S 2439 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUI I.DI NG-F.LECI'RICAI. PBRMTI'NO.
BUILDING DIVISION APPLICATIONA'ERMIT PLUMBING-MFCHANICAI.
BUILDING PROJECT IDENTIF'ICAT'ION 2439
BUILDING ADDRESS: ( SANI'T'ARY NO. API'1.;1( IONg11tMl'rIA1,DAH
I tgle r�Nd � � 99
OWNCIVS NAME: (JN /I/IQ q� CON TRACE OR'S N, Ili: LIC NO:
-Il/V {'� NA] CON'I'ROI.a
1'rECI'I' INFER: LIC NO: ADDRESS: ❑ / 2/
f Je oU4 / C_ 1p
CONTACT PHONE: BUILDING PERMIT INFO
❑ consultant Pecs Paid by Applicant(initial) HLDG ICLECIPLUMB Sri 11
3?-
ifl—
LICINSHD CON TRACT OR'5 DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aRnn that 1 am licensed under provisions of Chapter q(commencing JOB DFSCRIPTION
DzZ with Salina 71XX0 al'DivixinnJofthe Nwiness and Pndessinns Cale,and lay licence ix PERMIT'ISSUANCH RESIDENTIAL'
O in fill(ma,and Creel. ❑SFUW, ❑KI'I'CIIRN RF.MOUIi1.
W
QUV La,, Clans con API'LIANCIiS-RESIUIiN'I'IAI. ❑ADDI'I'I(IN ❑YLUh1HING NI?-1'11`1:
F-ZW Dmc Gmtmaor
ruga ❑h1UI.T1-UNIT ❑STRUCTURAL
F.,Cw ARCHITECTse DIiCLARATION PANIi1S MODIFICATION
OOyZ understand my slams shall tw used as public records UP TO 200 AMPS
❑INTIiRI(Ik ❑CHIhINIiV REPNR
j.1�W Lac cnaal l'ml'c..imad 201-10011AMPS IMPkOVEMIiNT SWIMMING P001_S
W s 7f OWNER-BUILDER DECI.ARAI']ON OVER land AMPS
BATH RI?MODEURF.PAIR ❑DEM01.1'1'ION
C C W Q 1 hereby anion that 1 am exempt from the Contractor's License Law for the
W O a U following reason.(Section 703 L5.1mor ss and Proressiaos Code Any city o,county SIGNS IiLIiCfRICAI. ❑OTHER
W a H which requires a penis to conamct.alcor.improve,danolhh,or repair any stmeture
LLQ
al prior) t :. also 1 theIIIIc If it tt 11 'g J:tt,n:.n SPFCIN,CIRCl11IlMl SC.
� Y tra,he I,licensedp rtu ama llue,rovio..... life Courflumvior,l 1 '1@ ptcry
W�CO (commencing will,Section 7000)of D vsion 3 ofthe Business and Professions Code)or T EMR METER OR POLI:INST. COMMERCIAL:
Ea.a e C that he is exempt therefrom and the basis for the alleged csmpuon.Any violation of ❑NEW BI.OG/ADDI'1"ION 0 DTMORATION
if^'LL Section 7031.5 by any applicant fora Permit whjects the applicantin a civil penalty of POWER DEVICES
W^N nano urethan live Fnn h eddollan($5W). ❑TENANT PO(ID SERVICE
I,as owmct of the n SW I l,1 M I NG POOL ELIiC1'R IC OTHIzRIMPROIiMIiNT
o ❑ these core is of intendedwin,wagC.n.talei(Sel.044 Bxanessat: ❑GTHIiN
Fa will Jo mo work,and mcarucmrcix not lmm�dcd nndicreJ for cult(See.7044 of
ILL 3 m and Profession..Cotic:The Contrenor's I.i v.,c raw docs nut apply to an owner or OUrrISrS-SWITCIIfS-FIX'1"URC$
p.,ny he l, ld:a,irrraca,Nelson.j J who J , h k himself ,hmugh
his own employers,prooiderlet: h iniparevements am-num intended or offeredfor N17W RCSIDENTIAI.FrFCTR SQFi.
sale.11 1hih hu 1 f 6 p e t Id II" y f I I'm the SQ IT.FIAOH RHEA EISV I'll
ovula nIJ¢will h,mu II holismof P'ov ,gthat led1 nt hold m'sprove forsur 2
1xn•t a',le 1e.
r of the pollen,,am e.cm.ively c'ontraning with licensed connector,to '1�.L: 3
nswn the traject(Sec.AH4.Hosiness and Professions C,Ac:)TLe Commerory Lb Aw 6 S
.al:,wmes nm atplymvn owncrofpmpcny who mllJa illi improve.thereon.and QTY. P M131NG PERMIT' FEE LV
what nmllncn lar snch Pmjcctc uam...... glncnxcd punwmnnll,c Cnnnumors /
Licca>c Law. VF,RMI'f ISS Cli C�
❑I an,exempt under So,. .B&P C for this reason
Date
AI:D'.R-DRAII!NP- ATIB(EAVALUATION
)wncr WOPRSCOMISMONDFOARATION BACK FrO PR( Iivi
hch uffinuundcrenulty lzrjuryocicrllwig,Ilfns' Q
D
O
GRAINS-Iail( .k0( ' .COND. STORIES 'IVI'I?CONS"CRUCI'ION
onion,os provided fa by Section 37X1 of the lana,Code.for the perfurn ance of the
work for which this tennis is I...vd. FIXTURES-PER TR• `
❑ 1 have and will maltnuin Worker,Co rlau'ation h w"anee,a,required by Section
3700 of dIC l.ara,Core,for file tedornian,colme ware far which tno,erll if k cord. GAS-HA.SYsniM-IINC401 rFIS Oce GROUT' APN
` MyW..kcr'sCall,tens:niun lnrconcecurne,and Policymmnitwr are'.
