2140 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIDING-ELECTRICAL I r Is rNO. O
BUILDING DIVISION
APPLICATION/PERMIT PLUMBING MECHANICAL +
BUILDING PROJECT IDItN'IIFICATION
BUILDINGADDRESS: ) SANI I'ARYN APPLICATION SUBMI'1'I'AL DATE.
i ,9VS aft. - �
W R'S N H: TIlNI° COMfRACTOR'S NAME: I NO.
��((� CHAM 9u� 73_a NIC (CUNTROLp
iECCl1:NGINFER: ,U �YUI�0� V ADDRESS: ❑ $ 7 a ' 9
CONTACT': 'V - . PHONE: BUILDING PERMIT INFO
A/� / e// ❑
Consultant Fees Paid by Applicant(Initis EhUO/' ELECT PM hIEC
'✓ 7 l(06 Y CJ/ f LU
LICENSED CONTRACIOH:S DECLARATION QTY Ii1.ECPRIC PCIUVrr VF
1 hereby mr n that I am accused ander precisions of chapter v(commencing JOB DESCRIPTION
WW�n'Z coin Sultan 9axB of n;vkinn3onlot¢asinesa and Profess;ans awe,ane myliaenae i. RESIDENTIAL:
F1_ in full forcoanddlm PP.kMI'T ISSl1ANCC
00 ❑SIsUWh ❑KITC1IFN REMODEL
�UZV License Class Lica gPl'hIANCIiS-121i51DEN"rlAl. ❑ADDITION ❑PLUMBINGHE-PIPE
yQ i Dula Canuuctnr
(..Dm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCI'URAI.
Z O anZ I understand my plans shall b,used as public recons MODIFICATION
OZ=� UP TO 200AMPS ❑INTERIOR El CHIMNEY REPAIR
I-. Fly Licensed Prafexsinnal _ ML'S IMPROVEMENT 0SWIMMING POOLS
❑
OWNER-BUILDH DECLARATION
Cat` F. MIAMI'S HATH REM1fODF.L/REI'AIR ❑DEM1IGLII'IDN
1 hambthex
y on at I tin empt limn the Comln
mcr's License Lou fur the
OAU ❑OLDER
W
a F following ransom fSaIinn 90315,❑nsiness unJ Pnduslnns CnJe Any ch{Ifj'puny ♦ S BhliCl'I11CAL
m which rcquims u parnll m construct.alter,h ijoess,demolish,m repalr 61}yl/tA cod
OQ prior to its issuance,also requires the applicant for such permit(it file a signedsmmmem SPECIAL.CIRCUIT/MISC.
f
a') prior
that he is licensed pursuant to the pro isions of the Commemr's Lieenve Law(chapter 9
=IY�0 moominar,with Section]000)of Division 3 afthe Business and Prof pr' fl'.MITER(IR POI.EINST. COMMERCIAL,
Il6 aa that he is exempt therefrom and the basis for the alleged cxcmpti�`n.An lellA�Y C1 NEW BLDG/ADDITION ❑DEMOLITION
N S,mroun7031.5hyany llicantfaraperaitmbjuro Ne�rit/mo ❑TENANT ❑FOOD SERVICE
W dollars(S.NXE. ♦♦,999
FZY mare OLHERVIiMENT
��6 wi Laaawncruflha mupimetur is not
ot amododoro Bred foxlha sect anus......inn, SWIMMING I'(1 L . C'C IC
and dotbewons ande:no ant is pots License
901J,Bmero ❑0'fIIER
til m
andProfessionswhohold,,,,,
Crede:The Contractors Licensc law does.,it applytoif ownerof OUTLETS-SWITCHES-PI%TURES
his o
property who bulds ar videdrth thereon,and who does such work himself or through
his own however,
he provide)that such mens vemena an nut intendedorm offerer.far NEW RESIDIiNT1AI,F.LECfH SQ n'.
sale.it however,the huilding orimpnrvemem is tall within one year .nfrnmpletinn.IM1e SQ.FT FLOOR AREA SISQ.FT.
Der-boilder will have the burden of proving lett he did ool build or improve for pun Q S
.nf !�3 W
h els owner of the prnpeny,ane axeluxively ionl o ling will licensed contractors t, I A
mxlact the project(Sec.70TL Business and Poclaskso Cmlef lit,Contractor's Li.
