S 1965 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY '
CITY OF CUPERTINO BUD,YING-EIA:CFRICAI. PEtir NO
BUILDING DIVISION APPLICA'1'IONIPERMIT I'I.UMA I NG-Mr..CHANICAL �J 1965
BIM.D1.N(:i-ito.IGCPiDI:N-riFICATION '
BUILDING ADDRESS! SANITARY NO. APPUCAI'ION SLI13MIPIAL ONE
e 91i ' - R0MO&I Y'- 7 -�'
s O 'NER'S NAA E: PHONE: CO ACTOR'S NAME? LIC NO.
N/C CONTROL#
Af .I11'I'IA'I' iNCi EI?I� LKTNO���axd) ADI)I<1i85: ��� ❑ r//�� J
COMP Cr: v 1Ii: _IVIG-.N�I /r a ( 13UILDI(N�GPERStI'I'INFO
�1�. ooly -nEw,,,u JR um yID ❑ Cunsa[Ian[Fees Pi idbyyAApTplicanl(Inrtiaf) BLDG ELECT PLUMB MCCH
L�HNSID CON,RAC IBM's DICIARAI'ION QTY. iFLI?CIRIC PERMIT ELE err
Ihomy ar ...let,l f d d p fCh 11 0( g J013 DESCRIPTION
W07o with Section 7(0)nfDuv on 3ofthe Businessand Pmfesto:Oltle.ind my licenmic PLRAIIT ISSUANCE. Q
q RESIDENTIAL
alyF full force and effect "Ir ❑$IUWL El REMODEL
QUO Lmenw Chis Lie.N,jam APPLIANCES-RINII)HIGIAL [I ADDITION ❑PLUMBING RILI'IPE
y�W Date Cnnvr / l S l r .
L CI 111PCI'S DI!CLARA'1'ION ❑MULE UNIT' ❑S'I'RUCfURAL
PANHLS
Z C)7Z I ti J t Ix s-l be used ns public reaads MODIFICATION
--4 Oil 10200 AMPS - Zt 20 ❑INTFRIOR ❑CHIMNEY REPAIR
F., Licensed o Ysymal n]UI..BUILDITI III
2BLIWIIAMPS IMPROVE:MIN'I* E)SWIMMINGPOOLS
apo
Q I h h Bir a hm 1 um exmn I Gntn Ino Cnmmmor'n License Luw for the OV BR IWMI AM PS ❑BATH RI?MODI!IJREPAIR DEMOLITION
aa GJlawingc n1.(. a,IVAir,pair an arooumY SI(1N5 LLECfkICN. ❑OfHER
� W y which,it, nil m c inelmc6 aIle,,improve,tlm rinif ,o le.,R any svueuve
LL�g pl.,he s licensed e.porlanan Io res the,iIa.r and fnr.wch ractue to licro,Law(Ch,mcnl 51'IICIAL CIRCUI'HMISC.
f�� mm he in licensed punuam a+the provuton.of the Commmnrs license Law(Chuptcr9
W,+ �0 (commm�eing x'ith Setlinn](IMllnf llivisionJn(the Nusinesland]'rnc,,ion'C.IO6r TP RMETBRORINILEINS 1 R 1'
11 c y' Ihal h pl lheref 1 Ih oasis I' II IlegeJ axe I pl n A y violin nn of _ :W BLIIC/ADDITION ❑DEMOLITION
0.
Section]Ip
F�xmQ na1.51 y any pl I' - I pen
'I subjects the appli- I I pwNly it POWpu DEVICES IN
❑ ENAN'1' A
❑FOOU SERVIC?
>' nm1mBva hunJrcJ s SM). IMPROVEf1MT
]hasn..Wndthe Properly,o, mwith wagesymc,sole compenxwinn, SWIMMING POOL I1.BCfEIC
�P.� willtb the work,andNrotmcturc is not imendcdorelresed formle(Sce.77 ,Buwlcss ❑OTHER
I�i1 m and I f:. CadTI C I t t L 1 d t pply t owner of 01J0 'S SW CIIfS PIXTURIS D
a'3 prop nY h h'Id p :Ih mJ I J .. ch k h m el thrangh
his n nyly p id Itl,t h' I t. t' I Revd lar NI:W RCSIDCN'DAI,I.I.LCTR SQ Fr.
:ale If l the bt'Id 6 tpnrve I : lw'Ihnn .y - rW plmlul line` SQ FI'.FLOOR ARRA �,g[,vQ.171.
wit rlu'll will huv.N thufficn of pro ubt ll•didnin aild.ruillforpur 11101111 S
Iwse of vle),
❑1,asr of the properly.inn exclusively contracting with licensed contractors In A
nreantm the project(See.7014.Businessland Professions ercle:)The Conlisfor'x Li. - -
n I I reply rp I ry n n 'I1. r p .m ,t , n QTY. PLUMBING PERMIT'. .. j. ' FEEI
who in tl,for such p-lW I with a saW., tx)fcenWdpu.... n I mi.Cohan,'
License Law. I'1!RMIT ISSUANCE!
I.nn exempt under Sec. ,B&P C for this reason
Owner Dale ACI ER-DRAIN&V1lNT-WATER IEA) - VALUATION
WORKIi1CS COM PENS NJ[ON DFCLAIN'FION IIACK FLOW PRQI'ECT.DB:V ICI!
