvisions t C Itri I 1
wCO (aI g with Section 9100) ID i l titheN :- 11 f w TEMPM OR NILE INSTCOMME
RCI�:
Q.W that M1 p theief d thebasis f 11alleged exemption,Any . El NDNADD
TIUN ❑DEMOLITION
WmSeci 031.5 yary 111 e,nt, p,rFIits hicevs11 u,pl..n :rolPen llyd POW I]TENANT ]FOOD SdRVIC
i UrVI 17
than live hunJmltlallard 18500)
C�O 01 ftn p perry y employee, tl g. that, pc . II I MMING WRDL IIICTRIC IMPROVEMENT
a3� widdolficv, k ' dd 't B t invaudialoroffiredf 11 (S oIon" ' ❑011ll:k
rindl R.A ,aC„de a elnmelyde IdeLaw dcant nplyw„riwne m' ou'uE'rs-awrrculs Plx'ruRPs
pmpol who builds or Impmvn thrown.Dred who does such work bilrnelf nr through
his own empb,ax,.pmvidad that.rich ierp oscowntd are not ialOnded of IHand Int N SIDENf9 AL I!LE(TsR SO Fr.
,:dell,Nava...IIIc Nrld ng o ...plo em is sold willh n oneyem ofeau...letioo.IIIA 50.FI',FLOOR AREA $VSO.EI'.
enbuilder will have the burden of proving that he did not build or improve for ptu-
pose of cdc'),
] 1,its ownet III the prulwny,am exclusively conoaedng with licensed contranalm to 'TOTAL:
construct the pr,Ijc,,(Sec.91,13,lousiness vI'd Pod,..Eons Code:)The Conlrador's Li- -
sense Law does not apply it an owner of Irropeny wino huildsor improves dismiss,and QTY. - Pl. GPER, T ' FEE ,
,he umnaas for such pmjcc¢with,,emtraeor(.O licensed pursuant to the Contntnor'v I:
License Law- PF.RMI'I'ISSUANCE
d y
+:
❑lath exempt order See. ,11&PC hn this rcawn jr,
C 1.AUFFR-DRAIN&VfN'P WIG17R(EA) 7TIONOw WORKER S COMIENSAI ION DECLARATION RACK FLOW PROTECT,DEVICE!Incehy R i pe ndry rpIU D f,I f II gd r f]III' mA wllnu t baCen'Ie ma1C Iu,t IQ,.II"shr Waders CnmPet' DRAINS-EIAUR,RINII.ARI:A,CONII' nn I
I '1N 'I �IIONQalion.ax provided fur by Sermon 9)00 ofthe labor Code,for the peifornance of thework fur which Ihis penal is.....it 19XrURES-PER TRAP
I] I have and will maintain Worker's ConlNusation Insurance,us required by Section3910 of the Ethnu Cde,for the performance of the work for which Ihis pcouil is irsucd. GAS-EA.SYSIEM-I INC.401JILP,TS GROUP APNMyWor}y{ C,yy p�� �lip Iy randPolicv n�f^�C vJ Mt1�i►\�1/1A,e� Policy N,Q1' A600 Irk}. CAS-EA SYS'IF,M-OVER4UiA)
CIF R'r11lCATE OP I!XEMII PION FROM WORKERS'
COMPENSATION INSURANCE GREASEANOIISTRL WASTE IN'I'FRCEI'I OR
(This section need not be completed it the permit is for one hundred dollars(S]t0, BUILDING DIVISION EEI3 't
r Ic ) GRDASETRAI' I'I,AN(III CK 11,
loarrfyH Both peH roft cie... fur wh ch th 'p f:':.med.isin J1 SEWER SAND LARY Sr FORM I!A.21X1Irl'.
to plY yPerson y , _ m qy to W k CCompaq ENER(VELL'
,t7. sutir I,��S X6 a 6� r ar t
Z
O Appl �r1 m l� J f 5lilt, I WAI'I.R HEAI11t N'IVI:NfIP1,I C1'It / GRADIN(.hhH
p4 NOTICE TO APPLICANT If,after making Ihis Carnival,of Excerption.You should WATER SYSTEMCREA1 NG
a ? become subject R,the Workers,Cro,cre de.provision,of the I.ahor Cada,you maul SOILS Il?I?
