S 2821 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICAI, FERMI INO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL C 2821 Q�1
BUILDING PROJECT IDENTIFICATIONO O 1
BUILDING ADDRESS: SANITARYNO. APPLICATIONSUBMITTALDATR
,P0 3'7.') S ; I V Eye
O
NEWS
NAM17 ^^r•1� p ^ 1I /I 1-14 E: /�-��Gr`�r pNTRAC'IO/k'},/,NA�\1P.: LAIC^NO.
�111rtF. 1'1�1,.L" CJ� Vra 2`Um IN55 NIC CONI'R(11,#
ARCHITECT/ENGINIiER: LIC NO: "D"ppR SS: ❑
,y3// sutzkojEe D2.
CONTACT' PHONE: BUILDING PI7RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) IH,DG ELECT PLUMB NIECII
❑ ❑ !O ❑
LICENSED CONTRACIOR:S DECLARATION QTY. ELECTRIC PI7RMIT FEE
Z,
XZ
hereby sur to dial 1 at licensed unite,prov6ioes a[Cho 9let teen'^g JOB DESCRIPTION
WOO i^In Section)OgOofOivisiun 3 of NC Business and Proessions Code.and my license is PERMITISSUANCE RUIDENTIAI:
H U w full force and e0cct , ^�kq �r
G 3Lie
/so S S p ❑SFDWL ❑KITCHEN REM0DF
U Liccn>e last Lie#
iZzw Uac L Comnnnr N AI•I'LIANCP_S-RESIDEVI'IAL ❑AUUI'I'ION ❑PLUA1BING RE"PIPE.
ARCHITECTS DECLARAF'I)N ❑MULTI-UNIT [I STRUCTURAL
F to PANI!LS
z O y ZZ I undentond,ny plao,ball bea,,d ,,.h is records MODIFICATION
Oz4—a Up 10200AMI'S ❑IN'FFRIOR ❑CHIMNEYREPAIR
F�f'LL] h ccrmal Profcs.ionul 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARAI ION
E]SWIMMING,POOLS
C 6 I hereby affair that I um exempt from,he Contras.,',License Law lir the
OVER HXOAMPS (_1 BATH RHMODEUREPAIR C1 DEMOLITION
W 3 uta.H following,tomo.(Section 7031 5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL OOTHER
F_�-O h which requires a permit to consume,,other,improve.demolish,or repair any structureA'
No'i prior o its issuance.also requires the applicant for such peand to file a signed streamer SPECIAL Cl RCUIT/MISC.
,,]hithe is licenced prism I as he prnvisinn.of the Conrraem's License taw(Chapter 9 — ,/U
f+lap0 Irontnotion,wish Section 700)of Dickie 13 of he Business and Prami,onm Code)nr TEM P.MISTER OR POLE IN Sr, COMMERCIAL'
a� tout he is e-o"'themf o i and the Amis to the alleged exemption.Any violation of o� [I NEW BLDG/ADDITION ❑DI!AIOLITION
W^„Jy Suction 7031.56y tory upplieem loropcnnilsuhjerrs the applicunnoa civilprnal,y of POWIIR DIiVICES ❑TENANT ❑FOOD SERVICE
_> nm more than live hundre,l dallier,(S500).
FI 1,as owner of the propeny.or my employee%with wages as their sale s,mpensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F. rill do the work,and the structure is not intended or offered hostile(Sec.70 .Business ❑OTHER
2and Professions Codc,'Ibe Contractors TURES
s License law Js not apply to an owner of OUTLETS-SWITCH -FIX3 properly who builds or improves thereon,and who does.such work htr„wlf or through
his own employees,provided that such imprnvemmats am not intended or offered for NEW RESIDENTIAL ELLC!'R SQ ze
FT
sale.it:M1.we,it,thehnildingmimpmlreme,is.old within one year.)completion,'he SQ.IT.FLOOR AREA $/SQ.PI'.
huilder will uo,,lm l nNon nfproving that bedid nal hold m in l,00e for pur-
pucrsc of Xaic).