I hereby affirm under penally of pejury ons of the hrlluwing de.lamt incl
au !havennJ will malmuin uCcrliOcnmufConvcnunself-insum fur Wnrk.,''Cmnpun- Z DRAINS-FLOOR,ROUR ARP.A.COND. S'rORll!S 'I'VI'Ii CONS'RUCHON
,union,us pmvidcd fur by seer n J9(10 of due Labor Codd,fur the performance of the IB
work for which this permit is i..wed FI%TURES-PFR'1 RAP
EI 1 have and will m arn.in Workers Cnntpenwlion Inmmnee•:s myuired by Seclion
TlWnfthe Labor Coi far the Wrfu.anwofthc work bawhkh lhi,permit lso,ued, CAS-IiA.SYSTCM I INCA j�rtliiiIs.I!'R \' G C .R(IUP -APN�
My Weri�.rx„�yyn , yyyw{�yricif
untl Policy no be,um: Z�
Cartel: /il/ Palley No.: GAS-1:A.SYSTEM-
CERTIFICATE OP EXEMI'IION FROM WORKERS'
compRNSATION INSURANCE! GRF.ASi91' STRI.WA !INTI!11CP'I BUILDING DIVISION ITES
(The,semionneed notberomp[eeld fthepcmtil isfntne hinlreddollan(SIIM) GRHASETR
nr less.)sort ify that In tPLANCHECK FIiE
he lmrfurmvnea nxll
flhe work fur which lhiv permit is issneA,lhuSHINFIt-SANT -S'r EA.211f1 PF.
not employ any pemmt in any manner m ata m become,uh)ecl I,the Will Compen- IlNI!ItCY PEEZ# 7_1
Z 'alien Luw,nr Califaniu.Date WATER HEATER !MF/PLECRZ APPlicant s GRADING FEE
NOTICe 1O APPLICANT:If,aftef mAingthis Cettificaue of Exemption,you should WxIFRSYSTFMGR ATIN
heatme mhjcct mthe WnrAcrx Compensminn mavisinnsof the Lnnor Cslc,you mwt SOILS FEB
IDnllwith comply witll,al provkitini or this permit shall he deemed revoked WA'I'IiR SP.RVICEUPI
CONSTRUCTION I,ENDINGAGENCV NEW RIiSIDEN'IIAI.I'hMB. SQ.FT I'A J17)10 I herebyalGnnthatthere saconstaretianlending agency Iia theperformance of Date
F the work far xt
'hich his pernil is iod(Sec.JIM)],Civ.C.)
O V1<nders NnmcI'O'I'AL: is
I<nJcr'x AJArc„ _ TGT f
H 1 c,lify bad I havc,,ad 11.. atal:PI Elul,
be I ' f :I. s _ IIlI11,DINGPiI
h torte t [agee[geeI c ply wilh 11 uy- d Alonaliondia..c,und,oll. IIt Ig e' QTY "MECIIANICALPERMIT El8
LJ s2 huilJ tgc aunt.nn, nJ huchy amhnnm reps,cowl vcs of lb sery toenmr upon the SI71SM .FE
above nmntioned progeny for inspection purposes. ITRMIT ISSUANCL
IWcl agree to rase,indemnify and keep Imnnlemthe Cityof Cupertino.'an't �V ELF F
Ilabililie.s,judgments,cme'and expenses which may inaly way asaueaginnolsaid City ALI'I!R OR ADD TO MECH,
In Can
'..tacos of the gli"t of to,perntil. I'LUMB O TB?
APPLICANT UNDHRS'I'ANDS AND WILL COMPLY WI'1'11 ALL NON-POINT A1R HANDLING UN1'r(r010,(X11
SOU�f);ERIECANTIONS, 1 CI'MJ r MECHA CALPBH
J/�,I Q/519V AIR HANDLINGUNI'r(OVER I),$)(ICEIM) CONSTRU. ION'I'A%
Sign/tenure s/clot ppliaenl/Conlmmnl 0 Title Z E%HAUSTHOOD(WIDUCT) HOUSING MI 'A'1'ION FEE
1[AZAR DOUS. 'BRIA I4 FISCLOSIIIU?
Will the applicant or While building occupant stare or handle bazaNam mmcnal 1117.A'I'ING UNIT('10 1(10,11001iIU) -
os defetl by the Caperlino Municipal CtWe.Chapter 9.12,and the Haolm unJ Satiny
Cods,
SSection 25532(0)1 HEW ING UNIT(OVER I W,Bf10 R'I'll)
❑yesI PAID -
I VIlNFILXTION FAN(SINGLE.RESIDE Uma Reccipl p
Will the u!"Pent Ill It Il ldin'occnpunt um equipment or device.swhich pOlhlil<-COMP(JIfl-OR I1111,000 ItV)
nil hueantaux air commul!nanre as defined by the Bay Aicu An Quality MamagenseW
Disuiml
❑Yes B0tI1,FR-COMP(OVER I00.000131U) -
I Erase randthe h ll onswourl, y ' t.ander Clingier 695 ofde Cl AIR CONDITIONER ^ISSl1ANCfi DATE
font I Itl &41 I Code S f :25505 25519 J 2,5534 1 :vnJ liffli f tam NEW RLSIDEN'I AL MACH. SQ.FI'. •-Q 9
baud' d:w IIILL a 1,Lot,Ia ty napt,56nyI,mullhe a, .. I 4
arm eyl:ireancn. mel ba mel priorm issaanaara cerlmcaln nrouapaney,
nT amhorieed agent Fare T ISSUED BY. v ✓`� /� 1 - ®
OFFICE
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