S 2952APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF,r.UPERTINO BUILDING -F.LF.C'DUCAL
llIEDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
IIUII.DING PROJECT IDENTIFICATION .
- PERMITNO.
BUILDING ADDRESS:
SANITARY NO.
A PLICATIG 'U M 9 , DATE
Z2�os- SAL4M All&c�,Q
OWNER'S NAME: PHONE:
PVL¢T I
COW5#CTOB'S NAME: LIC NO:
/S ,5"o5-7 7S `�
N/C
❑
C091ROLor
.RCHITECr/ENGINEER:NsJ)ZlooOu L Ti �/
CCffJJ__�I r
ADD 1. �� NOS of L?b
C/U-•V•
CON'T'ACT PHONE:
BUILDING PERMIT INFO
ebw w�lal 901111?7rcr9
❑ Consultant Pees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
6- Fos;/ 1;V
LICENSED CONTRACTOR'S DECLANAI ION
1 hereby ramp mat 1 an, licensed node, pmvidoas ofChnpter9 (cnnnord Ing
QTY. ELECTRIC PERMIT FEF.
JOB DESCRIPTION
TERM IT ISS DANCE
wish Section 701 Division 3 of Business and Pouf ,ions �C.o(�de,andmy l items, is
in lull force and affect. 577 U / ! p
RESIDENTIAL: ,-,".�
ElSFDWL Ey tCHEN REMODEL
APPLIANCES-RESIDENTIAL
License C'l%� i.ic.#
� Clrach' g nl fJRj/«f'I LCIb
Dale nn
[]ADDITION [I PLUMBING NI: -PIPE
❑STRUCTURAL
MODIFICATION
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT 0SWIMM INC, POOLS
ARCHITECT'S DECLARATION❑MUCfI-UNIT
1 understand my plan. shall he used as pnbiic records
PANELS
UPT0200AMPS
Licensed pree"ionnl
201-I000AMPS
OWNER -BUILDER DECLARATION
1 money ft that I pt f m C l I lu L for the
folly 6 to (Section 7031 .5, 6 eand P fewilan, CI y ly county
❑ BATH REMODEVREPAIR ❑DEMGI.TI'IGN
El OTHER
OVER IOIq AMPS
SIGNS ELECTRICAL
wbi h 9 Per." I n.t t It 1 daredp Y muurc
SPECIAL CIRCDIT/MISC.
priorto itsIssuance, also 1ites the applicantfor such pc d in fl :-g .ttcmenf
math Ice:edpinu u 0 p 'on fm C t our (Chapter9
(cot g will, Sect 7000) fp iso t ffl B ss d f .' :Cuior
1 EMP ME7P.R OR POLE INS' 1'.
C
tlnl h - pt Weref d Ih h :ic r th II 6 d xe y 'olle of
0�1� LDG/A �ITION DEMOLITION
Secllon 7n31.5 by any appl lel tforttpermilsuhjeelsll plm marnll Penalty of
POWER DEVICES
JJJJJJ FOODSERVICE
not marc than five hundred dollar ($5(10).
MPNOVF;MIiNT
LaSownerofthepm'i IY employec5 wages as heir sole cnnpinaminn,
wtll Jo the work, and thostmem isnointended nr dfor aie(Sce. 7(kl4.Business
ail I f o Cod, TM1 C t t L 1 d o lapply t owns- d
SWIMMING POOL ELECTRIC
❑OTHER
Q
OUTLETS-SWITCHESFIX URFS
property wh holds ' p them., d h kl If through
his ply p ' thin h p I' of t f Ecrcd for
wale 11 Iawcu.r, the be ld'n a mpns enl s't thin y f plctinn.lbe
NEW RESIDENTIAL. 9L9C fit SQ Pp.
SQ. EL FLOOR AREA
S/SQ. EP.
have the v'mg math in not build mimpravc for puo-
pueo-huilderwill
5eofsalnJ.
I, as owner of the property am exdu'uely contracting with licenced mmrunnn w
TOIA
instruct the project (Svc, 9fW, Brain and Pmfeccinm Gxle:) The Conwenr'S Li-
-PLUMBINGPERMIT
.el.awdoesnrnappgmnnowns,ofn pasty whohmid—rimpmna, theme, and
QTY.FEE
who contracts for such Into with a eommtlorfs) berated parsenal to the Canmatt
PERMIT ISSUANCE
License Lou,.
❑ I am exempt under See. ,B& P C for this reason
Data
WORKER'5 COMPENSATION DECLARATION
ALTER -DRAIN & VENT -WATER (EA)
VALUATION
/t
e9
BACK FLAW PROUIGT DEVICE
1 hereby I fin, order mally of po Jury one of the following declarations:
a
DRAINS -FLOOR, ROOF AREA, GOND.
❑ I created will mrinumbaCereficem of Consu,no salfmoum for Worker'.SCompcn-
station, e, provided for by Section 3704 of the Labor Code, for the performance of the
work for which this permit is issued.
STORIS
2_-
TYPE CONSTBUCI'ION
��
FIXTURES -PER FRAP
❑ I have and rill maintain A9orko's Compensation Rosman., as rcquireA by Smtion
3900uf the Labor Cade, fonhe venfermtmceofth, work l'orwhich this, ... ur isr,mad.
