S 2761 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY i L I
CITY OF CUPERTINO PLUMBING-MECH NICAL
/ / !RM °.
BUILDING DIVISION APPLICA7'IONIA ERMIT TING PROO.Mt:CUAN1FIC
I BUILDING PKIIJF:Cf IDF:.\'?IFIL-ATIUN
111JILUING ADD t5o � C SANITARY NO. APPLICATION SUE A.DATE
( lilfSN Mli: PHONE 'IR CT NAel IZ. LIC
s� NIC CONIROLro
ARCHI'PFCf/ENGINEER: 1-a-Al: DRESS5 ?4h
: ❑
CONTACT PHONE. !Ji' BUILDING PERMIT INFO
❑ Consultant Fccs Paid by Applicant(initial) µCDG ELECT PIXMR MFCH� V'J COJcwO
❑ ❑ ❑ ��
LICENSED CUN I KAU I'UK'S DECLARAl'ION QTY ELECTRIC PERMIT FL17
with Scene.7000)of Division3ofIIlCTSDEC�AR Profession,
Code,f9fcommense JOB DESCRIPTION
1 hereby^firm that I mor licensed under mcivis
w0c) festoons Gdc,and mylirenx is p RESIDENTIAL
W O PERMIT ISSUANCE
MODEL
Floculi❑are and ellen. ! ❑SFDWI. ❑PLUMBINREE-P[PE
QUU Limnsc Cl ns 1.iCro APPLIANCES-RESIDENTIAL ❑ADUI"fION [J PLUMBING RE-PIPE
FF--zta 6m C coo
NGa .ION MULTI-UNIT' ❑MODIFIVRAL
L,oA m PANELS MODIFICATION
OZZooAz b— Iun:lersalnd my pl:ms nM1nll he usedm public ru'nnls UPT0200AMPS
❑INTERIOR [I CHIMNEY REPAIR
F I?F'a Licensed Profcssi, 2014000AMPS IMPROVENIENT SWIMMING POOLS
�+ 5-q OWNER-BUILDER DECLARNI'[ON OVIiµIOPXIAMPS ❑RATE REMODELIREPAIR ❑DEMOLTI[ON
C Q I hereby mfinn that I on exempt from the C dracuo'.s Ulease Lew for the
�ta'OLV following reason,(Section]t1315,Business and Professions CWC:Any city or county SIGNS ELECTRICAL f ❑OTf11iR
1+13 a h whim nyuian a Permit m umswn,alto,imprnvm Jenmlish,m n'pamr nny stmnure
poor r' :' I" the
h .1{I tl 'hp It II -_k Lltemam SPHCIAL CIRCUITIMISC,
f�} thath dpursuant t the provisions IIIth CattirriLicerr,e La (Chapter9
J Ih f n:Code)nTEMP.METER UK POLE INST COMMERCIAL
W�p O (coengtaX . :
A.ry�o y that he is ewe opt Iherefr:n and the hats.I..the olhgcd uuupt at.Any v olid on of ❑NEW BLDG/ADDITION ❑DEMOLITION
W..in Section 7031.5 bytmy afflictionfor a permit subjects the applicant us a civil penaltyof POWER DEVICES ❑TENANT ❑I'GGD SERVICE
not more than five hundred dollars P5500). IMPROVE F 1
ySCI]1,an owner of the propcny,nr my Cnmploycen with wages nsihcirsilc mmpenaeiaa, SWIMMINCPOOLELFCTRIC pI�
will do me—evired NCstnlenrei'ma mendedoudiamd f^rsalc(See 7CA4.[in....Ca IDI'?R /t 1
W on and Prate%ions C:xle:The Contanor'x License Crew does nm apply la an rune!^f OUTLETS- 'IT S-NATURES
`4( n I f�lJ
property who builds or improves ancient,and who does such work himself orb..aid,
his own employees,provided tint such ilnpnwelnelnx ate not intcluled or offered lar NEW RRSI 'I .111.IECTR SQ F-
sale.If.however,the building or improvement is sold within one year ofcompleron,the SQ.FT.FLUOR AREA S/SQ.ICI'.
rbuilder will have the burden of that he did mat build or improve for f
owner proving p ser
pose of node.).
