S 2835 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNo
BUILDING DIVISION APPLICATION/PERMIT rl.unnunc-MECHANICAL S 2835
BUILDING PROJECI'[REST IFICAI'[ON'
BUILDING ADDRESS: SANITARY, APPLICCI'[ONSUBMITTAL DATE
53 �1^7 --Q
OWNER'S NAME: PHONE: CO NACTOR'S NAM LIC NO:
u / NIC CONI Rol.
�ARCIII'ECf/ENGINEER: LIC NO: ADORE I ❑
CON'TAC'T': PHONE: O _ CS(�_ z (/ C HUILDING PIiHMI'I'INPU
❑ Consultant t•ecs Paid by Applicant(InitOmp BLDG EhliCf PLUMB MECH
LICENSED CONfRAMOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy affirm mal 1 am Incensed finder provisions of chapter 9lcommencing JOB DESCRIPI'ION
WIZ with Section 9(XXl)uf Division 3oftM❑u,ineurood l'mfesion,Cade.and my liccn,-,, / YEKMIT ISSUANCE !"'O RESIDENTIAL'
I-__ in full lor.c,.mt QR. 3 ( ❑SITWL ❑KI rcHFN REMODEL
gU f License Clens 7� Lies.p
tx U APPLIANCES-BESIDES'1'IAl. [I ADDITION ❑PLUMHING HE-PIPE
F Z W Dine Contmaor
tn6a ❑MULTI-UNIT ❑Sl'RUC['URAI.
ANCf11'1'[CTS DEChA 'ION
F,p m PANELS MODIFICATION
Z O H E undersand of,dia,,hall he used it,Public record., Ill"1021XIAMI'S
oz— ❑IN'I'17RIOR El CHIMNEY REPAIR
F"I Liccnxd Prnfc,.in fit 201-1000AMPS IMPROVEMENT QSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IIXOAMPS [ 1REMODEUREPAIR [:1DHMOI.I I']ON
C C Q 1 hereby nffimi mm I um exempt from the Contmaotls 1 icemc Law f Thu
X U a U lidlnwing reason.(Suction]III 15,business and Professions Gtdc Y city ser oorI SIGNS EL[CI RACAL ❑l)I'Hlik
W 3(L y whim rcyuirtn a permit m construe,aper,im,nrve,dmn,li,h,nr rc r any rucI re /^� /J Q
F 04 prior Ind,i..,ance,aim nagrievheit,licanl Lnach permit bt fileosl ,moment SPECIAL CIRCUIT/M1115C. 1t/ C 16S
Ibm he is licensJ punuanuolhu provisions of the Cnminw(Chipler9
(atmrncncing with Section]UUAof Division lot the)tut fc„iom CotJcl yr )'EMP.M1IETHR Ok IYll.Ii(NST. COMMERCIAL
=E:-, Thal he i,eacmpt mercfrom and me k,ir for the,IlcgcJ a fly violainn of [3 NEW BLDG/ADDITION ❑DEMOLITION
^vi Section 903I5byany applicant fora pennil.mbjau pp no a civil penoltyvf POWER DEVICES ❑TENANT ❑IR)OU SERVICE
not more than five hundred dollars 185 W I. IMPROVEMENT
SD �I,a,owneof)hep pe rtyormYcmpinyc, w a,Iheirsole a,mpcnsation, SWIMMING POOL ELECT RIC
�,�� will An "In
andsstmnurc is nrn'n¢ndal tea Jlia salelSuo]1H4,❑u..,incss BOTHER
W 3 unit 14ofcneinna Cod The Cuntnminr' t ce the w df>ts nm apply 4f nn owner of OUThGfS-$WITCIIIiS-PIX'I'11RLS
0. plryeofly whu holds r impmvice mer m.; d who, �Loch wurk In ell or lhrongh
if,own eniployreu, r..dxl(hut ah^int, v trona are Bol intended or,filled fol' NE R14SIDENTIAI.HL1R2I'It Sp FT.
sola.ll;huwcvvq the abiding nr mmi.volA within ane year of cnm,letinn,the SQ.PP.FLOOR AIIEA SISQPI'.
