S 2096 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ULECPRICA L PESITNO. 2096
IIU1LDING DIVISION APPLICNI]ONME.RMIT PLUMRINC-MECHANICAL
RUILIIING PROJECT IDEN'I'IEICA'I'JON
HGILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'YO'AL DA'I'1
2.11.'61 /zftI;a6t.W {7.L. j0-6 y�
OW ER'S NAME: --�I• r� P(t1/ONL: CONI RACI'OR'S NAME _ LIC NO:
b/.3 AIfCAA.,J -I 6-S 70 Z. �(.0 �i� �ullOfl4L N/C CONTROL#
ARCO I ITECTIENGINFER. LIC NO'. ADDRHSX EJ 47
�L
Nat..A.J �j{,4/IAIC� C,NS39 SAME.
CONTACT. PHONE: BUILDING PERMI•I'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG/ELECT PLUMB MI!CH
zo Imo' C� ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT- FLEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W OMilli Seeam19000)of Division 3 of the Madness and l'roreo,inns Code,mehoy lwean is RESTDENTIAL:
p PERMIT ISSUANCE
1 11= in full forceand erre". ❑SFDWI. ❑KI'I'CHEN REMODEL
QUU License Class Ewe's APPLIANCES-BESIDIiN'1'IAI. []ADDITION ❑PLUMBING RC-PIPE,
I-ztat Dem Contractor
CD. ARCHITECI"S DECLARATION ❑MULI'hUNH ❑STRUCTURAL.
ZONZ I understand my plane shall be used as public records PANELS MODIFICATION
OZ4- UP FO 200AMPS [I INTERIOR [I CHIMNEY REPAIR
I__�W Licensed Prors"iaoal 201-IWOAMPS IMPROVEMENT E)SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I000AMPS ❑BATH RFMODEL/REPAIR ❑OFMOLHION
C'Q 1 hcmhy affirm IWn I nm cica"a frunl the Cumrodnr's License Law lot(be
x1 6 U following rcao,(Section]0315,Humins,and Professions Ctdc:Any city nn county SIGNS ELECTRICAL ❑OTHEk
u1 O y which re,mrs,It permit to Oarsman,alma,improve,demoli h,m repair any.,,amKG��J'L7GC y
prior to its issuance,also acquires the applicant for such permit lel file a slgrod satemcm SPECIAL Cl RC(11'f/hIISC.
vWvW��y'� tanlmisI'co'cd pursuant to the provisions el'On,CunI.. Uxinv,a Law(Chnpnr9
IyCpO (commenemg with Section T)00)ofDi,Woo 3 of III'Besides,add Prn�svionv Code)or 'fliMl'.METIiR OR PULP(NST. COMMERCIAL,
a a c that he is emmpl therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDWADDITION [I DEMOLITION
bGI� Section'10315 by any ep,licanlfor opermid subjects the applicant pew
I.a civil lty of POWERDEVICIS [:]TENANT TENANT FOODSERVICE
W ulumm den,l ice hundred dollars 48500).
y Z 7+ IMPROVEMENT
xd Q 6as,owner of M1e pmpcny,or my eulployces with wages an theta sole compensation, SWIMMING POOL I?LI3C'1'IUC
f,FO will dolhewnak,and the,o Ciandsnolimendedondl:does no,
I,ancromnus
HER
6'3 m and eny who b Cade The Cos them',License Law does urn apply m an r brought -IL OVfLFfS-SH'ITCHGS-ITXTURIis
his )on Won builds or improves thereon,mnJ who dues such work himself of Ihmngt
his own employees,e presided that such mentis aildw am nal intended or offered Ina NEW ItESIDBN'fIAt.IiLLC'TR SQ RI'.
sale.IL hnwcvernhe building orimpmremem is sold within one year of completion,IIIc SQ Il'.FLOOR AREA 8/SQ.PI'.
owner milder will have the burden of proving that he did not build or improve for par- /
pose of sale.),
[_1 1,as owner of the Property,am exclusively contracting with licensed containers to TOTAL. (�
m,uaa the project(Sec.]044,Rosiness and Professions Cn ic:)The Cnmmemr's (-
censa Law does not apply loan owner ofpropeny who buildcar improves thereon•and QTY, PLUMHINGPERMIT FEE
who comnmts for such projects with n eontmctor(s)IiwnsW pink am m the Contra"nr.
