29819 Mrrllk.AlV I IU rll_I_IN INhUHMAI IUN VIII I MIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-CLF.CI'RICAL PIiRMI INo
BUILDING DIVISION APPLICATION/PERMIT PLUMIIINC-MECHANICAL /J Q
BUILDING PROJECT IDE.f•II'IFICA'1'ION G o
19
BUILIANO ADDItISS: SANITARY No. APPIJCA I IDN SUBMI"1.1 Al.DAI Ii
l
)W'NbR.,NAMI; I'rrIONIi: CQ�IRACII IIi'S NA I: LIC NO:
^]ci�.:.,0 A Se-1�.C> 41. i2.5^ 133 Ce �aC `JGI N/C. CON IRULX
RCHIII;-1oiNGINEfat LIC NO: ADDRf:.S: nn ``'' ❑
mNlnc e rNGNr::
BUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(initial) BLDO ELECT I'LUMH MECH
❑ ❑ �' ❑
I.ICGNMTD CUNTRnnOR'S DIiC.bnxnn°N QTY ELECTRIC PERMIT FEfi
1 bony 0)af Ihm Tom Itnnmd utdcr miVmfin,..f eharyar 9 mmnmmnsi is JOB UIsSCRII'I'ION
„n,pZ withti finen11XM)of Divi,inn Jnl the Rugines and Pmfesion,C'oxle.and mylicence is RESIDENTIAL'
F � 'n full fnmeanJ efittl. PI!RMII'ISSIIANCii
�I..UE License Class Lie ERIgUWI. ❑KITCHEN REA1ODIil.
NQS Dnla Contrw4m APPLIANCES-RHSIDI:NFIAL ❑ADDI IION PPLUMBINI RIi-11I11Ii
{.7m ARCHIHTCI-S DECLARATION
CZt2Z lundenwtd my pinna sh�llNeueeJ ria public record, PANV S ❑humil IINI'I' ❑SIRUCI'URAI.
MODIFICATION
pppppp Ill'11111N1 AM1II'S
(/JEW LmenseA l'ndenonal 1]IN' ioR ❑CIIIMNIi1'Rlil'AIR
Y� OWNER-IIUIIAC:R OF.CLANAfIUN 21)1-IIXb AMT'S IMPPROvV EAIf:NF
O W U I hereby affirm than I Ant exempt fi om the Contractors Licence Low for the OVER HXXIAMPS ❑RAI'II RF.MODF.IAEPAIR ❑DEMOLITION
6 fullnwing meson.ISretinv 1031.5,Ru%inc%s aml Pndessinns C de:Any city or county ❑OTIIIift
3 LL TIN..... %hash m vires o .BIONS f:LECI'RICAL
R,O VI 4 Permit In construct,Ater.impowe,demolish,or repair any structure
m prioetn its i.amanagokn acquire,lle,applicanl far cosh pcnnino file Acignedgtuml'tenl SPECIAI,CIRCUFTIMISC.
;!I<� IhAl he is licensed purwamm the pmgvisinmof the Comoolnr's License law(Clmptcr9
apo (commencing with Section ylooIat Division J of the Business and Pmfeasions Codelor TEMP.M1.1'ER OR MILE INSI'. COMMERCIAL
p,o eG That lie is exempt tMrcfmin and the basis for the Alleged exemMion,Any vinlntism of ❑NEW gLDO/ADDITI(IN UGAIOLITION
YX1^'4• Section ln)I, 11 an,applicant forapnni.a object,the applicnm leu civillxmuynf POWER DEVICES
Zy trot more one.rive hundred dollar,6500]. OTENANT ❑FOOD SERVICE
k�0 1]L n,owner n!Inc pmpeny,ar my entplayws w ith%ogee ng dw•ir sole cnmpeominn. .SWIMMING Nan,ELECTRIC
'd1S- rill do the work.ad the stmcmre is not intended n'offered for title(See 1614,Hasinesa IMPROVEMENT
F.Nf
41 and Pmfoeions Conk:The Crou aceo's License Law Mss not apply Io un nwnrr of ()IffLE1 S-SWIICIII'S-PIX'IURCS
polnny x1141 no ildc or itnpmvct themnn,and who dorsu
s et,work It ell of througll
his own employee,Isoinvd Ihm mch imrrnvnne is are nm intended or nibnd for NEW RI!SIDEN'I IAI.IiI.ECl R SQ rr
,ale.It,hawxveelhe building m ituatoattem is mid wioninmm y.,,,f smadOinn.the SQ.PC I IfX)R AREA SISQ.Fr.
owner builder will have the hnnlen of proving than be did not build nr intpn to lot par
p,)a ort talc.).
❑1,as owner of the prnpeny,am exclusively contracting with licensed eonlmene to TOTAL:
construct the untied(Sec.11W,xoinec,and Frnfes,iuna CtdcO'Ihe Comemh....Li-
whosclnwdoes anPd, orin owneol No"By who bonds oriownse%Hereon.and QTY PLUMBING PERMIT FEE
contrarc fm such pngjecl,with a emtrmo"%I licansed punumn m the CatnrwaMs
License Law.
