28098 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
N 1,DN(:-F.h;CI RICA. IgiRMI I No.
CITY OFCUPERTINO APPLICATION/PERMIT rLunnnNG-MECHANICAL. 28098
BUILDING DIVISION BUII,UING 1'ROJF,CI'111FJVTIF'ICATION
SANITARY N(I. AH'I.ICAIIUNSIIIIDIII'IAI,DAIIi
BUILDING ADDRESS:
loro'16 tate-M��Rv qP.1 LOI g
OWNERS NA ,hppPUONE: CUNT RACI ORIS NAME, LIC NO: NA: I//pN'INOLp
•IIIECEA: GINEER: ..IC NO: ADDRESS: � 1
J l� J
MAMPS
'++:• rt- BUILDING PERMIT INFO
CONIACI: IaNB: QTY. .4.....�1 .,', . ELI; I'LlIMOPERMIT ISSLICENSED CONTRACTOR'S DECLARATION AP19.IANC1(ro OESCHII'I'ION
❑KZ Ihercbyi(Di-kml Pin lorvencdunder provisions nfChaPmr9(unnnancing with+TW7 Satin herchlofontht I lnfceBilnde prov'mrnsirma CrdeEurruniccnse with PANELSfull loaeanJcfft. U 0200200 ZW License Class Lie.g
Comramr 201-1010 ASQ.EL 11.00H ARBA 5(SQ.FI.
nNCHR1!CTS UECLARA)'ION OV,?n❑. ^ I an
Z_0 I undersand my pinna shall be u.d as public record,. _ � 1 L
zF'W SIGNS F:LEMICAL
Y0..K'+ Licensed Pndexslsmal
�e, OWN- UILDPR sCLARA'IION SPECIALCIRCUI'UMISC. `
CJa V 1 hereby affon Ihm m exernry from m.Cunn,ling L inns Low for the �,� y
LLOv~i followingrcmnar Sect ?01L5,Busirrcasand orcnion,Cods:Any city or county ll!MP.MGfF.R(OR RA,F,)NST. e-�
which rcgaircn a n to trmstmc,alcor,improv dcmnli,h,m Pe,dI any%want,
J ROWER DEVICES
rn} primmilaiasu ahorrymm"he.plirnntforaur rmitlofrleasignedstnemam
<C) That he ice ' lord pureuort ter the Pnvsoon%of NC Cor arms%License Law(Chaper SWIMMING MOL 17LEMIC VALIIAI'ION _
9(un n¢ncing with Scdinn Rggp of DirlildnJof NeB 'rte send hofc viola CrMq UE,
mNa he is vemNrhrrefnnn end dM - afpt Ne allcBed cminion.Any violation of OGILISI$-SWI)CIIIiS-I'IX'I'IIRIiC "I�1 rrL—��.({��
CZQ Sectio ]0)LS by any applicant ra_ii - eapp'camp%ecicilpenellyuf
int inn Than fve hundred d_ol (S NEW RESIDENT AI.ELECIR _SQ.FT. STORIES "FYPI:CONS'TRUCT'ION
€� ❑ L vnflhP «awiNwagnav "anlecompcn,aion,
willdnN work,endlh I, ndcdmoff rcdrhr ,(See 70,14.Business
and Pride si ons C "or',Ijeeme Law ds not appy m an nwnerenr
propenyw nbulld% iberson,andwhodoes hwnrkhimellmNmughhi% O<C.GROUT' RES.UNIIS
n emplo ttP.,rm4dPJ 0 aM1impmvemenls mihmmkdmoffeed,f ilk.If.
however th buildingora pr einem is sold tui nmeyearorcomplaion,SM1c owner
huilAcr will nvelhehurde of provingdint JidnmbuilJmimpmveforpurpaseof _
. IcJ, .tr" y""' l �'(„FEE.,* ILOOU],ONE AVN
Cl I.asowi r-efthepropeny.am ivelY contracting with llcehsed contractors w QTY. ,;,,,PLUMBING PERMIT,•"'e" ri '..7� ., ,0
comvucl the I jecl(Sec.]014. a sines%and profession,Code:)lloe ContousulPERMIT ISSUANCE
Licencel.awd noteMlyuran net nfpropeny wholaildver impfovesrt
thcon,and
whomnnnnafnrchprnject iN a commctortJ licensed pursuant n the Contnemr'% ALITR-DRAIN&VENT-WATER(EA) FEE SUMMARY
Berns.Law. O ISTD• ::5
❑ 1 nm exempt a tt. B&P C fm this reason
BACK II.OW PRRTECI'.Uf;VICEN
SANITARY Y�_
RT:CEIrlP
Dmc DRAINS-FLOOR,ROOF AREA.COND. SCIOULTAX Y N
WORKMAN COMPENSATION DECLARATION RECEIPT IT
I herehy coffin Nat l haven senifcmeofennsent to adf-whore,oracerlifcale of Il X'NRES-PER'I'RAP PARK FEE V N
Worker;Compensation I....unicorn cetilird copy Nercof(Sec.3R00.lab C.)which RECI!Till'B
enves.11 employee's at his permit. GAS-EA.SYS11IM-1INC.40 LISTS., BUII.DING DIVISION FES
Policy a
Cmnpmry GAS.EA.SVSIi!M.OVER 4(EAT PLANCIIE K11i1i Q `
❑ CeniflcA rnpy is berehy famished
❑ Cetilied copy in fled with The city inspection division. GREASIANDUS I RI.W H OR GRADIN(;FRIT
CERTIHCAIR OF EXEMPTION FROM WORKERS' GREASE TRAP SOILS FEE
COMPENSATION INSURANCE
(Un%section need not he completed iflhe pemtit is for one hundred dollars W00) SEWF- -SAN ORM En.2001-T. ENERGY PER
or tear.)
