S 2611 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICA I. IPERMIT'NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-ME,L'IIANICAL S 2611
I4UII.DINf7 IIROJEC'1'IDISN'rIFICA'I'IUN
BUILI)INGADDRIiS S: at SANITARYN). JPPLICATIONSUBMITFALDATI'.
2o569 131 o.S�soiin Lane CuPe✓hno 'Z �- ��
OWNHR'SNAME: PIIONR. CONTRACT 1R 10 E' Y 1,1 N�
r Z NIC (�COINIROLp
CIII'IECT/ENGINEER:, LIC NO: ADDRESS: —/ / Q 5-
CON
CON'1'AC'I':, �I�D�PHON .. , // NF
�w� /11 BUILDING PERMIT INFO
Sw� —O � ' ❑ CnnSallanlFeesPaidbyApplicant(Initial) P DG LECr PLUMB MECH
� P �'
LICITNSEDCONTRACrOR'SDECLARAI'ION QTY. ELECTRIC PERM IT PEI?
I hereby ninon Nm I ar,pranced ander...,..imams of Chan,9 or..mnennil, JOB DESCRIPTION
FGtLZ with Serio.70NnalDi,ama3nflhathroessand PrfillowcCodaanddty licence is O R ) N
ad. in full force and cited t / PERMIT'ISSUANCE
aUZU Liceme Class Lich •� s10 I SFDWL ❑KITCHEN REMODEL
HQL Dant Cnmramor APPLIANCES-RESIDIiNTIAL ❑ADDITION E]PLUMBING RE-PIPIT
ARCIBI'ECTSUP I.A A'I'ION PANIi1.5
F,pvi ❑MUI:rIUNI'I' ❑STRUCI'1112A1,
Zpyz Iundenwndlnyplansshah be used aspublic ricands MODIFICATION
O Z.+C UP TO 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
F 4.F.W License]Rafessinn0l 201-10NXIAMPS IMPROVEMENT 0 SWIMMING POOLS
OWN17R HUILDER DECLARATION
p, W sc I bamby tiff ret that 1 nln esuntpt Erin the Commnods Licrnac Law for the OVER AMID AMPS ❑RARE REMODEUR13PAIR ❑DEMOI.i LON
x 31 F following Temno.05Dnion 0031.5,Hucinem anA I'nde..kar,Gale:Any city or county SIGNS ELECTRICAL ❑(TILER
y which reyairen a atnit tet conmmet,aper,Improve,demolish,or eepmr any almmure
,F]y4W•� prior iitscense toroi requires Novisiommfnr Contractors
ams¢filera,Law
SPECIAL CIHCUI'I'/MISC.
Nmncis licensed toroidal to the provisions afire Cnntdivess l.IcaoselaW(CM1apter9
(amimm�cingwilh ticcliun]IXllpul Division 3al lbe Nusinee.aand l'nsfes'sinnv Cude)ot 'l1iMl'.MI?I'13R OI21H)LIiINSI'. COMMERCIAL.
��NNat he is exempt themfrom and theirs,for the alleged exentptioo.Any vinlmion of ❑NEW BLDG/ADDITION
IIION
Section 7WI.5 by any applicant a pcndit subjects the applicant m a civil penalty of POWER DEVICES ❑FOODSERVI
FZ} not also than five hundred dollars($50N0p,
❑•HiNANT El FOOD SERVICE
9G 0I,as ownerof the property,or my employees with wages is their sole compensation, SWIMMING POOL FULCPRIC PROVEMENT
F' wdidelliework,un Il hemmenne is nntlmm�ded uruffted fmmllu(See9fW4,Hu,mcax 'EER
W 3 w and 1'ndessions Cade:The Commdo,License Law docs ml apply to an owner of OU'll-JU:S-SWITCHES-1'IXTERIi,S O
property who builds or improves thereon,and who dsns such work himself or through
his own employees,pmvidrd That such improvements are not intended or offered for NEW RESIDENT[At,ELECIR S( FIf
sole lt,Lowever,Nc huilding oe nnprnvcmenl is sold within mtcywrnrcnldpinion,the .� -/Gr� SQ.FI'.IdOOR AREA $/SQ.PT.
