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APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,. F.LECI'R12AL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
IIIIimnsO PROJRcr IDRN'rIPICATION
�6
Pe ITNO
kJ 1270
BUT LDING ADDRESS:
SANITARY NO.
APPLE ON SUBMI'I'I'AI. DAT[
TN i�iitE !_
-4.
OW 'It''N pMli: — - PIIONIi:
I
CO A 'I OR"'NAME: IC'O I
,/. L
NIC
CON'T'ROL/N
1
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I:CTR:NGINI:F.R:/ n LCN'��>
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ADDR -SS:
CONPHONE,
CON'IACIT:
BUILDMG P RMI1' INFO
❑ Consultant Pecs Paid by Applicant (Initial)
BLDG ELIicp PLUMB MIiCk
Ey
LICENSED CON'TRACTOR'S DECLARATION
hereby aninn thin an; licensed under pon,kiuns of chaps 9 mmrmeneing
Q'pY. - EI.ECFRIC PERMFF FEE
JOB DESCRIPTION
PERMIT ISSUANCEE?SDENTIAI:
with Smtinn 9IX0)nf Uiviwion3nfnb, Business nnJ Pmfessinns Coale, sod mYlimnse is
in full force and eR'ca.p i2111
Liam Clens W Liax
Contractor Izko
0SFDWL [I KITCHEN RHMODEL
❑ADDITION ❑ PLUMBING RI -PIPE
❑MULH-UNH' ❑S'I'RUMURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
APPLIANCES -RESIDENTIAL
I:
--1 (IW CIRIE, DIiCL IA )
I undyderstanmplans shall he used as public records
PANELS
UP TO 200AMPS
Licensed l'ndessinnal
201-UMAMPS
OWNER-II1111.DER DECLARATION
I hemhy nn'Inn dual I trot cxnnpt `roto Rua Clormaelnts Liwnse Law lisr Inc
following reason, (See ion 9031.5. Business and Profession, Cale: Any any Or county
❑BATII REMODIEL/RI;PAIR [I DEMOLITION
❑ OTHER
OVER Irx0 AMPS
SIGNS ELECTRICAL
which requires a permit to tr nevus, eller, improve, demolish, or repair any structure
SPECIALCIRCUMMISC.
-
prior n its issuance, also requires the applicant for such permit file a signal statement
thus he is licensed porsuunt m the provisions of the Contractor's License Law (Chapter 9.
(connencing with Section 7000)atDivision 3ol'dm Bnsinensnnd (tool slow Coro) ur
'TEMP. MB' 1' ER OR 1101.1! I NST
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged axern,amr. Any vanstinr of
Section 703 IS by any applicant for a permit subjects the applicant n a civil penalty of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
WANT ❑I'DDD SERVICE:
POWER DEVICES
not mom than five hundred dollars(S5001.
❑I, us nwnendlM1a propcny,nnnyempinyeaswithwages usthcirsole enmpcnr;nion,
wJl Jethe work, and lbeauvelurc isnal inteadOdor nRered for auto(SmA044, Boiness
sad 11 fcwind, Cole: The Confro,on's License law does not apply to ua Owner of
IMPROVEMENT
❑OTIIiTi
SWIMMING POOL ELECTRIC
- -
OUTLE'T'S—SWITCHES—FIXTURES
prnpeny who builds nr improves therton, and who does such work himselfm through
his own employees, provided that such improvements are non intended or,(fend for
side. It, however, nhc hnild'mg or improvement is wild within one year Of ermplOion, the
�—
NEW RESIDENTIAL HLECTR SQ FT.
S Q' FE
-builder will bovcthe hurden el prrvmg Ind be did not bead or Imprvon fin our -
pasowner
s "i m1e.).
❑ I, as owner of the prostit xdusively cartoon, wilh limmed contmctotsm
.T ('1
i-
construct the project (Sec. ]014, Business and Professions Cal,:l the Commences Li-
-
xeLawdoesrunapplytoanownerof property who huilds of improves nnemon,and
cause
QTY. PLUM PERMIT FEE
who cunlrael.v fuLvucln pmjmta with a mntmgnris) liansal pursrum to the Cn..hion es
PERMIT ISSUANCE
License law.
El Iurn.c.,tunder Sec. ,B&PCforthiemason
Owner Dam
ALTER — GRAIN&VF: '—W ' EAT
VALUATION
O O CoVf/
WORKER'S CUM ofNSATIGN OECLAkA'GON
BACK FLOW PR(YI' " . E
? CON
1 hereby ul Erm under penalty of perjury one of the following dedarninns:
0 I have and will maintain a Cenilicam ofConsenOo self -insure for Worker's Compen-
inion, as provided for by Section 37M of the Luber Cade, for the PcO ormunc, of the
DRAINS -FLOOR, TOO.
STORIES
TYPE CONSTRUCTION
work for which this permit is issued.