I certify that in the Performance of the work for which this permit is issued,I shall WA'H!R T WNF,NT/Ii1.liCTR
nm employ any K—. in any manor P nes to berm aub*t la the wmkm• PAID
Coon,rualionlawnof Celifco ice. [)all-
0
am WATI!R SYSl1iM/IRIinTING Dara R eiNa
2' Applicant Z, , MECHANI0
Mg SQ.I'I 'ItYfnl.:
0 NOIICC TfO AI'PL1GN'I^.IL,Tint making Nis Ccnifcam of lixemptian,You aM1nnlA
Z � hcomesubjemmlheWorker'%Contpcnsatirnprovi.vionsoflheLNnCIMc,YOulsus BUILDING Hill �
fmNwiN rnmply with inch prnvision.mlM1ia Rmrit shell be decmN rtvoked. Q
1 Q SIASMICFCI? YO
CONS'IDUCT]ON IJiNDING AGENCY /aa
Z Ihembyvflirmfor thereisamnsmunionlend;,,,.,ncyfor The peffnrmnnceof I IiLECTRIC V' 2V
J O he work for which thin permit is issued ISer.:1f19].Civ.C.) _ _ '
Lendcr'%NamePLO G
lL QTY. AL PERMIT FEB;„'IsndI ran,Addh I mnily Nnt I haveread Nin vpplicminn vnd anile Nm Ne shove infomnlion in MTiCIIAN AL I iliconed.I.gree to cmply with nll city and rnmmyo innncevvnA score Iowa rclmingm
building wnarunion,vnJ berehy Pontotocreful rives of Ni%citym ruler upmvhe CON. IC`111 NTAX
Z
above-mamiorcd property fur;nap ma pnpnrses. AI;ILR UR AUU A)MECII.
twat ngrtt m save,indemnify send keep ham as the City of Cupcnine against AIR HANDLING UNIT(TO Ip,lBp CPMO
linhilities.judgmema,nnu ondeapena hlchmay anywayaccrue ngain3I, dCity
OW AIR BANDIINO UI'I
N (OVER 10.000 CPM)
m cons,nen ingnfdi per ril. o
Signature of ApplicamA:tmtra Uale EXHAUST 11(000 I WlDUCD PAID
IIN,ARTR)US MAl1!RIALS UISCLOSTIRE
IIEAUNGUNITOO W.00013'IU) Gum R cil
Will the applicant or forme building recupam.sure or handle Im.noll ant"ind HEn'I'INGUNI'I'(OVI!R I)0.00001U) IYTA L:
as def J by the Cupvnion Municipal Code,Chillier 9,12,and the)health and Safely
Cade.Section 25512(,)? VENTILATION PAN(SINGLE RESIDE
Cl Yea ❑No ISSUANC17 DAVE
I101LI!R-COMP(?IIP OR 100,001 RTU)
Will❑m apphcammfaint,ddcr,eg mrupemay AP Air Quality whidmmit
.nodous air cunumminal as dcfncJ by Nc Bey Arca Air Vuvlity Managcmcnl BOILER-COMP(OVFR 100.000 DIU) I! 9 1
District? G 9-1 --95 Vn ❑NoNEWRESIDEN'TIALMECII. SQ.FTI have read the hnevrdona one ills requirenmoD under Chnpler 6.9.5 of rhe
ifjusbonds, snormaPeoria. htitisyrelpeIuhdeastif@nt if Ne builJing Jae,nm m nts w have n st ls,thin it i%my rtnprce oility m irksa Na
aruPem of the requirements which moat Fe mel Rim m inosine of a Cenifcnm of IIT
hcupnnry.
Uwnn m nnNnriacd xgcnt Dam I' IgSI11iD Dl' � a✓�
OFFICE