S 2266 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Pull' ENO-E.LE.CI'RICAL PI! fITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMRINr.-MECHANICAL � 2266
BUILDING PROJECT IDh:NTINICA'IION
BUILDINGADDR1i,S : SANITARY NU. APPLICATION SUBMI'I'1'AL DAT
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OW is CO ' AC'- R'.' E: .NfI,S
V N/C COKE'ItOl.p
�ARC111'fECI'IENGINHER: LIC NO: ADDIo 13 le/til � ❑
CONTACT PHONE: BUILDING PERMIT'INTO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB Nil; It
9, ❑ ED EC
LICENSED CONTRACD)R'S DECLARATION rY ELECTRIC PERMITFEE JOB
1 M1ereby affirm Incl I am IittnxJ unJer pmvisinns of CM1apmr 4(cuaamaing JOBDESCRI P'I'TON
QWZ with ScniulnaXnof Division3ofthc Hucincss and Pntllsi ons CMc.aadavllccnscia RESIDENTIAL'
W O p 1117RMIT ISSUANCE
N U in Pial Ponce and ch _ ❑SFDWI, ❑KITCHEN REMODEL
UU Licc 11 ' Lit.p
Q U AI'PLIARCIiS-HESIUEN'FIAh QADDII'IQN 0PLl1MBING It Ii-I'll'li
FZty Dolce Commao
w Q c, ❑MDI:I'1-UNIT ❑MODIFIURAL
CATIO
.H ARCHITECTS DECLARATION PANELS MODIFICATION
ZOyZ Ilmdcnl:nul my plxnn shall be used ns polim
tic curJ.a
O Z,.Q UP TO 200 AMPS [3 INTERIOR ❑CHIMNEY kIiPAIR
F�1='ul Licensed Prnl'ecninnul - 101-1000AMPS IMPROVEMENT 'C]SWIMMING POOLS
Qct,���, OWNER-BUILDER IIECLARA'DON OVER 1000AMPS ❑BATH REMODEURITAIR ❑DEMOLITION
C=Q I hereby affirm that I am exempl from the Cnmraaors License Law ran the
3 W F lidluwing munnn.(tiMian]113 L5,liusinns unit Prnfcsei0a.CUJc:Any city nr mmnEY SIGNS ELECTRICAL [I OTHER
which requires.a Permit to attn.amtm
ct,still, pnnc,Ill.(or repair any Onto a -
Q an In ilsissuanex.zlm scamrestne applicanl fornuch fntnnnm tikesignedsaanelll SPECIAL.CIRCLE 17MISC.
}'
that he is licensed pursuant to the provision none Conmanur's License Law(Chapter 9
Wa�7 (mnnncecing with Section 7000)of Division J afthe nosiness and Profeaiom Cuoldor TEMP.xv l'B OR POLE INST. COMMERCIAL:
a a C Ilial he is exnnpl Ilanef ani un I the h v,for the alleged nnion.nptAny villation of NEW BLDG/ADDITION F]DEMOLITION
pd�LL Section70315by.any applicant lir a Entrant sub)ena the applir.Inl In u avillool Yul' POWER UIIVICES
��� nonoil than five hundred Ill.(1500). OTENAN'1' ❑F(IOIJ SERVICE
�Las owner of the n Yem In with wages their sole com lino, SWIMMING POOL. RIC OTHER LMLNT
prnpc Y,or p >ces xi gcs us pens. []OTHER
W will AUthcwod,nudMaatumisnoli Lacerate fonule(Scc.91 H4,❑use s
LLP � and P I:.' Cade,lit C I I Ia - L I rvncl'IIIyI wirer:( OUTI1;f5 SWI'FCIIC}
la,3 r property what ho nor itionorse,dociallon.and adr.dee,such w k M1 If Inmmgh
his own earidlEaravided that such inpinvermas am not intended V,uttered for NEW RESIDENTIAL I!I.LCFR FI'.
sate.If,however.the huddling at inlprovetnati,,anl w.thin one yeandcumpletier,the SQ.17.FLOOR AHIiA hI'.
ASO.
et'.bnBder w 111 have me haden Ut pts Ing that he did not build nr iapmv,harpar
own v
Few,al
salhe. DOTAL
I.as weer omilitary,the penam exclusively contracting with Iiecaed scomnlclon m
mustra
anlama the
avelaw AopnmLn (Seen]Ian,Bueines and P(rdehs7i Thc CUovanosl
not apply man 1pretelwho Inad,urimpmrvcs thereon.and
QTY. PLUMBING PHRMI'F FEE
who mninshprjre wt1,aniallaenix licensed
purvnam it,the Conmtvmr's
Licence law. PERMIT ISSUANCE
❑1 as exempt under Sec. B&P C for Nis ream.
