S 2389 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECT RICA], PERMI lNO.
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECHANICAL. 3 VX J^ 2389
N/N /1 /N
BUILDING PROJECI'IDENI'IFICA'IFON J L
BUIhDINO AIIIIRiiSS:
2 gANTTARV N(l. API'LICAI'IUN SUBMITTAL PAI Ii
CU C
U NI!R'S NAME' PHONE CONTRA OH'S AMI?: Ld _( AI NO�
Q It/ e NIC CONTROL#
*tARCHI'ECT'ARRINEER: / — LI(,NO: ADDRESS# ❑ D
J!
BUILDING PJ;I1ExI1T INFO
y,5, ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELI PLIIMI MECU
�c -z A �
LICENSE[)at ICONTRACTORS DECLARATION of CON QTY ELEM RIC PIiRMIT FEii
1 hmony amml mat 1 ultt licensed ender nr,1,ixh,n,ar Chapter 9(.nu.eneing 70B DESCRIPTION
HOZ with Section 91x0)of Division 3 ofthe Business and Perecianc Cade,andmy license is RESIDFNTIAL�
�F,W-_ i.bull farce and ece(t� Z— / ^� 1'FRMIT ISSUANCB 1l1lCITCIifiN REMODGI.
UU cove Cluvs Lia# S/.�' j �SI'DWL
F'ZCo mon APPLIANCES m< tc ❑ADDITION El PLUMBING k61'[l'E
1„p ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
y O d my plans shall used ux public r.nals MODIFICATION
oz— UP TO 200 AMPS
F�F"W Ltcenxd PrtJesstonal ❑INTHRIOR El CHIMNEY REPAIR
2(11-IIXMIAMI'S IMPROVEMENT
OWNER-BUILDP,R IIHCLARATION El SWIMMING POOLS
CC I hereby nffrmmm I am exnupt from me Contractor's License Law So,the OVER 1000AMPS ❑Bad]]RF:M(lDE1lREl'Alk DIiMOLI'1'I(1N
04 U fallowing reason.(Section 9011.A Business and Profession,Gale:Any city or county
w Y3. y¢ which reyuircv a proud to Illusion.,ober.imph. repos SIGNS IiLFCI'NICAL ❑ODiIiR
r..ve,dnnnlisnr repoany.mann
F!e!jy-] print to its issuance.also wal the applicant for such venrinn file a signed,mmmord SPECInI.CIRCUIT/AMSC.
O�P"1y Q2that he is liuoscd puu .n
rsuann the pro,knonsaf the Cmnors Liconse Law(Charter v
n1-.00 (emnnumangwirh Section 9000oofIivi,lon 30 the Business and Pmfn,0m,Cock)nr 'IliMEMEPFRORPOLEINS'I'. COMMERCIAL'
that he i,exempt Iherefrom and the naris for the alleged exemption.Any viol it of 0 NEW BLDG/ADDITION D DEMOLITION
W..y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
t nwre than five hundred doilies($500), []TENANT
❑FOOD SERVICE.
Fb- ❑ Las nwncraf the propeny.mmym intended wlm wvgesasedei( et.mmpcnxmion. SWIMMING 1'fH)L IH.IiLTRIC OTHER IMPROVEMENT
F will Jnehewnrk,and'he,wContranot,License offered.dor,
ap , I,ms70T4,a1His'imvss UGTIII!R
3 and profession,Cm.:Use Conwdor's License Low Joav not apply u.un owner of OUT
!'I'S-SWI'IClips-FIX'IVRES
pmpeny who builds m improves Ihercnn,anti who ds such x,111 M1imalf a thrtsugh
his own employees,provided that such impmvcmentx ore not intended or offered for IW RESIDENTIAL EIAICTR SQ FT
sale,lL however,the baildingorimprovament is sold within one yearo(enmpletion,the SQ.FI'.FLOOR AREA $/SQ.Fr
ownechuilder will have the burden of proving That he did not build or improve far pur-
pose of sale.),
❑ 1,ns owner of the Pallet ata exclu.vively contracting with licensed contractor.nr 'r0'I'A O
oaama the project(See.9041,Business and professions Cale:)The Contractor's Li-
eeLaw due,not applymonawncraf,au,uy who boild,or improve,mere...,and QTY. PI, rPERMIT FEE
wM1n contracts for such projects with a conlacloos)licensed pursuant nr the Comradur's
License Law. PERMI'I'I CF.