❑ h as owner ml the propcny,.B exclusively contracting with:)TImedhi nti to 4"
FP
m eruatheesnot (Sec.II air Businessandrty wh bar CWC:)The Contras.'. rd,noc.uwdoeorsuchp r loan oana onproperty wle.ledds or inmpruves thereon,and QTY, PLU e( .2M FEE2 6 1999
who umtrucn fursuch project withueommnor(sS liecnxeApunnam mthc Cmnhaamr'sAY
License Lmw. PERMIT ISSUANCE
I am exempt under Sec. .R&P C for this mason
ALT!:R-DRAIN&VENT-WATIi (EA) VALUAI'ION-
Owner Dam B
WORKEkS COMI'ENSAI'IOn DECLARATION BACK FLOW'PR(YILCT.DEVICIi Y �..�•
I hereby still
affmn under Penalty te.fCon one of the following wtmw lloC
I plhaveandwiC muinm Scefinilicmcoffee Labor Code,
lin Worker's Compo- DRAINS-NI OOR,RIX)P.AREA,COND. STORIES "I'YPF.CONSTRUCTION
smirk,as provided for by Semon 37 W of the Labor CWc,for the perfmnn:mre of the
[-ark for which his permit In issued. PIX TURES-PIiR'TRAI'
❑ 1 have and will maintain Wn kO'effe Ca ceofthe w rk for cc,as Ink,e d by Seclbo
J]W nl tM1e ln(�Mr,in1C'�rxle,for the performance nDhe wor9k%far which this permit is issued. GAS EA.SYSTEM-)INCA OUTLETS OCC GROUP APN
MyWoCum r:r�Qna nsumncc caninrl'nllcy N�{zZ5 GAS BA SYS TEM-OVI!R4(1?N
F CRRTI ATE017 EXEMNIONFR(i RKIEKSGREAS191NDUSTRL WASTE INU:RCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEB.S
(Ihuxmlio^need on to anuplcled it lbepclmit ix fur unc hundrWdull^n($100) GREASETRAP
nor less.) WVAID
' IIIiCK PCI!
I certify that in the prhavenoe ofthe work for which this permit is issued,l shallP
ARY-STOR
n I employ tiny porton in any manner so as m become subject to the Wod.vri Comped- Y FEE
ZZ swoon Laws of C:liforria,Date t WHEN VELG FEE
O Applicant
i..I rN-I NOTICETO APPLICAN'n IL of..moking this Cenifcnm of 13amption,you should49-REATING
a benmm subject m one Workers Cul^pmadao previsions of me I.uhnr Cale.you I,I IT3E
forthwith comply with such provisions or this permit shall be deemed revoked. E
lZ
Z CONSTRUCOON LLNDING AGENCY 'I AL.PLMB.OI herebyatlinn thin there I,.consnuaion le^Jingagency fon be prlmmmet,ofwe Receiptrothe work for which this permit is i...N PSCC.PN].Civ.C.)ULenders Name TOl'AL:0 LenderAddressI cenifyom 1 have read this application and state that the move information ie
f! h correct.I agree It comply withal)city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FLEE SI;ISM C E
V Z bulldingmnswction,and heichy authorize rePrenenlnlives orms city lnenter upon the AAL1
s"a Rove-motioned property for inspection purptrses. PERMIT ISSUANCE ELECTK .FEE a V 4
(We)agree to save.indemnify and keep harmless the City of Criptioo against
Iiubilaw,jndgmenb,cre,,and Cxpemses which lnuy ivory wayaccrue agoioxt said City ALTEIt OR ADD'IU MIiCH. PLUM NO FEE f
in nsisi cent of the granting of thin pennon.
APPLICANT UNDERSTANDS AND WILL COMPLY WI fit ALL NON-POINT AIR HANDLING UNIT I'1n IQIXIn CFM) MF.CIIA CALFEE
AIR HANDLING UNIT(UVF:R IPLIXIO CPM) CONSTRU.DON TA%
Signature ufApplican/CmnlacerShe EXHAUST 11001)(WANICIO HOUSING MITIGATION IEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicad or future building occupant store or handle humorousm aterial HEATING UNI'1'(TO[00.000 BTU)
m deformed by the Cupnino Municipal CWc,Chapter 9.12,and 0e Health and Safety
CWC,Section 2553200? HEATING UNIT(OVER 100.00OBTU)
❑Yes ❑No VENTILATION IAN(SINGLE RFSID1 PAID
Date Ri 4
Wit l the applictimnor"'amfit,ilJing occupant use C,minnem or de,ire,wh ich HOIL1i1t-COM P O HP OR 100TO1 BTU)
emit hamrdous air eontamimmos as defined by the any Area Air Quality Minalcl Pal Tf' �:
-Diadct? BOILER-COME(OVER 100,000 BTU)
Ycs No
I have mad the handrdaus materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomla Health&Safety Chile.Schots 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET ��--/ 2—
Ch
t
buildingil n I Currently have a Lem Nat itooYmsgourdulity m today theoccu, 1 L
myNte r`ytulremen1.yph t prior once of a Ce c of QcCu�n`y.
A�OI'�1lzedpi ISSUED BY, 711
Owner nl'nmhorinw ag nl Dntc TO f ,
OFFICE