License Law, PERMITISSUANCE
❑1 em exempt under Sec. .11&P C for this re twnl
ALTER-DRAIN&VENT'-N'ATF.R IEA) VALUATION
Owner Dam O
WORKER S COMENSMION DECLAIIAI'(ON BACK FLOW PROTECT,DEVICE
I heathy affirm under penally of perjury one of the following dcclnrmmns: 000
❑Ihasx aal will mainmino CeniOcam of Comnnmself-i n.do Rd Waders Compen- DRAINS-FLUOR.ROOF•AREA,GOND. DRIES TYPE CONST RUM]ON
,anon,as provided for by Seclinn 3](X1 of the Lahr Cade,for the performance of the
fork for whl,h this permit is iI'mal. FIXTURES-1'17R TRAP / C
1 have and will ou imin Worker's Compensation Imam eo.a,mquired by Section ✓
37M of the labur Code,for the perfmmance.1 the work for which this pencil is issued, GAS-EA.SYSTEM-1 INC.40UTI.EFS OCC.GROUT' AI:N
,My Worker's Compensation Imumnce canner and Policy nnmber.are:
Carrier: Policy Nn: (IAS-F.A.SYSTEM OVER 4(EA)
CERTIIICATE OI'EXI?MPfION PROM WOHKHRF' GRI?ASPIINDUSTRI.WASTE INI'131tCI1PTDlt
IL
COMPENSATION INSURANCE BUILDING DIVISION PEES
This section ncM not N,completed iflhe pant is foromn hundreddollars($100) GRF.ASLTRAP
or Ics,.)(TI'LANCHFCK PEE � L/
(certify that in the peel'ormun.coflhewnrk for wldch Nlnpamit ie isnval,I,lm1l SEWER-SANITARY-S'IORM EA.200FE
not employ any person in lay manneno as In hecmnc mhjed In lM1e Workers'Camper. ENERGY FEE
O Z saber Laws of Ca fnmia.Date WATER HHATER WNENT/ELECI R GRADING PFL
Z Applicant
M NOTICH TO APPLICAN'P,If,r1wr ,ouakiag Im.,Cedificew of lixcmplim,you should WATER SYS'I'EMaREAI'INC,
a , te,omx suh)om m the Workers Compcn,aa0n provisions of the Lubar Gsle,you Inca
W forthwith comply ssith such provisions or this pencil shall be deemed revoked. WATER SERVICE
1 Q
GGNSTkDGf10N LENDING AGIiNCV NEW RESIDENTIAL I'LMI1. S Ff. PAID
'7 x" Ihcmhy afOnn lh;n there iso mnslmcllon lending ugcnty for lM1c pvrfnmmnce,It at Receiptp f ,
the work far which(lits permit is issued(Sec 3097,Civ.C.) 1rj OCT A
f' Lenders Name 90TAL:
V Lecdcr's Address TITAI,:
rel 96 11...pa I
Ly I anify Thal I have rand this application and stale thin the alwve Inkarmulou ix 0
h coma.l ngrce to comply with all city and cnumy nrdinanacs nnJ smtc laws rdalingm QTY. MECHANICAL PERM] Illi
U Z bmidingcnnarection.and hershyxahnrizcreprewouttirc,andixcity ma
enrupun the B 51?ISM1C FEE
ahnvnmentinned pmpcny for an"i ion'it's". PERMIT ISSUANCE
(We)agree m save,indemnity and keep lac less the City of Capalmo agaba,t ELECTRIC PFR
Iiahildics.juJgmcra,cons and i,,eme,which may in any way accme.,ousl said City ALTER OR ADD'POM1!CH.
in consequcn CON.
6mming of 's pencil. PLUMBING PER
AI'PLIC UNDERSTANDS AN)WILL COMPLY WITH AL1,NON-POINT AIR HANDLING UNII'(TO 10,000CFM)
SOU :I GULATIONS. MECHANICAL FEE
AIR HANDLING UNH(OVER 0.000 CFM) CONSTRUCTION TAX
Stgmnure of Applicon + #star Date EXHAUST HOOD(WIDUC`G HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant nr furore building rect,r nl,lore as handle hazunluus an annual I II?A'fING UNIT(TO 100,000 BTU)
as defined by the Cupcninn Municipal Code,Chapter 9.12,uad the Health and Safety
Code.Section 15532(x)? IIHATING UNIT(OVI;R 100,000 BTU) ,rte L
❑Yes INo PAUDil �/ m71M
VhNTILAI'ION FAN ISINGhB BUS IDI Dam Rce"pllf 77, S
Will the app ontainfumae Melding occupantuseea AirQunrdevices which BOILER-COMP CHP OR 100,000 BTU)
emir M1amrJous air nmmminanu as JcOneA by the Bay Arca Air Quality Management TOTAL:
prima? BOILER-COMP(OVER 100,000It I Of
❑Yes e 166,09
ILavemadlhehv:Ion m I na4m uimnle I under Chapmr6.95of Rc Cali- AIR CONDITIONER ISSUANCE DATE
li+mia Ilcahh&Safety Cale.'cation,25505, 5533 and 25534.,undemand Thal if the N17W RESIDENTIAL MECO SQ,IT.
hulat Jnr of currently havcalcnant lhal it rayresrym.ibilily In nutil'y the(weapon
of the ryf a eats which moa lc nl"pnort suanceofa Cenificaleol Occupancy.
O er nr uuthnnzeJ"gem Date TOTAL: ISSUED HY ylk b/i.._�LI`�"��/
OFFICE