Tanhwhu comply will,such provisions orchis pcnnit Quill be deemed revoked. WAI'HE SERVICE!
aQ
r7 z CONS'fRUC1.1.1 LENDING AGENCY NEW HF.SIDEN'f1A1.I'LMU. SQ.<T. PAID
UO I for
rwhichouhm Jerre iQ:scnmlme.3097,Cile.C) cy fnrthe pm fnrmuncunf DUW Rcceiplp
Q. F the work Na whim this permit is issued(See.3097,civ.C)
Lender's Name '1 OTAE
P. Lcnder'I arrii,a TOTAL; iJ
(~ y 1 ecnee o comply 1 have read sh ll city+and c unand dime that the shove wv rmutinn is BUILDING PHI!'.
y condingcoect.I rcew ,and hereyautyandawntyotatives od and wamiawsrelminge QTY. MIiCHANICAL PERMIT' ! ]f t I°EF,i.v .,
building mntsouwium rry Rsirr,,horiu So,ax.mmivus nfthis c'nymenter upm tha SEISMIC FP.P,',, ,
nhovu-mentioned pm�ty fundece Its a pkeep ha '
(We)agree t save,inJemnily and keep harmless Elie City of Cupertino against PERMIT ISSUANCE. EL[LTIIIG FEE
liabilitiuv.judgmeu .cusum, expemcswhich may in anywayaccwe agamstsaid City ALTER OR ADD TO MECIL. - -'
in mnseq"save he gr Ihis pennil. - PLUMBING PGI:
APPLICANT ,JDE AN' LL OAII'LY WITH ALL NON-PDN'T
AIR HANDLING UNI']'(TO 10,(X01 CFM)
S(IURC R .IJLA rN5 MECHANICAL.IT:E
AIR HANDLING UNI'I'(OVER 10.000 CPM) CONS'BI)CION'PAX
Si urcw Applicanl/Con Dae EXHAUST HOOD(W/DOCr) HOUSING MI'I'IGATIONITE
HAZARDOUS MATERIALS DISCLOSURE
WIIl the applicant nr tutor hu'Jding,a'cupunl wnfo or M1nnJle hezerdnus mulcrial HCA'IINGUNI'I'('10100,000111'll
us defined by the Cupenino Municipal Code.Chapter 9.12.and the Health rind Salcty
Cale Section 25532(v)' HEATING UNIT(OVER IPWORfU) 719
]Yes ]No
• VENT LAA SINGLE ItCSID) PAID
Will the as ismo 1 lr fawn building orcppaB y A e.Air a or devices xhich
D e RaeTlx
axil hlreardonQ err cnm:nninunta us JclinaJ ny the Bay nrrn Air Qaulhy Munngmnnn 8011.8,1- - MP(3HP OR IB(LBBII RTU)
DlMrictl TOTAL' /
❑Yee ]Nn R011.lik-COMP(OVER IW.g013'IU)
I have rend the hmntdous erweriws rquirementx under Cbaplafi 95of the Cali- A I It CONE I ONP,R IS51I DATE
Fiat Health.F Safety Cate.Secllonc 25505.25533 and 25534,E undesumd that if the NEW RESIDING[A],MECH. SO.FE,
building 11-1 nal currently bm'ca¢nam,thw itmYn:apnnsiMlily to nrnity lM1e,emtpnn
it be nav plot ut issu.nev of a Ccnlhenc ol'("I"gincy.
Owner(orauthnnmd ager Elate 'TOTAL: ISSUED I3 VIt
OFFICE