] I nln emmpl node'Sm. ,B k l`C for lhisrenan PERMIT'ISSUANCE
ALTER-DRAIN k VIIN'I'-WAITR(IiA)
1)wnm Bar, VALUATION
WORKER'S COMPENSATION OF CLANAIION RACK FLOW PROIHCI'.DEVICE
I hereby.11m.aortic,Penalty of perjury one tilthe dnc following damlio
Ilave anJwill mninmin afenificme nf('41nxennnmll-invtire for Warker'g Culn(ntr DRAINS-FL(X)R,ROOF.ARBA.CONE. S'IY)NIIiS "I')'PI'.('ONS'I HIICIIUN
train.as provided fel fry S dit 111X1 of the Li aw Cwk,lin the M'rhgrmmn,,of the
wotrk for%Inch this wront is stared, I 0 FIXI'URIS-I'IB'IRAP
❑ 1 have and will maintain Workers Cnntpemation Insurance,us tenanted by Section
7RX)uflheca�lrhr Coale,Inr the perlannanae of the work fnrwhichthi.spemtit is,—ad, GAS-I:A.SYS"I'RM-I INCA OU'1'LEI'S OC(',ONOIIP AVN
My W'a'S p'- gpenSRIT IZgce aanier and Policy y/
CmnJra Pe-/s r A Policy Nn.: zz2e'S-? 1:5 (i AS-EA.SYSTEM OVER 4(EA)
CERTIIIGTF.OF IIALEMPFION PROM WORKERS'
COMPENSATION INSURANCE GREASMNDUS'FRI,WASTE IN'I F.RCEPIOR
Ilhi,section need not he completed if IM coni is for ane hendo d dnllnn IS ImR BUILDING DIVISION ITES
41r less,, GRIiASIi,'RAV PLANCHECK FIB.z
Irenifythro more mrfumorecofthe.snit for whi,h.hi,permit is lesunl.l shrill SIiW1iR-SANT fARY-SIORAI EA.21D IT.
nm employany rcr,on in an,mannervtan tit her cmhj,nO to he Worker:Cromem ENERGY FEE
� Zration Luwsnf Culilontia,Dom WAfIiN BEAT W/VIiN"I'/ELECI'R
Z A,licml GRADIN(!FORT
NQI ICE; 0 APPLICAN'VIf.ohomakingthis V,nifieamof Eaemplion,you should WAI Fit SYS',1:10(11 iN'INC,
a , Necrotic subject tit the W'otke-Contpennnion provisions 41f the Lahnr Code,Yon must SOII S ITE
fnnhwidtcomplywith,w•hpnwisi41nsanhi,pennilehellMdminMmv41ked. WATER SERVICE
0. C
.ti. z f ONSl'RIJC'IION LENDINfI AOI!NCY NIiW R1ISIDIiN'1'IAI.I'LMI1. SQ,lel', I•AID
IJ0 litkforrhyalfirhi t North
lending Agetmy far the perinmmwx til Ume Nneipa
W P the ark for which this pennh is ia<ucJ ISm.VMI,Civ C.)
Q Imdur,Nunn 'IOI'AL:
Icmf,1t Addre, PL
y I certify Ihvt I hate read Brie applicmitm end qnm Ihm the nhwe inhnnmlion it
N AI)))DING FEE
V) conccl.I ug'ee m comply with all city and vomny onlinanves and%tate law.,Tubing Io QTY. MECHANICAL PERMIT FEE
V z building congmctitm.and hereby nulhroire"re,rounivea tit hiscity toentar u"I'lc SEISMIC FEE ll
ahn'nmenli41neol pameny for in,pectino purpose,.
IW'c)agme m ta,r.indntintu
it,and keep Innle,t the City of Cupcninn np...lm 1'IiRMIi'ISSUANCE mt:CfRIC FEE
H.,hilities.judgmems.cots and expenseswhkh may in any way occoucagalnr midCiiy AIA Fit OR ADD TO mntMECII. ,Js p/r
in so i,,acnceol the gingnfthis pcntiit. PLUMBING FEF. � Is OV
APPLICANT IINDI!IIS[ANTS ANQ WILL CI)MPLY WI'1'It AIA.NON POIN I' All HANDLING 11111 1111 IILIXN)CI'MI
50URCIi RE.1 NS. / M1701ANICAL Alli
.� AIR I IANDLING UNIT'(OVER 10,000CF1,11 CONSTRII(TIONTAX
Sig r PP arimrc:nnmi n / Date HX11AOS'I'I OODIWIDIR-11 IIOItSINU MIIIG,VIONI'lili
I IAZARI RIBS MAI ERIAI S DISCLOSURE
Will the al'plicanlorfonme hudding^ccul:not,lorenr htindlc I it..11...roO'I IIIIAIINf1UNII't IOI1NkaN)IIILII
as defined by dm CuPrninn Municipal Conk.Chapter 9.12,unit the Ilcalih and Safety
Code.Section 255111x1'! BRAI'ING LINE'I"(OVER 100.0 XI RI'U)
(3 Yet -I No PAID vEN IILAI'ION IAN(SINGLE RESIDI
ale' N
N'rd the A,Om nl tit comm haMing by the It um e.Air t ter AM to %born, Y,
hlvadnut uinmm�miwnts n,AefinrJ by the lLy Area Air Qwllity Mlmngeman 11(llLliN-COMI'UIII•tIR IIXgXO gTU) TOTAL
atria?
C]Yet I]Nn IIOILIiN-COMP(OVER I00L010 pTU1
I hate reel lM hoomban mmerials M(ImM Walt under Cha lerfi95 al Inc Cali AIR('ONDI'IBONER P ISSUANCE DATE
4nnia Ikallh R Safety CIAO.Sections 25505.25531 am ua,Bdj.1 utnlehy I Ihm if Inc Nf W RIiSIOIiNFIAI.A1ECil. SQ 17.
,ifbe ardietnott, Id ;ham,,met Mmit ismyreeof.C'litycot ,ofythe,rarnn
of the rryuimtrcnis which mum he tort primmiseuawe nlri Cenilieme nffkrupnwy. ''// �
uw....... 11
mmlledAgelt D;w• TOTAL: ssl )B\:1J7y171"eA SL/
OFFICE