S 2179 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO NUMBINGING-MECH MECHANICAL PEI{�1""° 2179
BUILDING DIVISION APPLICATIONMERMIT DING,PROJECTID NI ITIC <V
BUILDING,PROJECT Im:N'rnacnTlON
BUILDING ADDRESS: SANITARY NO. API'LICAI'[ON SUBMI'TIAL DATE
'110DR &of-S AVE,- /l 9
OWNERSNAME �I ���f"' CO RACrOR"N 0 _ IA I^NN�:/J NIC CONTROL a
*?-
R LIC LICNOO` AUDRI_SS:„ (w/ANYMI Ave, [� ❑
cp"Tncr PHONE:- ozkim1I VV Ave,
BUILDING PERMITINFO
❑ Consultant Fees Paid by Applicant(Initial) HLDG ELECT' I'l MECCH
LICENSED•COvrRACI )R'S DECLARATION QTY ELECTRIC PERMIT PFF.
I hereby alum that 1 attt licensed ander provisions of Chapter 4 anmmenrinx JOB DESCRIPTION
{O�OZO with Section 900blif lv,kaon Sof the Bmiumsond Professions Code.and my license is PERMIT ISSUANCE, RESIDENTIAL:
F tall llaceand eRec Z ' + OShDWL OKLI'CHENRIiMOPEL
�UU License Chtss Lice APPLIANCES-RESIDEN'1'[A], E:1 ADDITION ❑PLUMBINGRI:PIPE
rF Q,L Date Contranor
S.7y RCHITECTS DF.CLARAfION PANELS ❑MULTI-UNI'1' ❑STRUCTURAL.
Z O'"Z I understand my plans shall be nsnl as public maandx MODIFICATION
OZ4^O UP TO 2s)AMPS ❑IN'IPRIOR OCHIMNEY REPAIR
�F'W Ucemsal Prnfcssinnal 2I1-I0MNIAMPS IMPROVEMENT 0SWIMMING POOLS
OWNER BUILDER DECLARATION
Q 1 hereby amrm that am exempt from oM1e Contractors License Law for the OVER IOX)AMPS C1 BATH REMODELJREPAR 0 DI?MOTLIION
aU following hansom.(Section 7031.5.Business and Professions Coo Any city or county SIGNS ELECTRICAL. ❑OPHL'
1+13 W in wtreb requites a permit ut camurct,aper,improve,der bah.or repair any.wnure 77
Ip"�OQ prior In its issuunee,also requires the...Incur f..aanp urn ou fileasigned,,oammem SPECIAL CIRCUTUMISC.
that he is licensed pursuant to the pnrvl.innsofthe Cunlraaur's License Low(Chtmter9
ID 00 (commencing with Section 9000)of Division 3 of the Business and Professions Cade)nr 'IEMIR Mlil FR OR POLE INST. COMME
d a oC Section
he is exempt emit and be basis boron,alleged aen,ti n.Any violntion of El NEW BLDG/ADDITION El DEMOLITION
Iy�
I LL Sinn 9031. cansubjects e applicant 5 by any applicant for a permit bjects thlio a civil penally of POWER DEVICES []TENANT OPOOD SERVICE
y
yZy tot mum tone Five the prrcd Am lasye NIL
{ OQ o Las owner uflhe ptrpcny,mmy nnufankswith wages astheir emc n+mpumAinn, SWIMMING POOL ELECTRIC O/1. IMPROVEMENT
MIiNT
.' wdl du the work,and the emmmmis nal intended onilTemlfur sale(Sec.?IIJ4,liusiness 'Cl ❑OTIIRR
1 y 3 m and Prnfcssions Coda:The Contractor's License Law docs nor apply to an owner of OUTLR'1'S-SWITCHES-PIXTUI295
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements aha not intended or offered for NEW RESIDENTIAL ELEC;R SQ Ef.
sale.It,ho,cor,the buildingor impmvcmntt is sold within arc year ofentnpletion,the SQ.FT.FLOOR AREA $/s Q.ET.
ter-builder will hove the burden of pawing that he did not build or impmvc for Pur-
,use nl'.ule.).