I Curti¢ Policy No.: GAS-EA.SYSTEM.OVER 4 CA)
CERTIFECATE OF BXHMPT10N FROM WORKERS' GRIiASI%INUUSTRI.WASTE INTIiRCIiYIOR
COMPENSATION INSURANC17 -IIAANG DIVISION IBIS _
(I hioccionacW not be C ITICtcd if the pronat is liar one handred dollars($100) GREASE'I'RAP
or lc..I PrANC CK ;Ii
I certify that in the performance ofthe work for which this permit is issued.I shall S13WBR-SANITARY-STORM EA.2001-7.
not am,],,,any pent anym rte,soda mbecomecubject,alae WnrkC,,Coarer- IiNENG\'1' Z Q
oZ arlion lawnof California.Data an WATER HEATER W/VR ELECIR
a Gk N ;Br.
A,h,a
NO1'IC17 10 APPIACAN'F.Rf after making this Ceaificum of Exomttlon,you should WATER SYS'FCMG R17A'I'ING
1" bmonm nubjca m Thu Wodcr'c Gm,panxaitnn prcin o of the labor Cta1c.you moa SOILS r SH
o
UJ foam adiunnpl,w'ith such Novei.iomo,this permit shall be dcemed,evoked. WAT RR SERVICE
CONSTRUCTION 1.1iNDING AGENCY NEW RP_SIDEMIAI.I'I.MR. SQ.II PAID
7 z' thereby union that there is acrionatimi lending agency or perfunnunmof U:nc Rmoipta
U
the w,,,k fn,wd,b dr.pC,Ilii i.i..am(See 3097,Co.C.)
nder.Name ° r
VLender,AJdma ).1.
>. ❑J Pis
1 certify that 1 have read this application and same @at the aWinfuriation nom,mion is HUILDINC
Fcornet,Iagree ,comply with all City and county ordinances and state laws relating a, CITY TMECHANICAL PERMIT
Vat neFEE SEISMI iP O
[JZ bungs ,letton,un,l hereby awhoB/CoT,e nauvaeof thl.cityucateri,minue
abovoncadclad property tar ro'e'lion puipow" PERMO'ISSUANCE I7I.I7C C Iili r 3
I WC)a,CCC to save,indemnify uad keep h ti nleao the City or Cupeninn vgoinvt
Iiabili,ies.judgmetns,costs and expenses which may in anyway accrue against said City ALTIiR UR ADU TO MIi i _ PL 1' Illili
,eyuence of the gramin,of this fermis. t I F'1
AI'I'hICAN'I'11NDIiRS'L\NUS AND IhL ONE I'LY WITH AL1.NON-POINT' All HANDLING ONrI'1 Q(1v�IXXI CI:MIV�\ f ' I•-• Iyt ISCHA ICAL PEE
SOURCE'HGUI,A'I' )pal I I_I
7 AIR IANDLING UNI I'(I o'so)CFIAB I I ONST CIE ON TAX
ignatu CIA icant/Couraw )etc EXIIAUST HOOD(W'R ) ED 10USING. I'IIGATIONFI;R
IIA%ARUOUS MATERIALS DISCLOSURE.
ill the applicant or future hnildingrecupam store or handle hvardous malarial HFA[INC.UNIT(TO It 1, XI BTU)
as Juthall by,he Cnpenino Munle'q,d Colla Chasm,)12,and the Ile:dlh and Safety
Calc,Section 25532(a)? IIEA'I'ING UNIT(OVI? @qXl lflill
Ste, ❑No � PAID
VFbn Inc TION I'AN(SINGLE R:B3T�^—�� Data Rec'pap
Will the applicantor furore building occupant um equipvmm or device.which HOII IiR_COMP 13IIP Ile I siol10 HrU)
s ill koanou.air cnnian,inanry n.letll¢J by,he Bay Arcn Air Quality Maus"' rent 'r
D'mtdal BOIIAIK-COM,(OVFR 100.0cm if I'D)
❑1'c, 0 No
I have mail the haatdous materialsrt a under Chapter&u5 of on Cali- AIR Ct INDIT10NIiR ISSUANCE DATIi
quism°n
forma Ilwlth&Safety Code.Sections 255115,25533 and 25534.1 undorstand that raw NHW RBSIDF.NTIAl.MITCH, SQ.FI'. �� Z r per. J
builAing .not carrel Yha"atC,act It lit Illy rc.plaoduity m nollly the Pam /�->•"��—r�
of0 'q,I cmcmnw hpl . h•m "Clove ala Caa�Bcv¢ Il, ancy.
1j VZVr jut a cd jgcna )me T ISSUED BY:
OFFICE