S 2419APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO
IIUII.DIN(: - ITLFC1'RICAI,
PCAIIIING-MhCI1ANICAL
PIiRMI'I' NO,
BUILDING DIVISION APPLICATION/PERMIT
IN'TIFICAI'[ON
141 ILDINC PROJEC'PIIR
S 241
BUILDING ADDRESS:
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CONI'ACI': PHONE:
SANITARY NO,
APPLICATION SUBMITTAL MET
(ag i Dr ANai:t.
WC)
❑ Consultant Fees Paid by Applicant (Initial)
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OFFICE
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CONI'ACI': PHONE:
BUILDING PERMIT INFO
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❑ Consultant Fees Paid by Applicant (Initial)
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In DO F.1 TO PLUMB MUCH i
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IJCUNSED CONTRACTOR'S DECLARAfION
I herein of iaT th,u I all] licensed under proetaons of Chapter 9 (eonrtnenang
wilhseetion]axpofni,kion3onhe Baxinessaml poll.. ions Cndaand l]ay
f 11 acne and effect. p., Lic. k 5'^ `2
Liana.lass i�
hale I —�� Conln con,
AI(CHITFCPS DECLARNT[ON
IunJem�J my plonx shall he n,eA mpuhlic rmoNs
QTY. ELECTRIC PERMIT I'EE
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JOI DESCRIP'PION
RESIDF.NTIAU
❑ SIDIH ❑KI'TCHGN REA10DI71.
❑ADDITION ❑ PLUMBING RE-I'IPh
❑MULTI -UNIT ❑ STRUM ORA[.
MODIFICATION
❑INTI?RIOR ❑CIIIMNIiY RIiPAIk
PERMIT ISSUANCE!
APPLIANCIS-RISIDL'N'I'PIL
PANEL l
UI'TO 20(IAMI'S
411"IA
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IMPROVEMENT 0SWIMMING POOLS
❑ BAT'H RF,MODFUREI'AIR ❑DEMOLITION
[]OTHER
"'enved Nor.. ma,II
OWNER-❑IJILUER UI3CIANAI'ION
1 hereby alarm that 1 an, alveolar from the Contractor's 111,11C Law lirr I"
following reason. (Section 7011.5. Dl]sinca and prnfednm' CIN,: Any city «county
wh ch reaptione, aperm t I Constrict. after, roproTc.dernatilikh. ... rep ny sl nuem
pn I, i'llean1c.al 4 flue,pni,anlla,adhp ruel fl F ed,l tnncot
Ihe, he is Itcenstalpum II 'in,p s,va will C t nr I Law (Chapter 9
(Comnrewing wit, Seat 9110014L,ixia..34de Husiarv,Cnd l4ofesions CCdc) C,
Dat he is exempt t,,,Cfram taut the hmis fur the alleged sernptbn. Any violation al
Selliva]031.5by;myapplicant for a permit subjects the applicant to a civil penally el
...( none lh:m five hundrad dollars ($50(t)
❑Ins ownenaf the pmpeny,nnny employees witM1 wages us their sole cnmpensmion,
will Jo the work.andlhestmcae is not imenJedia.11...J for sate Sec. 7(44, Itmines,
and profession, Code: The Contractor, License law Joel Bol apply nt un owner of
2M-1000AMI'S
OVF,R 1010 AMPS
SIGNS ILICTRICAI,
SVFCIAL CIRCUIT/MISC.
THMR AfCORR(IR TOIDiDiLE
COMMERCIAI;
El NEW RhIJC/Al1DIT10N E] IIEMOLITION
DrfNANI' 017001) SERVICH
IMPROVI?MENT
OTHER
()WE' DIVICIiS
SWIMMING I'G"LELIiCTRIC
OU'1'LfTS -SWITCHES- FIX R S
NEW RILSIDENTIAL HLHCrR S
pmpl'dy who hailds or Improves Ihereon, ad who dues such work him,clf or Ihamgh
Ill.' ch Improvucnas are tot io ndW or nnercd for
hisw ro, ployce provided Ill.',am
sale lL however the hoilding nr un't,"C"con i, old within onarcandcompktion, the
SQ.IT. FLOOR ARIiA
SItiQ. 171'.
will bwc the harden of pro ing that he did not build or improve for fou,
pour-builder
se chalet
71I. as Cwaa of the propenY, am c,clusivdy Contracting with licensed tan.0 o s as
l AI
insult. 11. projeel (Sec ]ON. Ilusinns and Prole—nos CWC:)'Ehe Conaaaor'a I.i-\p
ds and
Cal Law dues now apply mune.etrol prepeny who builds or 1111
QTY. PLUMBING PERMIT FE3
whir Contracts for inch proicen with a contrar,nr(a) Ii—led put aaaat In Bac Canmcwnrs
PHRNII IF ISSUANCE
Lwca c Law.
❑ I am eIverupt unser Sec. ,B& I' C far this reason
Owner Ilan
AMER- DRAIN & VHN'E- WATpR (EA)
VALUATION
/ L) O O
W01 iR'S COMPENSATION DECLARATION
I hcrchy :allirm under penalty of perjury one of the following declarations:
HACK FLOW PROfIC'I'. DI?\ IT.
