S 0437 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDIN;-F LECD'I RICA 1, PERMNo.
BUILDING DIVISION APPLICKFION/PERMrr PLUMB N1;-MECHANICAL S 0437
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY No. APPLICATION SUBMITTAL DNIE
10 35 A�teNr6 -3 77
'R
OW 5 A E: PHONE: CONTRACTORS NAME: LIC NO:
NIC CONTROLp
if"W
.�.\ T11TCT?:NGINFER: LIC NO', ADDRESS S.S
CON ' N BUILDING PEI✓✓✓iMIT INTO
Jt �� /_ /_ ❑ Consultant Fees Paid by Applicant(initial) .D 'Lor IiC�I' PLU h ;C
> LICENSED CONTRACTOR SDFC-ARAT[ON QTY. ELECTRIC PERMIT Flan JOB DESCRIPTION
I hereby afGna mal I am licensed under luesi.iam of Chapter 9launmendng
C=Z with$emion 01X1111 ufDlvLinn3nfmc]iusinas and Professions CIWc,Itud mY license i. I'ERMII'ISSl1ANCli `�� ID TI L:
1'-0p in full farce and eRut. r VOWh ❑KITCHIiN RIiMODF,I.
CSF
QUU Licence Clan_ Corm AI'PLIANCIiti-RIiSIDENf1AL TUITION ❑S1HO BIUR H&1'11'13
G L pre Coalmemr
ANCH]TECTS UEChARNDON PANELS ❑MULTI-0NI'I' ❑STRUCI'URAi.
F y Z I undemm�J my plans hall be used as Public mrnNs MODIFICATION
CATION
OZ�- UI'TO Xp AMPS ❑hN'PROVR ❑S IMMINGPOOEY L
F�~LLl Licensed Prof..found 201-10N)AMPS IMPROVEMENT SWIMMING POOLS
CM OWNER-BUILDER DECLARATION OVER IINXIAMPS ❑BNfH RF.MODEI/REPAIR ❑DEMOLITION
IY C Q I hereby affirm that 1 am exempt from the Contractor'.License Law for the
O y U fiollowing renum.(Seaton 7031.5,Hadre,s and Pudm,,ion.Csdc Any city ar county SIGNS ELECTRICAL ❑O'fHI:N pp
W E Ile Er/a� which te4 Permit t construct. II P J I h P any structure p gdk
F'E; prion t 1: 4 thel such It it 'g Ltt nem SPECIAL CIRCUIT/STSG.
H{ that he licensed l) I, lib p f.h Connector'I La (Clrpmr9 1,
WC p0 (cnnmewngw'tIt SCUiom 7010)n1D,,Ntn3mf the Budnus and P...c,domCde)m TEM P.METER OR POLE INtif, EJ N GT10 1{T p���aW DIib101.ITION
0.q o y that he is exempt Ihertfmm and the basis bathe alleged cncmption.Any vitiation'IfI
m vi Section 70315 by any applicant for a Terrorah,e,f,the ltn,fcam 1.a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
,t more man rye hundred donor,asuo. E�j'PIO }'EH(INU
F. MI. noe,ofthe propci,teployee,wwages ars
s theiole campemotion. SWIMMING POOL ELECTRIC
osmith
will do the work.and the suunum is not immmdedmndfened for sale(Sec.7044.Business
f" OUTLIFTS-SWITCIIIS_PIJ(TURFS
W 3� and Pmfe,.ina cede:The camllnetnla License haw does not amply to an owner or
property who builds or mmpmves thereon,and who does such work himself or proud, NEW RESIDENTIAL ELECTR SQ IT.
his m ,own employce provided but such intpnwencnts am am in¢nded nr oilcmd for SQ FT FLUOR AREA $1SQ.FT.
sale If.howevee the building or improvement i%sold within one year of completion,the O �k ♦
builder will have me harden of pmv'mg mat herd not hulld or improve fill par- 1, VL
of
rof thepm.7(kIam roes,and aomrmming with;)The
contractors or
m.La does non(Sec.1MJ,wner osandrty ,N)builds
or improves The Cnnlmman. Li.