❑ 1,toowner or Joe property,am rad.,ively commcl'mg w'nm
b licensed contraccsm T(Y L
consumer the pru,eo(Sec.7000,Business and Professions Cod,Bbe Contmnnrss ri-
nseLaw does nor apply toanownerm'property who builds.,impmveslhonto,and QTY. PLUMBING PERMIT FEE
whocnnonmm for such pmjoets with a ennmmrous)licensed ptrsuanuothe Cu beemr's
License Low, PERM jr,
ISSUANCEs SQ
ElI ant cxcmpt under See. ,B&P C In,this reason
Dirac, Dam ALTER-DRAIN&VIiN T-WATER IRA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE � 3
1p I hereby afro under penalty of perjury one of the following dalarmlons: - O
❑ I have and will moition u Certificamnl Consent lnall-irvwlre far W..km,Cuntpery DRAINS-FLOOR,InARP ,CON
O
,minutes provided fns by Salicin 3700 of the Labor Code,for the M,fit arrant mo S'10111135 'I'YI'13 CONS'I'IIUC'110N
work for whim this permit is issued. FIXTURES-PER TRAP
45rl have and will maintain Workers,Compensation Insurance,as required by Section
I nfthe labor Code,lir the performance of the work for which this permit isisued. GAS-EA.SYSTEM-II 3 OCC.GROUP APN
My Wmkcr'gCqmpa1tilinl and Policy mon;bar.: GAS-IiA.SYS'fEM-OVEk4(13A)
Corrin': 1i1��/^la1� ,Policy Nn:.Jh
CER1 II9CATE OF EXEMPTION FROM WORKERS'
GOMPriNSALRN INSURANCE GREASI'INDUSTRI.W "I'. NTF I:PTQ
BUILDINGDIVISION FEIS
(This section need not be completed item pemtit is for one hundred dollars(SIM) GREASLTRAli
it,less.) PLANCHEC "13 Z
I certify that in the performance of the work forwhich(his permit is issued,l shallf
not employ any pe„nn inanymonner som In necomesuhjannthe Waders'Contpnt- SEWEN-9ANrrAI2Y-5'1'ORM RA.21X1 T' ENI31tO I I9.
Zz mficn laws of Culi9rmin.Umc WATER HEATER WNI3N'fllil.GCTR
O Applicant GRAD
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER S YSTF,M/IREATING O
become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FF.
forthwith comply with such provisions or mice permit shall be deemed revoked. WAT17R SERVICE
l Q
CONSTRUCT ION LI3NDING A(L13NCY N9W RESI)F.NTIAL I'LNR. SQ.IT
U O Dam ken to
1 hereby aeon thoa there is sued(Sm.3(1 Lending agency fonhe perfnwmce of f
the work for which this pemtit is issue)(Sm.3(19'1,Civ.C) TI
u" 1-'' Lenders,Name T Y AL�
L) Lnmcr'n'Address 'I'f1T
RWi I ecrofy that 1 have read Lha appluntion and sem that eeabnve information is til hDING p1313
iF. to correct.I agme to comply with all city and county nminmmes and some laws rdeing to QTY MECHANICAL PERMIT FE i--
U Z building construction,and hereby tolume,mpresemativesafthiscitym enter uponthc S ISMIC FEE O
shove mentioned property for inspection purposes. PF.RMI'1'ISSUANCE
(We)agree to save,indemnify and keep harmless me City of Cr Krtino againa .9 TfRIC FEE
liubllhics,jud menta,aoms:md cspcnses whish may in any way ommo in,;, tsaid City ALTER()It ADD TO MP,CI 1. 1'IMBINGIni
/ O
squcn fthc gof this pcnnit. . li 12-
APPI .,\NT ' S',NDS ANTI WILL.COMPLY WITH L )N-POINT AIR HANDLING UNIT(-O 1O,(MNICFM)
SOL' MI3C NICAI.hili
111 qV AIR HANDLING UNIT(OVER I0,Wt)CFM) CONSTR CION'I'AX
Si t mem Dam EXHA UST 11001)(W/DUC'11)
Ij IIALARDOUS MA's. IALS DISCLOSUR (LOUSING MITIGATION FEE
Will the applicant or future building occupant smhaorhandie haufdons material HEATING UNIT CIT , Mt BTIB
as defined by the Cuperino Municipal Code,Chapter 4)12.and the Heullh and Safety
Com.Suction 25539(a)'r HEATING UNIT(OV! 0)) )
E3 Yes1'AI II
VEN'IILA'I'ION PAN I' �.IiN' Dnte Receipt#
Will the applicant or furore building oc Giounl we colmlau tr or devices which
emit hazardous air contaminants m defined by the Buy Area Air Quality Management District?
13H1 I W, ll)
District? T A
�Yet, No BOILER-COMP(OVI IIp,000PTU)
AIRCONOI'DONER p
Ihavercadmchaa nsmam.... haquiremem under Chnprerfi95 tribe Coli- B ISSUANCE DATE
fomia Health&Safety CMI.Sections 25505,25533 and 25534.1 undesmnd the if me NEW RESIDENTIAL MliCH SQ.ET. / G. / /`
buildingdo es not cu endy bavc a tetmm.that if is my resprmsibilioy ons notify ohc«upant C
oflhsmqulmmemtswhichmasthemet pdmmismaceofaCettlimmcif Occupancy.
Owner or authorized ng em Dem *1OTAL: ISSUIEDBY: ✓ "' � " • T
OFFICE