S 1788 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELF,C1'RIGM, PE IT NO.
BUILDING DIVISION APPLICATION/PERMITPLUAIR NG-MECHANICAL
1788
RU ILDING.PROJ E,CI [DES"I FICA'1'ION
BUILDING ADDR ISS ESANITARY NO. APPLICATION SUBMITTAL BAIT
R
OWN I'I I(INI!: ]O Cf011'S NAMI?: 0C�
179 IX)NTHULM
ARCHITECIDENGINEER: L C NO ADDRESS: L
k �
CONIACI': PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG BL1'CI'/PLUhtg� htECH
❑ rLvJ( rLyJ� LSI/
LICENSED CONI RACTOR S DI!CI,ARA'I'ION QTY. 1?LI?C'I'RICPERMIT ITE
0 I hereby mfirol that I ant hccused under pnmision.of chapter o(commencing JOE DESCRIPTION
with Section 7000)of Divicion B of the Business and Profusion.Code,tint my license is RESIDENTIAL:
u1O A O PERMIT ISSUANCE s.�
F in full force and efWa^ N- +� ❑SFDWL ❑KITCHE REMODEL
at ~ Liccnac f as Lic.p
d U f APPLIANCES-RI?SIDENfIAL ❑ADDITION ❑PLUMBINGRE-PIPE
Z Z M nota - c• ,wmr
ARC] iC SDECLA N ❑MULTI-UNIT' ❑STRUC'I'UICAL
ZptoZ L smnJ my -tall rtcorJa PANELS MOD114CAFJON
OZ UP TO 2IMIAMPS ❑IM1TIiR10R ❑GHIh1NEY REPAIR
F.
-1
.kens, 'nfnsiun,1l 201-1000AMPS IMPROVEMI'..Yrr E]SWIMMING POOLS
WNI?WHIIILUER DECLARATION El BATH RFMODFIJREPAIR ❑I)FM0Ll'I'[ON
a I hereby ammt that 1,1111 exempt mon the Contractors License law tot the OVER IIgl1AMP5
X 3 C U following reams.(Section TBBL5.I{minx
c and Professions Calc:Any city or county SIGNS ELECTRICAL ❑Of11ER
ad Us N which quires a permit ho consnum.aher. ,impria demolish.or repair any'aft ort
FLL04 prior it)its issuance.also requires the applicant lin inch permit In f le a signed stimmem SPECIALCIRCUI'VMISC. `
$yN tied hu is licensed onn-cia Ito The pruvisatmofthc Cn tractors leans Law(Chad,,
�CpO Icommuncing whh Sccion 9000)of I)ivinion Jif the latein,,I (Prom rem,Cook)or TEM1IP.ME COMMERCIAL
OR POLE INST COMMERCIAL;
i 6 C that he in exempt therefrom and the hasia for the alleged exemption,Any violation of ❑NI?W BLDG/ADDITION ❑DEM0EFPION
0
Way Smtion7031.5 by any applicant for a permit sublets the applicants a civil pcnnhy of POWER DEVICES 0TENAM1T CFOODSERVICE
not mum than Free hundred drilla,(55(X)1.
H'L> 011[ERVIiMIiN'f
d ❑Lacowner
sork,abc pm�+hy.or Nuot intendph"eed tooderedfrthease,7094,Business SWIMMING POOL BLIiCI'RIC
f G will Pr thcwotk,Co,The Core le hors License Law
dos not sale
pply to
whereof ❑U'I'IIER
6 3= and property
who
Calc:The ove%t emou License Law drec not apply an owner of OUTLETS-SWI lC '_S-FIXTUNfS
prrtpe n who employees,
or improves thereon,and who Jus such wad intended
ohimself m throemd fou
his w mployces,pmviJeA that such inhpmvcmmaa are not in ended or nRcmd Got NEW RIiSID6N til .CFR SQ FF.
stiff.lL howuveo lM Fu'dding or impmvencnl ieeoldwithin nuc Yearof cv-11111mh.the SQ.tile.Iq,001t DHEA gISQ.PI'.