ALIER-DRAIN&VI,NT-WA'DiR(EA) VALUATION
• Dwoar Dile CJ
WORKIiR5 COh1PGNSA'PION DECLARATION BACK IL(IW PRUI'ECf.UEVICIi �2,Z10O
I M1umby affirm unJer penilly of perjury one of the following declaalinne
IhaveunJ will maintain aCcndmincof Canenito wadessure for Worker'.Compcn- DRAINS-FLUOR,ROOF AREA.COND. STORKS TYPE CONSTRUCIOI
,tion J,E, 111 h,Sontinto 37101 i he Labor Civil.to),tipid of the /
,ak finr whicht1':perm Iissued, FIXTURES PFR'.RAI'
1 have and will inaintain Warkers Colunm%ation insurance.as required by Section
3400oRhe Lab r Cutte.forthe perfnmanueofthe walk for yw�1h�4ernpµtit�s permitI,Qissued GAS I.ASYSTEM-IINCAOUTLELS (KC.GROUT' AI'N
My Worker' mbz., Innura 'a earlier and Policy n/1"1H�//fQ GAS-EA.SYS TEM-OVER 4 EPA)
Cw'ricr r _Policy Na:� Y
C11 R HI71CATH OF EX I-M1?ION FROM WOR KERS' GREASI%INDUS'1'RL WAS'117 I N'IIiRCEPH)B liz
'COMPENSATION INSURANCE BUILDING DIVISION 1712.69
(Thlsseniannced nut M1eeomplmed if Ehepennit i.foronehunJmJJollan(SIOf) GREASETRAP
ANC
a Ica.)
,JuyPhilmi J.perfornmal-,a.,cwork fut ,tula NirpunniCnisauod,lehaE SHWI31l-SANI'I'NtY-STORM HA.2(01171 -
nnt untploy any peann in any nnnner cit us to hemne mnjoeu4 the WUrkcri Compco-
Z ration Laxsof Califomia.Dac WATER HEATER W/VENTIELECIR -
z Applicant I DING FEH
NOI'LE TO APPLICAN'E It,alter making this Cenllicae if Excmptium yn.should WATER SYSTEMn RENTING OILS 9
C> become subject nI NCWrnkar's Compcnastion pmvisinas nl the Lanor Cole,You ores,
{k7 Iimhwilh comply with such pmvnionaar this Damen shall to Jecmad revoked. \4'ATER SERVICE
Q g1FCONST RUCION LENDING AGENCY NEW RISIDF,NTIAL PLMH. SQ.FF pati ReceiptN
U O I hurchy affirm Ihat then is a m.wraoina treating name,Ga the per6nuann et
LL F the wank to,, h,vh,hi,Permit is issued(Set.3P)],Ci,C.)
O UI<nder's Nan.i
Lcndch
Ahrens BUILDING
L:
fy I tity Ill.,I h,tw reit!this naplixed..n and slate Nut the ahme infarnlainn is BUILDING PEP. S'a cf
en
tq curve,I agra to rand,w't01 all city and county ordinances and stale laws relnGng to Cll'Y MECI IANICAL PERMIT I PEE SEISMIC amEIB! j•
U Z buildingnnction.and hemby annual representatives oflta his city Encoder upthe
alXrveaeminned Property for inxiectinn purposes. PERMI"T ISSUANCE ELECTRIC PEI,
Otte)agree m save,Indemnify unit keep naadns the City of Cupcuino against
Iiuhilitiea,juitcoalsand cape" ay,whichm: lttmry w:'accrucugainx1.1ad City Aid IIR OR ADD'I O MGII;
CH. PLUMBING I
on m
aseyuen fEhc gaming of Elis Tarrant.
APPLICA.- NDERS"ANDS AND BILL COMPLY WI'I'It ALL NON-POINT AIR HANDLING USED(TO 10,000 CFM) MECHANICAL IEE
$UURCI' .GU41T1 5.
/ / AIR fIANDLING IINI'P(OVIER gBoll CEM)) CONS')RUCE[ON TAX
j911/f4- 1216i
igramre of Applkami 4mmnor ft Dsm EXHAUST HII(ID IW/OUCTI HOUSING MI'I IGAI PON IEE
HAZARDOUS MATERIALS DISCLOSURE
wlllhcnppla,annrlcture building occupant amrcorhunNc hamrdouW reammal HEATING UNIT(TO 1(1),1001 BTU)
as Judnca by Ila Calterlinu Munmtp.d Co c,Chuptcr 4.12,'an!the pcahh una SafclI
Gdc.Scninn 255)21ay! HEATING UN,-(OVER IFELPE,13'IU)
�Ics 1 VENTILATION VAN(SINGLE RESIDE INID ��Z� -
. _ U,cU,c -y Receipt M
Will does upplicxc on Btmmbuilding o I(lie ur any Are a lir Qu Ur Mace,which
nagement HOHdiR-COMP OIII'OR I00.( N113'1'U)
milM1mmJuus air amanninunl.es dcfnc �Ihc lAty Arca Air Quality Munagcmem '1UI'Ah:
Dislaa^ BOILER-COMP(OVER Iall BTU)
❑Ye, S•9 S
I huemWlhc haanluus tmnnialxn d undo,Chuiter 6.95at tic Cali- AIR CONDITIONER ISSUANCE DATE
y2 533a . _
,area He &Safety C Sections 25505.15533 soil 25534.1 ualemm�J the if Ne NEW RIiSIUHN'1'IAh MI!CII. SQ�Irl'. Ell
olJ
Mlimi.g snot eanrt yy��eeEe anE.tn Ii.Imy RRpna[inirnWy
panl
Uf he It ..elmnp cel •I to is seance t�ra Cy'. 1yaO n rvuthnmd.a vitt
'ITl1'AL: ISSUED HY:—�� 1?tk � •—
OFFICE