❑ I,as owner of the property,um exclmively contracting with GrvmeJ crmtrucurs to TOTAL:
mswe the pr jmI(Sec.THL Brains,and Profccsi.ns Code:)The Cout rsm4 Li-
ce,nelarvdoe,nulapply b,aaownsof prnpeny who builds.,improves lhemen.and QTY. PLUMBING PERMIT FEE
who mitran,for such projects with a contusions)IicenmJ punuam u,the U,mracher's
Liver,law. PERMIT ISSUANCE
lam exempt under See _.R&P C furthis mason
(IwALTER-DRAIN&VENT-WATER(EA) VALUATION
ner Dale
WORKERS COMPENSATION DECLARM ION RACK ROW PROTEC'1 DEVICE
I hereby affirm under penalty of perjury one of the Billowing Jeclatinmi¢
Ihaveand wilinainutin a Cenifir,heof Consent o self-insure for Worker's Cmml,cn- DRAINS-FLOOR.ROOF,ARITA,GOND. STORIES TYPE CONSTRUCTION
,lion,as pmvided for by Section 37W of the lda,abra Cufor the perfam nee.of'he
work for which this permit is issued. FIXTUREto
TRAP r V
❑I have and will mairu,ir Worker's Compenwtion Inwmnce,as"hired by Section
3700 of the labor Code.fir the Performance of the work for
Which his Feel is i.sned. GAS-I!A.SYSTEMTY.VCVeriTI'BI'F9--- —..-.I OCC.GROUP APN
Corn cs-=aUill �t].�yf nlgyfau/G rzicl'olay Nny�"�J_��� GAS-LA.SYi'I' (VEN4 ;11=\
CCN'1'IFICAI'E OP EXEMP HON FROM WORKERS'
COMPENSATION INSl1RANCL' GREASIIINDUS ASI'E IN I'ERCEPTOR BUILDING UIVISI(1N i13f:5
(Phis section used not IN completed it penin is for.nchundred dollars(Sind I APR
t __ _
nr les.) GREASETRAP I A R Q 19!)9 u 17
1 cenify,hat tothe per..hs,of the work for which this permit is issued.I shall PLANCIECK FEF.
nm employ any parson in any mvnnerw as w love nme sasses 1. he Workeri CompM
Curative- SEWER-SI Y-STORM F.A.200 FT. ENERGY FEE
OQ Applicant WATER IIT;ATE NT/ELECTR
2
z GRADING 19E
soon.Laws ofCalifornia.Done
ti NOTICE:TO APPIACAN'1'.lt:after making t his Ccnilicam of Event you shouldWA'1IiR SYS'I'IiM N
la,u e ,,bj,, ,,The Wader's Compcuation poo ion,T toe Lchor Code.'On hou.l SOILS FTSE
fnnhwiihcomply with such provisimts on his p,ainil shall he deemed mvnked. WA'I'Hk SERVICE
= z CONSTRUCTION LENDING AGENCY , NEW RESIDENTIAL PLMIL SQ.ET. PAID
U C) I herehyalBmuhm lbemisacon auenn lending agency for the perfnwnce of Dhe cei U
nR
L, F the work for which this pem,it is issued(See.3097.Co.C.)
UI<nders Name.
leader's Address T TOIAL:
y I certify that I have read this application and slaw That the above inrornulin i is D BUILDING ITH
(Zi corral l agree m comply with all city and rowdy mJhnmces and'aaw laws rodent,Two QTY. MECHANICAL PERMIT FEE
U ,Z aikloi' ai'mm,l.n,and humbyunlhoriu mp,w,, e,vcs ofThis lily to enter upon the SEISMIC ITE
„hill-doni.ned pmpcny sur ia.pecuon par
pores" PERMIT ISSUANCE
(We)
s,ju agree s.cove,indemnify and keep my i an the City or against said
City ELECTRIC Flili
liabilities,judgmenu.tour and expenses which may in any way acerae against sail City ALTER OR ADD TO MECH.
in
APPLICANT
NNegruntingS NisDWIL. PLUMBING IgiF;
APPLICANT UNDERSTANDS AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010.00I CFM)
k)URCE REGULATIONS. MECHANICAL IT
-69� AIR HANDLINGUNITIOVHR10,S)OCFM) GQNSTRUC'HDNTA
Signal real Applirunl/Cnntmclur Date UNHAUS'I'1 IOOD(W/DUCT) HOUSING MI'1'IGA'1'ION FEE
I IA/',AII0005 MATERIAL S DIS OSURP.
Will the applicant or future building occupant store or handle hazardous muwnal HEATING UNIT(TO 100.000 B U)
us defined by the CupeNna Municipal Code,Chapter 9.12,real Health and Safety
GWc,Section 25532ho? HEATING UNIT(OVER 100.00 BTU)
❑Yes No
VENTILATION FAN(SINGLE RESID) PAID
Will the applicant future building occupant use equipment or devices which Dan Receip a
hithvardomssurcmtonninums ns defined by Its Bay Area Air Quality Manage too BOILER-COMPOHPOR 0p0(X)BTU)
Dintn'd4 y'
(]yes OOILIiN-GDn1P(OVER IIXI.IXO❑TUI
I have read the M1arardous materials reyuirs,nnb under Chapter 695 of the Cali- Alk CON PIT IONER
Timis Heahh&Safety GJc.Seen...25505.25531 ad 25536,1 understand ISSUANCE DATEiaNif the NEW RESIDELTIAL,MECU SQ.IT
building on"
noL curmn,ly haveahenam,iha it ix my mnpmsibility to notify Nc«cupam W
f uimnL..w(tichm timet pnona is.uancc ora Cenifcatc of(kcupancy.
fusim,ratelsol agent -�nu TOTAL' Q
ISSUE[)BV',
OFFICE