S 1813 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-P.LECI'RICAT. "S"
No. 1813
BUILDING DIVISION APPLICATION/PERMIT' PLUMING-MECHANICAL v`
lit)I LDING PROJECT IDEN'n FICA'1'I ON
WILDING ADDRESS,. - SAN'IT'ARY NO. A I'PIACAI'[ON SURM I 17 L DAD:
//-/3
O IiR:S NAMTi: PHONE: CUNI'RA rOkM LIC NO'.
y (, NIC CONfROLp
A RCIII'I ECT/ENC, 1!1!R: LIC T: O ADM: 7f�J 11CONfAM. IIONNE: BUILDING PER h11T INFO
►^ �-6 '19 3 3e(� ❑ ConxRlten[Fec:['aid by Applicant(Initial) SLUG Cl' PLUMB CII
I.ICIiNSIiD CON'I'RACrOR'S DECLARATION Q'I'Y. ELECTRIC PERMIT FEE
III... JOB U SCRIPTION
xl)inn That am licen¢A under Drovisinm of Chnpnr 9lttnnn¢ncing
O a Z with Serum.70otol'Iy icotq of the l moos,and Prafesinm C ole.and my license is RESIDENTIAL:
CZ
/ PERMI"I'ISSUANCIi
C WU— nfu lfotec unA eftee. � `j �J I)� (i ❑SFUWh ❑ �N REMODI!1.
QUU I,iccnsc CL sN LiC'N / AI'I'LIANCIiS-RIiSID1iNTIAh ❑AUUI1'I(1N PLUMBING RIiPIPIi
FZW Uulu Cnotmctur
VIQtl• ❑MUMi-UNIT' CSTRUCTURAI.
ARCIII'I'E<:'r'S UECI.ARA'TION
~A z I nnJ"'o,al n; I rill be u,,,]r, 11 J PANELS MODIIlCAf1ON
OZ-- YPunsxnt put lc recurs Ill"IO2IXIAMI'S
❑IN'fINVER ❑CHIMNEY REPAIR
NA W Liceonl Prcicxsinn;d 211-I000AMPS IMPROVEMENT ❑SWIMMING POOLS
ION
OWNER"BUILDIiR DELAI
CUM
y.Y OVER IIN)U AN"S ❑BA'lll RIiMOOIiIJRIiPA1R DEMOLITION
C C Q I hemby intim n Ile I ant vent,tram the Contract( 1 Icenxe Law I'nr Ihe
Iaa�13 W UU folketio.n....I (Scctlnn 9).115LBminso,and Professions Ctdc Any cityarcounty SIGNS ELECTRICAL ❑Ofllhlt
sloth rgdres it In coo..rum;tiler,improve,demolish,or repair any on cone
F x'06 priorR,ilninwenco.alsorequires the upplicam fonuch permit to Eleasigncd slammem SPECIALCIRCUITIMISC.
�PtnY� thct he is licensed punuannn the provision of the Contractor License law(Claper9
W X00 (comntcncing with Section 70001 of Division 3 of the Business and Pmfccsions Cde)or 'IEEE MTrI'Iik OR I'OL NST. COMMERCIAL
a 1 e C that he is evennpl therefrom and the basis for the alleged evcmpbon.Any violation of ❑NEW 1 LGL/ADDITION ❑DEMOLITION
X Section 9(131.5 by any applicant for u permit subjects the applicant to a civil Penalty of POW[! 1: CES ❑TENANT' ❑FOOD SERVICE
not mote than five hundred dollars(5510). IMPROVEMENT
~Za ❑Laz oxer of the property.or mYanployees with wages as mcir sole ttnnpensainn, SW'IMMIN( .ELECTRIC
willdotnework.andihesuacmm is not itnendedorolfered for sale(Sec.9(1W,Busineu 001
F_-
13 w and p ntessiotu Cole The Contractor's License Low does not apply m an owner of OURErs SW 'If ES-FD(TUR
property whit builds or improves thcmon,and who does such work himself or through
his own employee..provided that such improvements are not intended or oBered for NEW :SIULNrIAL 'C''
sale.IL howevep the building or improvement is sold within one yearof Vniplction.Ihe . T.11,11.00\\R��AR'I 3 'I(� p T
Cir-builds,will l:we the harden of proving that he did not build or in-prove for put- NO V 1 k7 IJ O
prase of safe.).
