S 2552 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL I'ERM1lNO.
BUILDING DIVISION APPLICATION/I'ERMIT PLUMBING..MECHANICAL S 2552
RUILDING PROJECII'WENI'IFICA'I[ON
BUILDING ADDRESS: SAN 1'1'ARY N(l. APPI.ICAIYON SUBMITTAL DA]17
OWNER 0. hJ C�I...I)NI:: h T CO ORa SX-F� ' V S �LI �:OQ
VVI d � NIC CONTROLp
ARCHI'1'I;CT/I;NGINI:I:R: I,IC Nt 51ADDR5S. S, -9'tY _ o rAczi �,V i �15 ❑
CONTACT: PHONE: J dU1LUING PIiRMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HI.DG IJJiCI' PLUMB MECH
❑ ❑ W-- ❑
LICENSED CONTRACTOR'S DECLARATION QT'Y. ELECTRIC PERMIT FEE
I hereby affina Tha I ant licensed under Provisions or Clod's 9( m
omenang JOB DESCRIPTION
p d'2 with Seminn7(X0)of Uivi,inn Jof the tlusinesa and l'mfe..int,Code,and my himic,els RFSIDF:NTIAI.:
W p PERMIT ISSUANCE
�cc= in i al l lo"o and id's,/ -3� '� 1 QD ❑SFDWL ❑KITCHEN REMODEL
QUU License Clan. 4 LieX APINAANCP_S-RESIDENTIAL [I At)[)[ El PLUMBING RI PIP17
F Z W Dane-1 L.L-CS—Cnnlracmr
yZW ❑hfUl.9'1-UNIT ❑STRUT-TURA[.
A CI IITI IC'S DECLARATION
F un I understand my plans shall he used as public record. YANF:LS MOOIPICAq'ION
O'Z`~ UPTO 2011 AMPS ❑INTERLOR ❑CHIMNEY REPAIR
1-4t:W Licensed Podecsinnd 201d101AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IIMD AMPS ❑RATH REAIODET/REPAIR (]DEMOLITION
5 Q I hereby ul'Enn that I um exempt Gmn the Cnntracmr's License Law her the
X p a U follow ire rearm.(Section]Ill I.S.[insides,and proPos,ions Coale:Any city or county SIGNS ELECTRICAL � R
W 3 LL y wl' 4 : P i t 't It p J I'.h p Y t cturc
h.M,t prior I I, 9 .theapplicantf 'hpe It 11signedstaco rd SPECIAL CIRCU I'1'7NI I SC.
E �. math licensedp a thep . n of the Contractors L Law'(Chapter 9
C`�Q x COMMERCIAL:
W ano from untag ithS, n700(pol Div,: i Irl B :' II t .-C nlcpir TLMP MEI'I'R ON POLI?[NST.
a 1 e IE that he in exempt flavfmm and 0e basis far me.tlleged exempt on.Any violation of ❑NIiN'13LD0/ADDITION ❑DEMOLITION
Xmas LL Section 7031.5 by any applicant for a Pvin it subjects the applicant to a civil penalty of POWER DEVICES C]TENANT ❑FOOD SERVICE
d y n more than firm hundred dollars 5500).
2S0I.as owner of the n IMI'ItOVHMhNI'
d props Y•ar my employees wnM1 x'agesatheir sole compensation. SWIMMING PO(IL ELECTRIC ROTI{ER
N will do the work,and The snuc;armOns not onled.....deceit farnala(See 71)44,11u.i neer
W 3 R and Professions Code:The Contractor,License Law does not apply it) own
i sur of OUILEY:S-SWI ICI1E5-PIX'I'UR a' 4-1
pmperty who bmlds or improves thereon,and whir does such work himself or through
his den employees,pnm'idea that such improma,nu are not Intended ra nClc,,d for NIiW RF.SIDFN'I'I Al. iI.F:CTR SQ t7
SU.PI'.IROON AREA $ISUPI'.