er-bullderwill Luse the punk,of proving lhal he did not build orimprnve for put- / p 9
❑'Patent al '3 Z-7 A Is
I,as owner of too pmpen'am suasively rommomg with licensed commdnrs to Torn ,
construct the project(Sec.70LL Business and Professions GvleJ'Ihe Cnntmcmr's Li—
verseLaw docs fiat apply to an owner of property who huilds or improve,thentn,and qry.. PLUMBING PERMIT FEE ( , (Q
wooer, dsfranehpinjeclxwithautnmo...(oIiernsedparxnammmeenmrarmr�x `T 0 41
License law. PERMITISSUANCE
❑lam eserratoder Sec. ,B&PC Latinsnoon
Owner
ALTER-DRAIN&VCM'-WAT' 113AJ VALUATION
Dtim
WORKER'S COM PEN SA'IION DECLARA'I ION BACK PLOW PROTI!CI'. )RVICE
I hereby anion under penalty of perjury one of the fallowing declarmien's: 3 3 O
,J l baveand will meimmina Certificate of Consenuomlf-insure fr Worker's Comped- DRAINS-BOOR,ROOF AREA,CO S'rOR1E5 TYPE CONSTRUCTION
stain,as provided for by Section 3710 of the laher Cak,for the performance of the
work lith wh¢h this Ixrmit Is isaueJ. FIXTURES-PER TRAP
❑ I have and will amimain WanI,,',C ater,alin 0]it..rant,m rcyulred by Station
37Woflbe Labor Codcfortheprrlimnunce of Ne w'orkf rwbicb this pemnii is issued. OAS-EA.SYSTEM-I INC.40UTLETS OCC GROUP APN
Aly Workefs yyM' yyppnJnp r�tt+{ J I'dli mer
'it Carrie¢ �'( nnV/LI /rye Potlicy No GAS-F,h SYSTGM.OVIiR4(EAI
C17RTIFICATE 017[EXEMPTION PROM V1f
2K6' tea/ ^ GREASI91NDU5'I RI,WASTE.IN'I'Ii11CIiY TOR
COMI'I?NSAfION INSI112ANCF. UU /` K
fUnlseeHonpadnotbee, initted itdoprm
eit is Intone humbed dollars PSI W)
or less) GRF:ASE'BAP BUILDING DIVISION FEES
PLANCIfffill /
1 certify that in the perfomwncc of the work for which this permit is issued,l shall V
not mdpiny any pcmon in any manner so as to herr SEWER-SANITARY-S'IDRM EA.2W Up
hi In the Worker, ENFRU iF
Ozcation Laic,of Gaftidnia
0 Applicant Date WAT'LR HEATER WIVIiNT/ELECfIt
GRADE EL'
yNOTICE¢TO APPLICANT:If,after making,hix Certificate of lixcmption,you should WATER SYSTIiM/rNEATING
f~ > bennnen..
mbjethe Wnrkefs Grmpcnsation pmvisions of the Labor Cale,you most SOIL. PI v
Ltonhwith nnnply wish eneh pmvisions or this pcnnll shall huAanned remtkal. WAF17R SERVICE
LIR
U z CONhen iso ali LENDING AGENCY NEN'HFSIDI3NTIA1.E'LA1R. SQ.Pr. PAID
U0 l herebywhich hnhcond i isacomwninn lending agency btrthe pednnnance of Date Recciplp
L4
he work for which this permit is iswN(Sec.JW],Civ.C.)
Q f-" Lendcrl Name TAI: 71 O
Linder,AHdrees - T'OFAL. 4 ,
y I certify that E have read this Inde aia.and state Nal the above information is BUILDING FEE
ErEA stirred,l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FE.
UZ building construction.and hereby auNnnee represenmtives of this city m enter upon the SEISMIC
.bit ve....adred propany ii nol,ldfn pamnaca. qp
Wel a y and 1 Cir,of pe g PERML ISSIJANC17 i% s /
( gree to carve,indelnnil d kec t handless the Cil f Cu Winn a mind F.I,IiCI I .FF. LI
liahilities,judgments.cnslsendexpenseswhichnmyinany way um.....int said City ALTER OR ADD TO MECH.
consequencein of the granting of this Permit. PLU BIN
API'IJCANT UNDERSTANDS AND WILL COMPLY WIT'll ALL NONd'OIN'r AIR HANDLING USE'I'frO Edition CFM) ME 11 I ,G
SOURCE REGULATIONS. LITE 7
AIR HANDLINGUNIT(OVER I(LIXX)CVM) CONST' MON TAX
Signature of ApplicantlCnnmmor - Dare EXHAUST FLUID(W/DUCT) HOU NG MITIGAI'I(IN FEE ry 3 . DO
HAZARDOUS MATERIALS DISCLOSURE.
Will lhc.pplicuuarNum beilding uccupum marcor handle Emzardoua nnlealed HEATING UNIT(TO 00,000 B'I'B)
a defined by the Cuperlino Municipal Code,Chapter 9.12,and Inc He llh and Safety
Code,Stan,,.25532(.)! HEATING UNfr(OVER 1 W,110(1 B'ru)
Fl Yet ❑No
VEN IT LATION FAN ISI NO LE RNS I D) PAID J
r Will the apP ndroint rfutura building by he
pm Qualitn or y
Management
Date ReceiPl
(l nit lutnnrdous sir rmnwminams us def ped by Ne Huy Arm Air Qutility Munugclncm BOIL(;R-COMP(311POR IOO.IIW if LED
imrict' TO'T'AL:
L
❑Nn BOILER-COM1IP(OVIiR IW.f100 HILI
e ad dm hazardous m:eerilds regnimlnl.under Chuplerfi95ul'Ia Cali- AIR CONUI'r10NBR ISSUANCE.I7KPE
Sufcly Gale.Senimw25505,2553]and25534.I understandthat ifthe NEW RESIDENTIAL MECH. SQ.FL �IU hnipancy.
still
nFia �/D TOTAL] 0
1 ISSUED BY:
OFFICE