S 2641 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELVC I RICA], PERMIT NO.
IfUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECDANICAI, (� g]C /I
4
BUILDING PROJECTIDEN'FIFICYI'ION' J L o
B(/ILDINGADD ISS: SANITARY NO. APPLICATION StatMI'ITAL DATE
Q ITf,Lop 13- .,'-- 2
OWN 'SNA III PHONE: CONTNACf SNA ': LIC NO:
ZI C ( u NIC Q/ CONTR'Or1L p�
�A 1'I ' I!NGINfa!It:` O AI'.IC O: ADDRESS; ( ❑ ` ✓
a5 V l 7
c(NTAcc PHONIZ. BUILDING PERMIT INFO
aJ�] ❑ Consultant Fees Paid by Applicant(Initial) Bld2c ELFCT PLUUMBB MECH
LICENSED CONTRACTO :S DECL, ATION Q'PY. ELECTRIC PERMIT FEE 1 nen;ny Ido n dint nIn lecnxv i:IBJ hrn.iaimI,of Chaplee 9 amnmencins - JOB DESCRIPTION
OaZ with Section7000)of Divioon 3 of lire[business and Pooessiers Cgle,and my license is RESIDENTIAL:
W O p PERMIT ISSUANCE
F,= in lull force and eReel. ❑SFDWI. ❑KITCH17N REMODEL.
a�+VyU License Closes Conte APPLIANCES-RESIDENTIAL ❑ADDITION ❑PIAMHING RE-PII'li
N Q W Dom— Gmtaclnr
VIG JHITECI':S DECLARATION ❑MULThUNIT ❑MODIFSTRUICATIO
F '7 y PANELS MODIFICATION
ZONZ 1 la roll be uudbpuM1lic records
pZ�rQ Ig L&GCJ UI'TO 200AMPS El INTERIOR _ ❑CHIMNI?Y REPAIR
=^� IJansco Imsiannl - 201-1000AMPS IMPROVEMEMF ❑SWIMMING POOLS
AMCC •,] OW iR-BI111.DI!R UEChARA1'ION OVpR Iqp AMPS ❑BATH REMODE1BEPAIR [I DEMOLITION
herchy M.that 1 em exempt frons the Contmum'a License Law for the
X3:LU following reamm(Seniors]O11.5.Boniness and l'rofeszions Cade:Any city or coumy SINS ELECTRICAL [I OTHER
y Whleh douiren:t pemnl In constmel,Illler,implale,dcmolilh,ar repair:Illy 4NCIUM
F�Oa prinnn It issn:mcc,also rcynires lbe upplicam l'onuch lwrminn 0knsisnal nmtemunl SPECIAL CIRCUIT/MISC.
coo
than he is licensed pursuant to the pruvisimnoflhe Contractors License Law(Chapter 9
CW O (chmmenong with St n I700)of Division 3mUhe ltusinesna!Recessions Code)or DIMP.Ml-.fHR OR POLB INST. COMMERCIAL:
6 thnl he is exnnpl therefrom and the basin for the alleged exemption Any violation of ❑ EW IJ,UG/AUDITION ❑DEMOILH ION
Section 7031.5 by any applicant for to annit odP,,rs 0o appllemll m a civil penrllyol' POWER DEVICES fENANf El FOOD SERVICE
Bat nmre than five hundred dollars(S5gB.
Z Y I'kOVEA1CM'
a ❑Lo theowner
wink,the pmpcny,re is
yemntendes with wages astheir(SOc cnnpensanah SWIMhfINGI'OOLEhECfRIC
�=O will da the work,and the structure is not intended or offered for Bale(Sec](N4,nosiness
❑OTE{I:k
I I I'm es,ions Code.'I Lc Con eusckus License Law Jams nut apply hI;m owner oT Jll'I LETS-SW I'I'CIIES-IsIXTilltli5 �C
4i properly who builds or improves Ihercon,and who Awe such work hicau ll or through
his can cmployres.Provided that mch impmvenmms are nm intended o,mailed far NEW RESIDENTIAL EIAIMR SQ EL.
sale.IL however.[lie building or improvenmm i.nnlJ within nuc ycnrof amtplaion,lire SQ.FT.FLOOR AREA NSQ.fir.
o -builder will ham the hnnlen of..seeing but hadal urn huilJ or improve lar par- ^
pose as own. R.J
-1 1.m
other of ct progeny,am exclusively Professions
will limbed ram emes i- T r Ia
construct the panject(Sec]1400,Business and Professions CmIeO'111c Cnntmmofa Li-
xu Law dace na apply le tm owner of p wa.'P who..d'nI Impmvcs Contra.nnA QTY. PLUMBING PER I'P FEB
whn.omame fnrsuch projects with ac ontrnaar(0licebed punuum m the Cantrvefo/s
License Law. PERMIT ISSUANCE
❑ I um exempt under Ser. ,B&PC9rclhisreasnn O
A111FIl-DItAINAVI!N'I'-WATT' , VALUATION
M
Owner Date
l/`�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECII DEVICE
I hot amid under penal,of perjury one of the following deelzal inns:
❑ Iloveund will nsinmin I,Cendi,awif Consent aself-insure lin Worker,Compam DItA INS-FLOOR,ROOF AREA,CON I INN STORIES I YFE CONSI'RUC I'ION
sari un,as pnavldcd fm by Scot a 3]00 of the LaMn Coda,for the perfonnunce of the 'S
work for which Ilia pcmlil is isued. FIX'FURFS-PER TRAP � 1 1
❑ 1 have and will maintain Warkee,Coul,ammia I Insurance,us requimd by Section IBJ
3710)of the Lubar Coda,fm llie rfanmzncc oflhe work for which this lis issued. GAS-EA.SYSTEM-]INC. 0UTI.HTS n
pe permit OCC.GROUP ^ I OAT
Worker's Onnpenaminn Insurance carrier and
,,.y nuro
vlr am
C.