E]I htweand will maimiina CCNncale, of Consent oself-insure lar Wnrke"Cnnapen-
a Glc, for e perlornaanof The
,mina, as provided for by Sectio 3700 ol'the IrMthce
DRAINS -FLOOR, ROOP;A ' .GOND.
S'EORIliS
'I'YI'E CONS'I'I<UC'UON
work he which dd, pencil I, i,med.
ITKTIIRES - ITR TRAP
❑ I have and will maintain Worker's Comlwnrmian In,uran,t,, us othan ed by Seainn
1]Igl of the lWMa Clde, forthe perlormunae ofthe work fur which mid lwnnit is isuN.
My Wad."$y tope Iwo ltuurance carrier and POT icy lm ' a'
Carr rier:-tjf/fl61 i- P.aJ� Iblicy Nn.://e3yaLiL
(JCC. GROUP
MIN
1�S�as,{D
.•J)« J11J1
GAS-E&SYSTHM-I INC4OU'1' L"
GAS-13A.SYS'TIiM_OVER 4IF.M
GREASIilIND115'I'RI. WASTE INTERCI3PIGR
CGRI'IFICAIEOFIiKI!MITION FROM WORKIiRS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Tbisscnion need now be aunpletal iOhe scradit is forme hundred dallars($100)
or lCsn)
ORE- SHTRAP
_
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PIANCHICK FL'E '7
IcenifYwhaw in the perfnrmanceol the work tar wM1idnhi, permit isinweJ,Islmp
ou'loployany personin any nennerioastoheconre,uhj,lI,Ilhe W..scm'Cnmpen.
SVWER-SANITARY-STORMIiA. 2CHIT.
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sunion laws .1 California, Date
Applicant
WATER HEATER WNENI'/ELECTR
GRADING t .
NOGCH'EO APPLICANT; If, afwr making Its Ccrti Ocum of limmptinn, you should
became suhleat ,, the Worker, Campco aton nruci,ion, of the Lahor Galc, you molt
Ibnnw'itn comply with sucM1 pmvi,ion, onhis pemril,hall k teemed rcvnkeJ.
CONSTRUCTION LIiNUING AGENCY
th""naere isacaan,macli3097. Cil, C.) ag,'ncy lar lbe lmdurnranee alIT,
thework fm which this permit li IssnW (5ec. 309]. Civ. C)
work
hcnJer, NumC
WATER SYSIEM?REXI' NG
Sons
WATER S13RVIC17
PAID
Ilene Receipt M
N21 It'7SI1l1iNTIAI. PLMB. SQ1'. I'
TOTAL:
TOTAL
Lentos Address
-
H )1G FIG Z I 7
I acuity That I Irava reuJ This uppliatian and xmtc That the uMwe infnrmalinn is
c recw. l agrec o, taply will all City and county ordinances and stale low, miming ha
haildinyconstrvctinn, and heavily uuthariu mpreientmivcsnfwhmentor entor upon the
above-mentioned property for itnpenion puHasm,.
(We) agree as save, indemnify and keep hrill Ibc City of Coleninn again...
QTY. MECHANICAI. PERMIT FFF
e
FEET �
SEISM PL'H 3.t7
PERMIT ISSUANCHS KJ
In.liC RIC T IE
AI:UR OR ADD III MECH.
Ll. ME
IECHA' AL
'itics.judgment .. costs anti eapenmsw]rich may inany way accrue againxw said City
in tamequence of the gaming of this pcm,iL
APPLICANT UNDERS"1'ANDS)WILI. COMP-P(IINT LY WITH ALL NON
SOURCE R12GULATIO,INS.
AIR HANDLING UNIT TIO 10,000 CPM) �
AIR HANDLING UNIT(OVbR 1400X1 CFM(
CONS''' ' IN
Sk�ntt/ tt/r)coMpplicontJ/C-a�amnciur r'4)...
13KIIAUST HOLD(WIDUCT'1
I( SI a I IG F1iH
HAZARDOUS MATIRIALS INSCLOSURR
HHATIN, USE I(TO IN1,000(ITU)
Will the applioam Cr Imurebudding oaar'son sworeorhandle hamNno, material
as defined by the CupedinC Municipal Calc, Chapter 9.12, and the Hicallh and Sack',
Code, Section 2553 SL
HEATING ONIT (OVI3R IN),000 BTU)
VIiNTILATION PAN ISINOL13 R1?SILO
❑ Yes LFlR11
CCCrrr
Data RecciplM
`
Will the applleunl or fano, building ocatptm n,c cIf pn CaI or deviacs which
dued by tide Ray Area Air Quality Alanagemmt
emit haanrdna.vair cnmami aunt, mnn
IBIILI3R - COMP1311P OR 100.000 11TH)
TOTAL:
IbHI.HR - COMP (OVIR I W,IIIXI RTU)
❑ivriol^ YC'
I have tout the hl]amdnus mala' ,reyui nder Chapterfi950 he Cali-
forma Health & Safe c, Seetint 25505.2 3 u11534, 1 undemand Thal if the
AIR CONDI'TIONIR
ISSUANCE DATE
NFW RISIOENTIAL MICA. SQ. FT.
El
huildingJce, ly baveate ,dold x y rspnndbility nnunify the «cupunl
of the morin Isis muq to Irma n , nee Cfu Cc/".iliaaaof q(an a�it 'n
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OFFICE