FIXTURES -PER TRAP
❑ 1 Lion unit will mainmin Worker's Cn.. a.,a lun Insuranm, icm Bad by Section
3700ofthc Lobar Code, for the performance of the work for wbialadva permit k o,oul.
GAS - EA. SYSTEM I INC. 4 OU I'I.II'T'
OCC. GROUT' AI'N
'unions Compensation Insurance currierind Policy no ny, �r �`.
mcr:� p t'oBey No.: I I /--O (
GAS- EA. SYSTEM.OVER 4(EA)
GRF.ASIAINDl15Tkl. WASTE IN'IERCIiPI'OR
CE PI A' F EXEMPTION FROM WORKCRS'
COMPENSATION INSURANCEBILI
11
IVISION IDES
isentor need nut M:romplatW if ]in pent is Tornio, hundred dol ars Hl pro
or lest) (thse
GREASH TRAP
PLANCHItC E
I T,'sw
I acetify than in the performance ofnhe work fnr which this Nornit in issued, (shall
not employ any pern n in any rummer toto to Emanate subject It, Clot Worker, Campen_
SEWER - SANITARY - STORM HA. 210 14.
ENERGY FE' wit �r
WATER III?AI'F:12 W/V I;NTIBLBC'flt
car; laws of Culmmniu. Dam
Applicum
GRADING -E
NOTICETOAPPLICANT:If,agermaking this Certifies, of Exemption. you should
beu+mcsubject the Worker's Cnmpetssnes. pmv cions Of the l.uMn Code, you most
WATER SYS 'I EM/IREATING
SOILS 'E
f,nhwith comply with such It...siims.nhis permit shall he desaned revoked.
WATER SERVICE
CONSTRUCT ION LENDING AGENCY
he perfomance of
I hereby aninn than there is is construction lending agency for r
NEW RESIDENTIAL PLMB. 'SQ. FT.
PAI
Dane Receipt
]he work for which his permit is issued (Sec. 3097, Ci, C.)
Lenders Name'
T IAL
TOTAL:
U:nJcrls AJdresn,
BUILDI G FEE itsitx
1 acridly that I have read This application and .into that the nerve inforandnn is
correct, I agree to comply with all city and county ordinances and state laws refining to
+,er arum she
building u+mwmiun, and hereby authorize pmwemmives of this city ¢m
QTY. MECHANICAL PERMIT FEE"ZilalO
SEISMIC l?F.
PERMI I' ISSUANCE' f
ELECTRIC -EP.
ohnve-Mentioned property for inspection purposes.
(We) a,mc un sus,, in lot By and keep art I.ss the City,,[ Colrain a ngniml
AL'T'ER OR AUD TO MIiCH.
PLU RING
liabilltics' pa u, avms'n nxs which unity in any way came agvinst sail City
' +. quenecof in 99.6 gOf his permit.
AIR HANDLING UNIT(To 10,000 CFM)
ME ALK
AP .ICANT ON t X.. NJ ANG WILL COh1PLY WITII ALL NON POINT
SO CLREGU 'IONS
AIR HANOLINGUNII'(OVI3RIO,IgI1CVM)
�S'flitl I TAX sliso
z_ry_L�
/�
:ignela pl unVCun t Dom
HAZAR IJ 1 TERIAISDISCLOSIIRIi
Will theupplieum ortature burning Occupantstore Or hou&heism—,material
EXtIAUS'I'i{WD(WNUCIT
HOUFILJG MITI NITiE
HEATING UNIT(TO 100,001 BTU)
as defined by the Cupenino Municipal Code, Chnptaro ,12, and run Heahh mal Safnry%
Code, Scetirn 25532(a)7
❑Yes ❑No
THAI ING UNIT (OVER 100,001 BTU)
��
PAID
Gate Receipt
ION FAS INGLE RESIDE
VENTL.ATN
BOILER- COMP Q KPOR 100,010 if I' U)
Will the applicant orfuture building u
nnoccupantm,, IretArnenr or devices which
emit hueanlnux air ebtminunty m dclined by Om Bay Are,, Air Quality Munaginnent
Q
i)isaicB
E] Yes Fl N.. '
TOTAL
BOILER - COMP (OVER 100,1100 T3'ITH
AIRCONDI'IT0NER
I have read the havWnus materials reyniremenb under Chapterfi95 of tea Cali-
ISSUANCE DATE
NEW RESIDENTIAL-MECH. SQ. Fr
form, Hecht & Safety Code. Scallions 25585, 25533 and 25534.1 undamand That frthe
huilJing doves nm arren0y haven mnunl teal it is my respnmibilitymnotify tea tscupam
?% � / � —
Of the requirerwnn which must R Brut prior m issuanre rf a Cenificcte of Occuryncy.
(��
ISSUEDI3Y:
TOTA
Owner or authorized agent Data
OFFICE