c se law does not apply m an owner of property who builds or improves thereon,and QT•Y. PLUMBING PE711MIT FF.E
who commnsfar inch rejects with aeomrocmgs)IiccnuJ pursntnunthe Cammcuer's
License law. PERMITISSUANCE (/ V
I]I am eaemp oder Sec .13&I'C fo his rcasnn f
ALTER-DRAT VENT-WATL'It(Ii A) VALUATION
❑Inc
WORKER'S COMPHNSA'I' NDECLAFA'I'I)N BACK IT PROTECT )EVICH / ry^
randy afMn under panalfyol perjury one ofthe following declarations: 2� / / C �
]I have and will mainwinaCenihc:deafConentioselr-insure for Worker's Compere ORAL . -It. OFWk A,GOND. STORIES TYPE CONS"I'RUCTION
satian,as pmvidW fa by Section 3161 of the labor Calc,far the perlhrmance of the -
work for which this permie is Issued. FIXTURES-PER T
❑I love and will nu main Workers Compenmtion Ineumme,as retailed by Section
3901 ofthc Labor Cate,for the perfamanm of the work Sur which l his permit islsmed. GAS-IiA.SYSTE INC. 'LETS OCC,CROUP AI'
Nly W..kar's Compansminn Inmmnea curer and Policy ri he,old s
I Policy No, GAS-PA.SYS'1'HM-OVE (ILA) OI
CERJ IFICATE OF EXEMPTION FROM WORKERS' GRF.ASEJINDUS'1'Rl.WASTE INTERCEPTORCOMPENSATION INSURANCE: BUILDING DIVISION ITPS
(This victual need not he completed dthe permit is failure hundred dollars(SIa) GkGASE'I'RAI'
anus.) PLANCHEC43E ^�
1 candy that in'he performance of the walk far which this permit is Reload,l shut l SEWER-SANITARY-S'TORM EA.201 FT.
not anploy any pcunn in any manner en as to helium subject to the Warkees'Comprn- IiNIiItG
,Z xtaior Lawnot Califbmiu.Date WATER 11HAIFIR W/VEN'111HLECIR x
Applicant t GRAD
q y NOTICE TO APPLICAN'Elf,after making this Certificate of Esmaption,you should WAI ER SYS'I'EMOREATING
a , beaaee subject m the Worker's Compensation provisions of the Labor Case,you must SOILS :F
t37 forthwith comply lith such provisions or this permit shall be deemed revoked. WATER SERVICE
Gr A
CONSTRUCTION UNI.ENDINGAGIiNCY NEW RESIDENTIAL PLMB. SQ.fir PAID
U z IhercM1 I'lirm thunhereisncnnxtnmtinn leudin far the rformanrnnf )ora Itc¢iptp
U O yn .C.) y Ire
f~ the wink a whish fills 1x:meit Is issued ISce.3099,Clv.C.)
U
Lenders Name
Lender's Actify - 1'' f
} 1 1 certify That I have read this application and stare the the thus information is - BUILDING FE
FtA correct.I agree to comply with all city and county anlinances and state laws reaming In QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby authorice representatives n(Ihiscity to eneerv,sn the SEISM(. 3 "2 , O
alive-mentioned property fur inspection purpues. PERhf I'I'ISSUANCE
(We)agnea he save,toilsome,i I Reap ha ,lasx the Chy of Capenino agmmf E 'E
liuhilitiu,judgmuna,toxo and expnesex which may in any way nocme ngninu suiA CIIY AhT'HRORADD TMECH.
in consequence of the geming of this Nrneit. .Jh NC PEE
APPLICAN'r UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT fTO idult 1crm) M1 .'11ANICAL FEE
SOURCE GULATION&y'
- �a L_ / AIR HANDLING UNIT(OVER III,IMp CFh11 L NS'f11UCT10N TAX
Sig mreof AppacanitCvond �I� Date EXHA US'T HOOD OVDUC'1) HOI SING MITIGATION PIiIi
IIAZARDOIIS MATT;LIN.S DISCLOSURE
Will tbeapplicent or fmure building uecupam store orhnndle coarda Illour ill HEATING ONIT(TO J00H(o If IU)
as defined by the Cupertino Mo. iptl olds,Chapter 9.12 Iuul the Hculrh and Safety
Cody Section M532fn)'I HEATING UNIT(OVER 110,010 Ill U) -
Nn VF.NTILAI'ION FAN(SINGLE RESID) PAID
Dine Ricci t
.11 the applicant or future building reccupanl use equipment curdevices which
I� nnhudadmov air nmmminano fn
asdemll by ]in Bay Amo Air Qemldy Monngancnt BOILER-COM('(3HP OR]at)Pat BID) -
)imrin?
cc]Ya, BOILER-COM('(OVER Ilxl,lllxl N'I V)
I ' s .No
AIR CONDITIONER
I havHealth
Salta ha ore, a tions 2 505,25533 ¢ 2553Chapter 6 tend that Cuh Q ISSUANCE DATA
(omit Hralth ffi Safety Cade,Sections 25505,25533 and 2551).1 understand that if the NEW RGSIDCNTIAI,h1ECH. S FI.
uildingdr sracurmml t,'t, Inant,that it is my responsibility to notify the acupam
ofthere rennnsw' must ham priormissuancer Ce mmao nu ray.
Owner or ut unimJ legunt Z Du 1� ISSUED IIY:� —T—Q)
'F .'- OFFICE