GAS-EA.SYS'1'EM-I PsC.40U'U_FpS
OCC GROUP
ARN
My Worker's Compensation ➢reaping carrier and Policy number Eire.
Carrier: Policy Na.:
CERTIFICATE OI' EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE,
6'2
GAS -EA. SYSTEM-OVER4 (BA)
CB1iASFANDIISTRL WASTE INTERCEPTOR
- BUILDING DIVISION PF:BS
(This section nceJ not he completed if mepennit isformic hundred dollar, ($100)
or less.)
GR9ASP. TRAP
PLANCI IECK EEE
I cenify lhal in l he pe,fnnnonce or the work to, which W'nperutkis ned, Imall
not employ may person' yamener so us,t bµµff�m y�ecnn the Workers' Compcn.
SEWER -SANITARY -STORM EA. 200 [It
ENERGY ITE
WATER HEATER WNENT/ELEC'1'R
GRADING ITE
ammo Lowsof Ccliften >at Y ��7' / /
Applicant ` /Y IV [%170
NOTICE 10 APPLICANT: IL afte, nmking this Con,ofcate of Exemplion, you should
heunnn subject m the Workers Copp ....on pmvisione or Jan Labor Cole, you must
WA'PER SYSTEMITICA1'ING
SOILS FEE
WATER SERVICE
forthwiffi On ywithwehpmvisions or tho,surea,hull hadaamalnvoked.
CONST RUC' 1ION LENDING AGENCY
I hereby alfion dial here is o construction lending agency forthe performance of
NEW RESIDENTIAL PLMB. SQ, F.
PAID
m 41F RN,,ipl®
-
me work for which mos permit is is,wed gap. 3097, Civ. C.)
. me
LenderNa
'
LI.enders Names
'1'0'1' O
'I'QI'AL:
,
BUILDING '
I certify thou l have mad this application and state that the above lnfornatu n is
-
rect. I agree m comply with all sty and county ordinances and state laws rmming m
bulldinga,neVualine, and lmreby aellmnsempmsenudivesofed, airy mmnterupon he___
QTY. MECHANICAL PERMIT FEE
I -
-
F
SE I S M IC °
PERMIT ISSUANCE.
PEE
above-mt red ptmpnnyfoo inspection purposes.
(e e agree o anve, indemnify and keep Ironies, the City of Emperor. againstELF-GYRI
ALTER OR ADD TO OECD,
PLUMBIN( IIiE
Ilahilitie ,j dgmm�ts,cosdand expemes which may in any way outside run, us, aidCity
the gaming of Wis parmil.
PLIC AND WILL COMPLY WITf{ALL NON -POINT'
SOUItCI 0,A1'IONS.
SOUR I Ce .Al IONS.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANIC LFEE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONST RUC' I ION' FAX
Slgnmurc ofApplican ar Uran
HAZARDOUS MATERIALS DISCLOSURE
HAZARDOUS
EXHAUSTHOOD IW/DUCT)
HOUSING MITIGATION FEE
IIEA'TING UNIT TO W,II(NI BLU)
Will Tho applicants Ian
hulling nmupnnscore nand
Muni Ie I trot and Story
m defined io We 32(a)? nu Municipal Gide Cbapn, 9.12, and the Ileahh and Sol'ety
Code, Section 25592(x)^
HEAT] NO UNIT (OVER 100,0011 U'IV)
E] Yes 19 No
VENTI LATION FAN (SINGLE RES ID)
PAID
--
Orta Rcceipt k
BOILER - COMP(3HP ORIndust)HTfA
,he applicantorfuture buildingdecnptnl use scuipren o,daOuN which
u..,dons air eomeminants e, defined by the Bay Area Air Quality Management,
TOTAL:
BOILER -COMP (OVER 100,000 BTU)
Dixnicf.'
E] Yes L:I No
FF"
i
AIR CONDR IONER
Ih Adm h N t Is rey l- Clr pt rfi95 1'thc Cal'-
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ, FT
fnni a He h & Solely C de Saner, 25505 25533 d 2504.understand that f the
build I , Iyh I I bar tl yy++yy��.l Idayt ffyd occupant
-� �
ill''
of lLerc ten winch nwa M1e m suanw aria Cen'feme of (kntpnncy.
Y
l
ISSUED BY:
!
Owner nr rmmoriud agem Date
OFFICE
Qpn
APR 1 9 1999
`uO•CNSPECTION pEp
A
n OFCUPEPTNRTMENT
APPROVED
IN ACCORDANCE WITH THE CITY
CUPERTINO CODES AND ORDINAN(
DATEI.
_L
SIGNED
This se_rw n �h®=i c
sat,in,dnsit 6i
o ma'E1,6�; or aleraOFFICE uU�n utt
ame rnth; t v
:he bwdn,"' "
;nF
The slampmgcl ah: a,,,
SHALL NO, be t : _, net ati
a: he
approval of the v1";W,n of ;., pa.vjsi
'
An, C,t, 0 d nance or Stptr, f aw
K.IrcHEw -�EMooEI_ ALT rAAIER RES IPEnfct
Z2(v06' MEM AVE Cufearfnb CA gsoIq
o"