Cartiee PolicyyNNu.: GAS-EA.SYSTEM-OVER 4(EA)
CERDFICAG?OFEXI!ML'TION IBOM WORKERS'
COMPENSATION INSURANCE GRHASE/INDIJSTRL
BALDING DIVISION PEI15
(This nullon neulha lmronyticlW if lire pernail is fornnu hundred:Iollura($180) GRI: raioli - "�� •,�,/�
nr leased � 1'LANCH[CK PEI
I cumin,that in the lcafoncomdo Bathe work for whichlhin pl'.if is issued.l shall SEWINIl'ARY-STORM I?A.2001T. G
its
Bol em ploy any Person in any manner so us o,became subjectto the Workenc Compan- [INF.RGY14d: /
O Z rmlun Lawsu1 California.Dim WA'fH HP Tfilif IVBN' d 4999
-
x, Q Applicant GRADING FEE
N NOTICE TO APPLICANIt If,race making thin Ceni6eme of F.wearl You should WAIT. YS'1'IiM/fR-APING
a
17:
M:colne subject to the Worker's Campemame provisions of the Labor Cale,You ratio SOILS Itis!
I wouhcomply with sued I......ill ons or this..camp Aull badeunlcolicmded, WA'I'L3 SERVICI!,
a O
C(JNSTRUCT(JN LENDING AGENCY NEW R'S .Q,F1'. PAID
a z ILercM1y affirm that there isaeonxwnion lending agency for the per6,mwnec of Necciplp
C 1 the wok to,which this peonll k Issued(Sce.3097.Cl¢C) u
u' F" Lcndcl's Name - 'TOTAL:
V Lcndc/s Address TOIAL:
I��,I M. I canny that 1 have rand this application and slate that the above informal ion is BUILDING I'ai -L
4.Ih correct.l agree to comply will,all city and coumy nrdina,r.,I Inmtc lawn mlating to QTY. -. MIiCHANICAI.PERMIT I°I?I? .�
C.) ,"[ hullAing conswefinn.and herchy nuthnriao represenwdves oflhisclty mentor..pan the SEISMIC/
?li
above-mentioned pao for inspection pugwxs. PERMIT ISSUANCE LIF
(WO)agree to save,indenmify and keep harmless the City of Cuperina against IiLI!CfR ,PEE
Iiahilllic,,judgmams,coo,;nd expcbea whichn.y in xnywvynccruc agit sail City I:THR ORAIJII'IO,,CMF [I 2
in ammqucnce of the antingo thiv permit PhUMBIN FI!8
APPLICA "UNI . .1' AND WILL COMPLY WIT It NO -POINT AIR HANDLING UNIT(TO 10,(00CPhp I�
SOURC ill(J
MECHANICALI2E l'/ 7 D
AIR I IANDLINO UNIT(OVER 10.000 CItM) CONS'FRUC,ION TAX
Signawe al pp .aVCrm nor - Dam EXHAUST HOOD(WIDUCI')
HAZARDOUS MATERIALS DISCLOSURE: HOUSING MITIGATION FEE
Wll theipplicant nr Rome building oraupnnt aomora to hamrdoaslnaerial HHATING UNIT(TO Ill BTU)
as defined by the Cupertino Munic,oll Code,Chappa 9.12,and the Health wad Safe,,
Calc,Search 25532bd? / DRIVING UNIT(OVER 10,000 BTU)
Ycs g Go
VP.N'rILAT10N FAN(SINGLE REBID) PAID
ILvr Rceoiptp
Will this applicant or furore bidding by the B axe e.Air a or Mvires which
emu.a,' ons Bir umrnminums os dcGnal by the lay Area Air Qualify hlanagemenf MOILER-COMP(JfIP OR I(0,(N0 B'fll) T \L:
Dinricl^
E]Yes �,,/ BOILER-COMP(OVER 1(0,(100 BTU)
lyao
I have read the If v I materials rcyuiremenls under Chapter 6.95 of the Calm AIR CONDITIONER ISSUANCE DATE
tomia He A, ay S .,r 25505,25533 nnJ 25534.1 understand that ifew NEW RESIDENTIAL NI!CI I. SQ.IT. 2-
mild, ax
nl e chant
,],a,c ,drat it is my ruponsililityl ori[ cupam "f
1 of I he,all paiur to ixnhanm al'u C• ifi ac of nry.
1 woe , amhariacdegen ae T ISSUED BY; T-P
OFFICE