a-moder will have the human o1'Proving Led he did not buold or improv fur Puts
P A i D
❑ L as owner of[tic pru,sT am exclusively contracting with Rcenxed cnmmemrs to 111.: t eV
consent,the project(Sc,.9014.Business arta rrnfdsione Code I The Cotarnno,].I-
aLow,drsount aPPly toanownerof propcny who bnJA,.or ilnpowts mcrcon.and QTY PLUMBING PERMI"P PEI', ���� •1 XI1kl
Law, O A►IptO
whnenmeets Gtr such PT ith n contrar.ods)licensed punn1 atn to the Contractor's p
License la . PERMI'1'ISSUANCE 3s:
❑ Ism exempt under Sec. .R k 1'C far this reason _
ALTITR-GRAIN&VENT-WA'HiR(EA) - VALUATION 00
l
Owner Dwc
WORKER'SC(IM of perjury
on DECLARRDON HACK II,UW PR(IDiC'P.DEVICE Qom% .1 'Y
Ihe,cbyallmaiirion author pearCtdty oeofCryencnfthe ireum IorWdkce%rias. yy V �!V
v '❑ Ihave andwillfar by ScCeulfiente of Consenbe Codr,for on,
rforrouNcof H- DRAINS-PIAOR,ROOF,AREA.[(INU. f> STOR b TYPE CONSTRUCTION
so....k I as provided far by Section 7910 of the hvMtr Cale,for the perfnmrume of the
work for which thin permit is 6erker IH%TI11t115-PER'IRAI'
❑ have and will inanition hon Worker's Compensation theInsurance.,Iforih ermined by SM9ion
3]W nfthc Labor Code* the lerlimnvncc of the work f�nr�wllich�lhfic permit in jawed. GAS-IiA.SYSTF.Md INCA(IUTLEfS OCG CROUP AIN
ooMy WorI}7fyCppyr�y yycJryc� �urtic l nlicy Ntny /LTf^� K GAS-1?A.SYSTEM-OVER JIUI
CI?R'I'IIICAI E OF I XEMPI'ION FROM WOIZK17RS'
COMPENSATION INSURANCE GREAS191NDUS'I'III.WASTE IN'I'ERCIPTOR
BUILDING DIVISION PEES
(Thixscaionn Wnat bee offered ifthc Permit is(nr nuc hundred Aollan(SIfA1) GREASE TRAP
or Icac) I`LANCHECK PBIi
I"iip,I,,inlhepermrntan'.of the work for whlchthixpcnnllie,sued.I shall
nEWER-SANITRY-STORM EA 21XF1'
Inot employminanynmnenu secat hcenme ri the Wndmn'C... NiRGY FEE
Ozration lawaof Califumin.Date WATER 1117ATER W/VEN*UFI.HCITO GRADING FEE
Z Q Applicant
N(l]ICETO APPLICANT If.after nuking this Certificaeof P ocrutiun.you should WATER SYSTEM/IRHATING
1'+ ? I.ecou¢aubjem at Ihn Anders Congsnemion pro me al'the Labor Code.yourmuss SOILS FEE
WI ofith comply with...h,n omna or flokfv,rul hall heAco, drevokcd WATER SI',RVICE
Q
1 7z CONSreMICE isacION LENDING AGENCY NEW RI?SIDENf1A1.PLMB. SQ,R. PAID Date RecciplN
U Q I herthyumnIi,peo ereiwco (Sce.311 lending agency Goalie Rdnmtnn[c of
the work for which this permit is issued(Sec.)IN9,Civ.C.)
Lenders Name TOTAL
IrnAcr'I%readyAddm%st TOITL:
t1 1 adify that I hove toad this application and attic that the above information is BUILDING F[li
rexcommet.l agree set comply with all city and county onintocce and stmt laws mating to QTY. MECHANICAL PERMIT FFIZ
U z Indiingeonatmution.and herehy aulhodeE re, ,I city to cmm,ugnm the SEISMIC FEE
above"(We)ag d Pntpeny Gonne..........puvpuw' PERMIT'ISSUANCE }�s
Taft' set wvc aide, and tZyinan Cit dCu Lina u•amct t� ✓- ELECTRIC FEE t
gree y t per 6
Incuieco,ain ments.e at to a ichl dCity ALTIiN OR ADD TO MECH.
nscyucntt nl the antingo h rmit. PLUMBING FEE /y
APPLICANT 1 ?HSI'A As)WILLC 'L'WI'FH ALL NON- )INT AIR fIANDhING UNI'1'('1010,IMMICIIM)
SOURCE . U.� M111!CIIANICAh 1941 Y
�— AIR IIANIJLINGUNI'F(OVERI(Moold CFM) CONSFRUCFION'R\Xso 4 l�L
Contmemr Date EXHAUS"FGOOD(W/DUCT) 1
IIA%ARDOUSildI. l ALSDISCLOSURE HOUSING M1tI� ��ic�'rn PEE
Will the upplucaut HAZoAR"DOUSrm M' eIlIAL DISCLOSUREchmufdeua neater tri HEATING❑NIT1'I'U 100,000[110) 2• ZJ
as Jc]inN by the Catarina hlunit Calc.Chapter 9.12,and the Health and Safety
Cod,Section 255720d) HEATING UNIT(OVER IIp.fYlll B"1 U7
]Ye - Nn VENUI,AFIONI°AN(.%INGLEI(I;SIDI PAID ]�` Hx-1,J]—
i,I to
/ Will the lgtplicanl or Imam bw ng nccepant me alaipmcnl ordes"tc which BOILER-CGMP(3111'OR 100,0011 R]U)
! emit hazardous air enmamiruna tie fined by the Day Area Air Quality Management
T(YI'AL: I 2-
District? BOILER-COMP(OVER 100.0001{'FU)
Cl yee Nn
AIR CONDI'FIONIIH
1
have mud the hue re,,'," Pi%mypm%jhifiI
pter o-)5 othat[wi- ISSUANCIi DATE
fixnia Ilcalth&Sae use, 'tions 25. anude amt Ih:n iRhc NEW RI3IDENFIAI.MECH. SQ.IT.
building Joe wrmn vcammm t ruytheoxeupmrt
ofhhc nawhmhmu hca f(
� �a L � �N
Owner ext. c oriral Of Uwu 'IYl'fAh:L��-70 I55061]BY �
OFFICE