❑ I,aN owner al the property,not eveluovely contracting with Ilcenwd convectors it)
TAL:
ms mit[lie project(See.9(94.Business and Professions Cade:)I It Cnnlral-r'N I-
�Lttwdaes nolapply it,on,owner of progeny who builds or improve%thereon.and QTY. PI,UMBING PERMIT I°F.E By
who contracts lltr>ach projects with a reauructonx)licensed pursuant m the Cnntmcmry
License Law. PI3RMI'f TSSUANCIi
on exempt touter Se:. .It&I'C for this rcamo
AEI E.R-DRAIN&VENT'-WATER(CA) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK PLOW PROIISC1 DEVICE
I hereby ultilan under[renal tyof P'lu. one of the follow ingdeclumfionN:
�Ihuvu and will nwimain nCuollicum of u
Cnnnenu Ndf-insure(or Worker's GmtPm DRAINS-FLOOR.ROOF AREA,GOND. STORIES 'TVPI!CONS LHUCI'[ON
salion,as provided lot by Scallion 3900 of the lahor Code.for he perfommncc nl tche
w 1 h
r far which this pered,ixlsmed. PI%'IURIiS-I'IiR TRAP
ave and will maintain Worker's Compen.Nation Insurance.as required by Section lEEi
390 India laMn GNe.lbnhe pvrtontrataccofthe work for whirl this permit is issued. GAS—HA.SYSTEM-1 INC.4 OUTLETS 'C GRODUMIN
My Worker's nmpensau nlonurnce carrier and Palicynum GAS-HA.SYSTEM-OVER4U:A)
Camcr. l'nlicy
C iRl'IhIC OM ET ISATI N INN PROM WORKERS GRI:ASI:IINDUS'IRE.WASTE INTERCEPTOR
COMI'I:NSATIONINSURANCF: BUIT.)ING DIVISION ITIS _
(Pit,action need not be cnmplelN if the petmh is for one hundred dollars(5110) GREASE 1RAI'
or less.) I'LANCHECK 191i
I certify that in the pedonnance ofthe work for which this petmil is issued,I shall SEWER-SANI'T'ARY-STORM EA.200 F,
not andoy any Person in any intoner sit so,totceome subject to the Workers'Carapace. ENERGY FEE
Z sdiro lasnnf Cvlinia.hnDate WA'T'13R I IEAHIR W'IVEfTLECI'R KJ GRADING IIiE
z O Applicant
NOTICE TO API'LICANI':If,after making this Cenificu lc of Event tion.You shouldWAT IiH SVS'ILM/I'RIiN'ING
a ? become subject to Ihe W,,rkce,Cnpenn:ninn provisions of the Labs Code,you moot SOILS ITE
W ... ondwimrvs''tmi
contply with such pnns nthispert shall MJcencA revnAed. W'AI'I!R SERVICE
PAID
CONSterms❑'cION onstruction
AGENCY N13W RESIDENTIAL PLATE. SQ,FT. Date Receipt#
UO lot d,Ir him,clht iivu...I(Sri.on l7. gency for the performance it I .{
the work Int which him,cont is issued(Sri.91x)].Cr,civ.C.) N
haltdtt�N:;;lte TarAL VZ, 'Drrnl.:
r LU {1
tI Lenders Addeo. w
D. 1 eroily thus I nave read This upl'Iialion and sem that the above ofonominn is
111.DIN(1 IlilC
'
iFi U1 corren.l agre,l oplY with all city and county ordinances Doti smfc laws rdmingm QTY. MECHANICAL PERMIT FEE SHISMIC I71Hl3
U bu'dmnp eon.00r,ion,and lereny anlendlertnra]anmfivtN ofmixtons to enter uponlite
F' an uve..nemie...I pn.peny tm'tnxpeevon rutpoles. PIRMI'1'ISSUANCE pLECI RIC laAi
(Wc)n"ce m rove,itdenmly and keep hamdess the City of Cupcnina agnino
Ii,deldics.)udglncnl.. .....and cs,,otx which may in any way accrue agmn.0 said City ALTER OR ADD TO MECH. PLUMBING hili
in uaptenee of the granting of this permit.
APPLICANT UNDEHS'I'ANOS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT TO IUdMO CFM) MECHANICAL ITE
SOURCE REGULA'I IONS,
AIR HANDLING UNIT(OVER IR000CEAI) CONS TRUCIION TAX
Signature of AppliontfComractor Date VX14AUSF HOPED(W'/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future tmilding excupaat store or trundle haradoasmaterial BEAT NG UNI T'IT O 100.000 BTU)
it,defined by the Cupertino Municipal Roc.Chapter 9.12.and the[health and Safety HT!A'I'ING UNIT(OVIiH I(X).( BTU)
Cole,Section 255320)'t
(]Yea Fl No VI!NI'l1.AOON FAN ISI I.fi R.MD) INIO�
ate Receipt#
e Will the applicant o future bidding occupant enc equipment or devices which yl11LIiR-COMP[ VOR PUptoo BTU)
nlil h:¢uNeux air cunwminams as defined by the Boy Area Air Quality Management TOTAL:
Oiurill' BOILIiN-CO '(OVER Bo.olto BIG)
❑Yes Fl No
Ihavenad the hvunloolnmmn:dNrcDin Lv trach,Chute 695 of deCall. AIR C(L 'HONER ISSU NCED E
h II ),III &Safety Clyar Suction¢255115,255)3 and 25534.1 undcrnnnul ohmic the NEW Ilf:SlUI3N'fIAl.Ml3ClI. SQ.lefl
nnilmnq Jo anal con Toth blow mm�anLthat it Lsmyre"noutelify to nobly fluocurano
ul lbs 'Rich ural be lnel(prior t,,tortoise nfu Ccilic e It Orr lir
Owner,,unthonred ogenf D le 'BYfAI.: ISSUED ITV.
OFFICE