Mmans',srsuchlomna ithamfpmpeny whosedd,mor'hlineman.art QTY. PLUMBING PERMIT FGF,
who nmtracts fur such projects with a rommen,Hs)licensed pumuannn the Canmractor s
License Law. PERMIT ISSUANCE,
I am exempt under Sec. .B&1'C for this..an
ATTER-DRAIN&VENT-WATER(IEA) VALUATION
6z 32- K
W ER5 COb ENSATIO )EChARAI'10 RACK FLOW
PROTECT.DEVICE O'O
I hereby m under penalty of Perjury one ofthe folkovingdec]umtions:
I haven d1maimnina Ceniliene of Conscmla,elf insure fur Wader's Catalan DRAINS-FLOOR.ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
smion,as provided for by Section 37M of me Laff r Code,for the performance of the
work III,whet this perm"'is iswed. TEXTURES-PER TRAP
1 have and will maintain Worker's Compensation lmmmnce.its m,.imd by Section
37M or the Labor Code I or he periiunetwe A the work fir which ibis permit is issued. GAS-EA.SYS ITIM-I INC.4 OUTLET'S OCC.GROUP APN
My Worker's Compensation Insurance tamer and Policy number are: GAS-EA.SYS'I EM-OVER4 T:,A)
Comer: Policy No:
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEANDUSTRL WASTE INTERCEPTOR
COMI'ENSA'I'ION INSURANCE. BUILDING DIVISION PIiF_S
CD,is senion need not M completed ifine Permit is format hundred dollars($100) GREASE"TRAP PLANCHECK F[li 2(
or les.)
Ia,fid,not inure perhrmanceeOhe work for wlochnii,pernit is issued.i shall SEWER-SAN]TARY-S'IORM EA.20014. ENERGY IT-H O
not employ any penan in any manner sera In became sim,v,t to the Worker,'Coinfen-
Z ration Law.of Culifomia.[)ate WATER HEATER W/VENT/EI.ECTR GRADING ITB
Z O Applicant
y NOTICE TO APPLICANT:If.after making this Certificate of Exnnptim,you should WAIT ER SYSTEMO BEATINGSOILS F13L'
O
became subject ,the Workers Compensation provisions of the Lubar Crock,you muo
n
LY fnnbwim comply sim,mb pmvkiomordii,permit shall W deemed revoked. WATER SERVICE
e
Z CONSTRUCTION LENDING AGENCY NEW RCSIOFENTIAI-PENN. SQ.hC PAID
U tc Receipt b
1 herebyaffimuhatthem isocu (See.3n 7,Cil agency for the perfonnuncx of
CUL.0 'he work far which this permit is issued(See.31191,Civ.CJ TOl'A L:
Q Ulenders Name
DJ Lender'.Address Rl I. G1 'L' �I
Il I agree that I have mad this applie coup y o stem that the show laws
relainn is
��. lin correct.lagrecma,mply with all city and county oNinwces and era laws mlotingm QTY. MECHANICAL PERMIT FGF; 51i1Sn 'Fl3F
UZ building viastmction,and hereby aumrti,ee representatives of this ekyrenter roman the
ohnvnmentinned prnpeny Por inspenion pur,osec. PERMIT ISSUANCE: ELECTRIC PE
(We)agree u,save,indemnify uad keep harmless the City of Cuprnino against
liabilities judgments,costs and expenses which may in any way accrue agdnstsaid City ALTER OR ADD TO MECH. PLUMBIN :EE
in onseyuence of the granting of this permit.
APPI.ICAN1 UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT CFO[0,001)CFM) MECHANICAL HE
SOURCE REG
AIR HANDLING UNIT(OVER I0hIXX1 CPM) CON5'IRUCI' >N'TAX
ammof A, C moor i Dum EXHAUST HOOD(WROUCr) HOUMNGM 'GATIONFEE
HAZARDOUS MATERIALS DISCLOSUNIi
Per,applicant or future huilding occupant acre or handle hazmdaus nonmetal HEAT]NO UNIT(TO 10,000 BTU)
us defined by the Cuperinn Municipal Cale,Chapter 9.12.and Inc Health and Safety HEATING UNIT(OVER Iannual It'IU)
Code,Section 25532m)1
❑Yes ❑No VENTILATION PAN(SINGLE RESIT) PAID
Uute Nwe
Will the applicant or future Wilding occupant use ayuipnmm ter devices which BOILER-COMP(3HP OR 100.000 BTU)
-mit mearm err,air cam� ts
m .inanas defined by the Bay Area Air Quality Management ']'OTA.:
Di"n"e? 110IL17R-COMP(OVER In).000 HOU)
C3 W, C]No
AIR CONDITION HR ISSUANCE DNI E
I have red the barman$tions 55 5.mquircumats under Chanter 695d theded Cali
hurter Health&Safety Cade.Sections]55115.15533 and 25.5.00.1 understood that if he NIiW RISIDI!N 1'IAh MliCll. SV.FT.
building cities nor
o,conically which Imst a met p1al ioro ismymof a Cerliyb,leof the xat
of the rt9uiremems which must be and prior izmanm of a Gutilicme of(Xcupalu�y. �
Owner or authorized agent oar �' ISSUED BY: I eN1
OFFICE
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