"One builder will o ve the hard of pm ing that he did not hu'Id or iin,nrve Iia par
p,, if sale.), v
p I,as owner of the properly exdusivdy nmtrening wim liccnud amlreator,m U' L:
connmO the project(Sec.] u ami Prof Liam CWc)The Commca,rlIl
c uhwd,e,nut apply u'ano'urof property whu build„r improve,thcaun.and QTY. PLUMBING PERMIT PEE
who contract,for such pmjWs will ontractut(x)licensed Pursuantto the Contractoh
License Lfw. PERMIT ISSUANCE
0 I am encrust under Sec. ,B&P C for thin rtxam
ALTER-DRAIN&VFN1'-WA'I 17R(EA) VALUATION
Owner, (late
WORKERS COMPHNSA'I'ION DECLARATION BACK FLOW PROI'IiCL DEVICE
Ihereby'ft t India ry 'IIy of p ry l i1he toll gJ P f,n, O
0IIrier.ind vollniaintain a Ccrudicate ofL ocid to vell-hourefor Worker's Cotpcn DRAINS FLOOR.RGUF,AREA,CONI(. S'f IES 1 YI'13 CONS'1'RUC'OON
FYI p J d f rby S I 791X1 ,I lic 1 1, C Ie,for h p fdolla,unce of the 11
611t",nrk f or wh eh M,perm t i—,o W. I 1%1 ORES-PI3R I ItAI'
1 have and will meinlein Worker,Contpcnsali,n In urance,as reyuireJ by Sceinn
7WM),f the •I Vil&
f the work ft whichthi, Ini ucJ. CAS-EA.SYSTHsNIINC.4OUILETS UCnC GKOUY �,�I'N
My Wer um hr rmidl',;;r,du �I GAS-EA.SYSTIiM-OVI3k 4(EA) // � [['J
Cum Policy No.:/
CERMPTIONFRONT WORKERS GREAS USTRI.W B�NTERCC R ION INSURANCE, BUILDING DIVISION FEESnu t J it the,cnnituforonehunJmJ Jollm(51101 GREASE'RIC 1
r less) 11 PLANCHECK ME
Icemty lout in he perfnrnar,cofthe send tirowhich do,permit i,oared.I,hxII SEWER- ARY-S'PORN 13 21
nor employ any perso n any manner xu as et hvvsn wbjec t Ili Volker' 'rmpell- n II ITN17RGY FEE
Z ,aria..haw,of I" Rn' Dine WATER H ''ER W IN PELF"IR
na
z O OINUING PLC
A,Plic:nn
= N(HICE'O APPLICANT'.11:roller making i d,Ccruhcate of F mnpuon,you shuuld WATER S Eldr REA'I'IN6
E
, For( I,,rhj,,I (,,heW
the Wnrkci,Cu ofroorfion nv ons of the Labor Cal,Y mumrsf SOILS P1313
i,i
� lm
ihwith cornply with such Pmvivon,or lhi,ryrni shall be deemNavnled WATER SE V13-
1 PAID
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLM({, SQ.Fi. )ate Re<ciplp
UO I hereby affimvhaOheir is.con,,.ctlon lending agency for the Performance of
LL — the work for which this permit i,blued(Sec.JIFF,Civ.C.) TOTAL
O V Lcrall Name
LcrdONAJdres T
0. 1,.city thin 1 have read Thi,oppilation and smte that the above immolation is HUII. TNG
1
Fto comply and wimall cityand cenntYmdinel,of anJstaa ln,verdaor die QTY. MECHANICAL PIiRMIT 1°IiF; SEISM 'F '
UZ huilAngn netnmti,n.and hereby nuthnrinmpmcenative,of fhi,city In enterugmthe
ubnvwlncnlioncJ ProP:rtY tar lnn,cninn purpnma. PERMITISSUANCH 1: pC'r 'PE13
(Wes)agra ,I save,indenutit'y and kraft harmless Ihn city of cepennn,agnln..
Iiubilitics,judgment.,,e,dsond expenso,vii,holay in any way aceruc ogeinawid City ALT ER OR ADD'1'0 MECH. _ 2D 1'LlM TNG FEE
on n,aporce of the granting(if this perrnit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1,NONPOINT AIR HANDLING UNI'VOO 10.000C M13CII NICAL FEC
SOURCERE 'LATIONS.
_ _ AIR HANDLING UNIT(OVI3R IILBgI CFM1 CONSTR Cf1ON'fA%
(gnat reef Applicant/ untmeba Dates EXHAUST FOODGODUCI'1 HOUSING MITIGATION FEE
HAZARDOUS MAfTiRIALS DISCLOSURE
Will the applicant or future buildingerculem store or handle hazart material HEATING UNIT(TO 100,000 B TU)
as Jef toad by the Cupetlimn Municipal Cole,Chapter 9.12,and the Health and Safety
Col,Section 2551200? �r. I HEATING U NIT(OVER 110.100 BI U) -
cn ❑Yen �N"' V ENTN
ILATION PAS INGLE RESI O) PAID Ilam n
Roccipt
W,IImenppllcantnrt'tnutc building occupant use equipment or devices whidt BOILER-COMPLUIPOR 100,0 )BIU)
fit haranlma nil eonfmmn ipl n,drfo,d by the Itay Ara Air Codify Munugernenl 'l
Ilisbicl! BOILER-COMP(OVER 100.1100 BT U)
❑Yes, Vu
I have read the hazmdom material,mBibefficon,under Chaise,695ot the Cali- AI R CONTI'I ION13R ISSUANCE DA'I
fnmia I leallh&Sucre Celle.Section,255115,25571 and 255X.I undersand that if the NEW RESIDENTIAL MECH H. SQ.FT �)
building does non currently have a tenant that it is my resixurethilklY to notify lherccupan. 7
the myui%g%IIqwhich rant of n Cememte of Oce ,micy. 1
C7f
OWN efr� I orveJ,gemIc OTA( ISSUED tlY:
OFFICE