sole If h theh Ith g improvement IJ lti o Y f or pra_ +-
h 'IJ ll h' theburden I'P bah tl JJ nh II w p ftrpur
ryne of
is I ) f,�zs
1 hh p P tY ly t i 6 vth l t rets nt 'I OTALcot 1 ct tM1 p j t(l .7Md Im .. dl I 'Cul ITM1 C t' Ttrs l:e ,e Law does not apply to an owner of progeny who buldsrnmprmes thereon.and QTY. PLUMPING PERMIT FEEwhomnfords Ensach project,wit a eanmctors)licmded Pursuant ai dieCommctoraSQLicense Lax' PIiHMIT ISSUANCE I stn cxanpt under See ,II k P C forthis reasonALTER-DRAIN N VIiN'I'-WAFER(EA)Owner DaeWORKER'S COMVEN SATION DECI.A RAT ION BACK FLOW PR(TI'ECK DEVICEI hereby affirm under penalty of perjury ane of the following declarations ._.•�+""�
Ih;rvo unA wi 11 mainatn a Certificate of Consent to self-insure for Worker,Comped- DRAINS-FLOOR.ROOF.AREA.COND. STORIIiS 'TYPIi CONS'IRUCIIUN
ration,a,PnrvIJN lin by Section 9700 of the Labor Cade,tar the pefloadwnce of Bre
work lin which this permit is morcL FI%TURP_S-PER TRAP
I hove nnJ will ntuinain IN Ike,,Compensation In,mance•av rcamired by Section
37M o1 nuh"haCtde(r the perhannanm of the work for which this permw
it isisud. GAS-EA.SYS'II?M-1 INC4OUTLEIS OCC GROUT' AI'N
My Worker,Cnmin,`i;innn Insurance carrier and Policy number are:
Cartier Policy No.: GAS-PA.SYS'HSMaOVlik 4(PA)
C17K'I IFICAFE OP E%LMPIION FROM WORKERS' GREASILINDUSTRL WASTE INTERCEPTOR
COMIIENSAI'TON INSURANCE BUILDING DIVISION FEES
(Thi,metionneudnm becnmpleted it the .if is Iran.hundred dollars IS BIG) GREASETRAP
I'fANC11ECK PPF:
or less)
Icrnilythat in the any mnnr so
1 work linwhich this pcnniT'w laucU,Ish;a. b'IiWlilt-SANI'T'ARY-STORM HA.2100 Pf.
not empinyany - Ymannerwmmbecnme suh'cat Babe N'nr• - l IiNERGY Pfaff
O z n'vlinu Laws nl G I:Buis.[)are WAFER I MATER W/VIiNT?LIiC"1'k U , GRADING Igili
z Q Applicant T `Irk-� A
G NOTICE TO APPLICANT':IL after-%ing this locconfisme of Excmponn.You should WATER SYSTHMaREATING SOILS FEE
a > bcmnie subject To the Workers Conipensidam provisions oI The Labor Lose you i n st
D.1 .. forthwith comply withsuch providiarcurnu,permit shall be deemed revoked. WATER SERVICE
p A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI-MB. S0.I71'. PAID •teff
z I hereby affirm that there in a con.nruction lending agency for the performance of Dote Pin
Up the work lar which this permit is issued(Sec.3fy)].Civ.C.) J 'TOTAL
OLender's Name
U Lender's Andres, T(YfA,. J
a. 1 certify that I have read Otis apphemim.and sale that the abawe intomtation is 11UILUING
A'f" g TY. MECHANICAL PERMIT FEF N uirrccal agree to with all city INA county ordinances and,are law.miming 10 Q SEISMIC FT:F:
U z building construction.and hereby auflaa,c not,rescnecives of this city ,,enter upmnhc
dswc-.mioocd Property for inspection purposes. PERMIT ISSUANCE ELECT RIC P:17
(We)agree It vivo,indemnify and ov,,hunnic„the City of CnpeAno against
[m1rIitiecjudgmcnu,ensu and espeme,vdichmay many wayacerue agadull said City ALTER OR ADD TO MECH. PLUMBING zE'
in nsequenceof the ur lingof this permit.
APPIACAN'I'UNDERSTANDS AND WILL COMPLY WIIII AL1.NON-POINT AIR HANDLING UNIT"P(To 10,000 CFM) MECIIANICAI.F ?
SOUR[ . tIiGULAT10N5.
C_Aw.�pUl q S*_ q 9 9 AIR HANDLING UNI'1'(OVEH I(I,IXXICPh1) CONSFRUCCION'15%
Q�
Sig col ApplimHAZA.1 nr Dam E%HAUST HOOD OVIDUCT) HOUSING MITIGATION PEC
HAZARD re MA'ngeventu eventual
DISCLO9JRE
Will the applicant or future Wilding aculeot seed or handle hvradnun mmerial IIIiATING UNIT LTO IB0.00X1 BTU)
a dcfned by the Call0a ,Manicipnl Code.Chapter 9.12,and he Ilevlth;Bid Safety
Core.Section 2551200° []CA]ING UNIT(OVER 100,00013'1'U)
Yes !t{Krr VENTILATION FAN(SINGLE RESID) PAID
Dna Remiptn
)T.
Will the applicant(it future building occupant use equipment or devices which BOILER-COh1P(311P OR 100.090 RTU)
Brit hamrdons air aurran,occo n,defined by the Itny Are Air Quality Management .
District? BOILER-COMP(OVER RO.00013'TU)
❑Yen J?r.rr
I haverevd the hav,rdea, medun
alsrearimmem, der CWpmr695ofdw Cali- AIR CONDI'I IONI3R �i ISSIIA DAhIg
m ,5
fnmia Health if Safety Care,SeeTlons 25505,25533 and 25534,1 maenland than if he N17 RESIDENTIAL.MECII. SQ,PE Y^ Y
building it -n dounenllyhaveatcamit mit inn mNam,mility to notify the occupant
al the Gary ct nwwhichum Mac onoiss enfaCrnificac of lRaripme,
Owner nramharimd agent Ilam 'TOTAL: ISSUED BY, T^�
OFFICE