❑ I air exempt ender See. ,it&P C for mi,marrn
OwnerALTER-DNA NT A'I ER(17A)Ilam JAI ION
WORKP.R'S COI'
MI!N$ATION D17 [ON RACK FLOWPROTH .D O
1 hereby affirm under penalty til'perjury one of me following declarations
O l have and will maintain aCerTificmc of Carocnuneelf-insure for Warkeis Compen- DRAINS-FLOOR,ROOK.AR ,COND.
satlon,ax provided for by Section 391X1 of the I,ahar Cade,for the Ecl...nnnec til Ili, S"TUR ES TYPE?CONST'RUC'TION
work for which thjs perosil is icwed. FIXTURES-PER TRAP
1 have and will maimoin Worker,Conlpensnnter I.....o c,it,required by Sedi,1n O
3900 of the Labor Code,for the ixrfonnerve of the work for which this perma ,,sued. OAS-EA.SYS'I IiM-I INC.4 OUTI.F"I'S (LCC.GROUP APN
My Work ',Com ensmion lnvumnce artierand Policygnum�Mj-ramd) /�
Carrier:{�Pnlicy Nn'/Q/6x7—%off GAS 17A.SYSTEM-OVER 4(FA)
CGRP IBCA'I'II(IP EXIIMPI'ION FROM WORKERS'
COMPENSAdION INSURANCE GREASE%INDUS'IRL WASTE INTERCEPTOR
(This section need not beenmpined if the permit is far oro hundred dollars($10)) BUILDING DIVISION FEES
ar less.) GREASE,RAI' — ---
I'LANCHECK FEE
Loy toy that an the Perany lmner son,
become soich ject thispermitisirsueglshall
an, SEWER-SANI"MEN-.
oat employ any#croon in any nwnnor nn ns la became xnhj.an alis Workers Compem STORM EA.2(X1 IT. I!NEROY FEE
z satins lawn,1l California.Dam
0 WATER IIfiATIHt WNIiNT/ELIiCTR
z O Applicant GRADING FEIi
N emple object
APPLICANT Lire NT.R;miennaking this Certifcmo ole a Labor
o d, ,,ashould
most WATER.SYSTI!M/I'REA'1'ING
a > heronit subject m Ilii Workers Compeer this provit shall
of she labor Cole.you mull SOILS PER
forthwith Lia Ponhwith comply with such provisions or this permit shall hx deemed revoked. WATER SERVICE
0. Q
7z CONSTRUCcIONLENDING AGENCY NEW RGSIDEN'I'IAL1'Lh1B. SQ.FE I'ND
L)0 Ifor by whificaffirm that there iatiamsnv.eion lending agency lbnne perlorm:ma of Da¢ Rettipt#
W HOm wutk far M1 thlx parmil i,Issunl(So..3097,Civ.C.)
Lenders Name
V TOTAL
W Ixnder's Address TO
I unify that I hur,c oud rots application and sane Ilial the above inl'omuninn is BUILDIN
` h comet.l agree lncomply with till city and county ordinances and state laws relztingm QTY. MECHANICALI'F.RMI'fdo 10
1) z building conuuction,and hereby authorize repmwmmiresofthm e
is city teruM pRlSI?IS Y� 0
above-tocneioned property for inspection purposes. PERMIT ISSUANCB
(We)agree to save,indemnify and keep mand,ss The Cie,of Crienin.agai.Ot IH,.CTkiC FEIi O
liabilitiev,judgmentx,costs and expenses which ntuy in ally way,cane against said City f
in coplarmnec'Ifmo immin flhin I AI,TP.R OR ADD'I'O MI!CH. 0
gn pond. I' C$el
APPLICANT UNDERSTANDS AND WILL COMPLY WITH DLI,NON-MINT ALR HANDLING UNIT(TO 10,000 CF
SOURCEREGULATIONS. MECUANICAI.PRE O
AIR HANDLING UNI'1'(OVER 10.0100 CFM) CONSIRUCfIONTAX
9ienumrc of ApplicaHAZARDO Date EXHALES HOOD(W/1)OC)
HAZARDOUS MATERIALS DISCLOSURE ON F.
Will the applicpm or furore building.,.Paul store or handle hazanlaus mamnal HEATING UNIT(TO 1((k(X)(1 B'I'G)
to,Julinel by the Cuproino MO Opul Code,Chapter 9.12,anti the Hellin and Sntory
Coln,Section 25532(.)9 HEATING UNIT(LIVER 100.000 BTU)
E]yes [I No
VI7N'I'lLAT10N AN(SINGI.Ii SC TD) I'all�
Will the applicam or fuw¢building..,of m me a �/ Uutc her #
IWJ g e a Air
Vacesennot BOILER-COMP QHP OR 1(X1,(1011 RTU)
emit hazardous air contaminants as delineA by the Puy Area Air Quality Management
Disu'id'f
F1 You, ❑No ROLLER-COMP(OVER 100,000 BTI# O
I have mad the hwmdoes ntmerials requirements under Cheposr 6,95 of the Cali- A I R CONDI'I'I ON ER
foram Health&Safety Cede,Sectio.25505,25533 and 25534.1 understand that if the ISSUANCE.DATE
building does out currently have a Roam,that it is my msrym.sibiliry to ..only the'Ve.pam NEW RESIDENTIAL.MECH. SQ.FL / D �_ � � ` � O
II me myulrtn
e ,nts whichmel must be #nosurnc
r to ise ul'u Coddler,of O,coptmcy. (/
Owner nr auth..nocu over' Date 'TOP L ISSUED BY:
OFFICE