S 2343 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'TINO BUILDING-ELEC1'R1 CAI, PERNU I'NO,
BUILDING DIVISION APPIACATIONIPERMIT PI-urHHNG-MEC,HANICL �]
I5GI LDING PIEOJECF IIIEN'I'I FICA][ON J
BUI.MING wrIiSS'. SANITARY N(1. APPLICADON SUBML'(-IAL DATE
of p UR��e Cit �rtmo cA 9so �y-' ��i
OW,,[ 5 NAME, I �O PHONE:� I - CON IHA EOR'S NAME: LIC NO:
V` fln, Or- /� ^y� /� NIC CON'IRIILp
^CIIITECI'/LNOINIiFW LICNO: 296/Ll�/IlAS / 'em�/� `�••9¢S39 ❑ O -
/eNn ��IVit
CONTACT. PHONE: BUILDING PERMrf INFO
G/eyq C¢ti (:;23.7B9t ❑ Consullanl Fees Paid by Applicant Qnilifd) BLDG LICI PLUMB MICH
LICENSED CONTRACTOR'S DECLARATION QTY. ELGCI'RIC I'L'RMFF FEE ItJ CJ Lrn`Y/
I thereby arena mm 1 at',fi.en.ad nmmt pmnislnm m C,na"e.9(e..mmea:ing ('�/� JOB DESCRIPTION
W 00 ZO with ScOm.70M)ofDivision 3oftheBosinessand Pmfeasiom CWavndmy belows PERMITISSUANCIS f / V RESIDENTIAL;
CIF- In full forccundrhr,,. ❑SFOWL 6 KITCHEN kEMODEL
QUO License Class Lic.N APPL.IANCCS-RESIDENTIAL *ADDITION [I PLUMBING RE-11111E
F L¢I Unto Contractor
vat Qy ❑MUI,TI.UNII' []STRUCTURAL
ARCI{O'IiCPS DIiCLARATI(1N
F'z I nnderatmd my plum.��ll h used ev public mmnp S M(IUIhICATION
OZrN— U1"1Y 11 I'S
XHER�
IOR ❑CHIMNEY RI?PAIR
1:�P]W Licenced Prutc,wional I-11 PS VEMENT (3SW[MMINGPOOL.S
OWNER-BUILDER DECLARRI']ON IiR MIL NEMODELIREPAIR []DEMOLITION
C C Q I hcrchy affirm that 1 ant cecmpt from Inc Contractors Licemc I nw for the
XO a FU- following reason.(Seetina 9011.5,Holmes,z I Rol'ecsinnn Code'.Any city or cuu'nY SIG .I,I 'HLT which re 't e,construct,am,improve,mlnmlish,or repair any Slmnure0� "i q 'k I h p(f.. If hl a tl .. g Ia ,Bel I: ALCI ) IISCE[5p„Ymal dP nua tit p s Ith L I I 1 La (Ch pter9 I -
�a�� (cmnumrnmg wnh Sono h"IIXNpnf D'v xiunInflhv Branca.md lmfsvionv Gdc)or TI:MP.MICI'E NIY)LEINST.
M S e C that he is esempl Ihcmfmnn and the basis or he alleged aanptinn.Any vlulminn ill ❑NE BhUGIADDTTION ❑UEMOLI'TION
X04- Section 9031.5 M1y any r,51am for a Inn il1-meet.Thu applicant n aeivil penally of P(1WFR Il 1 :P [I TENANT 0FOOD SERVICE
W rn al mmrc Than Five hundred dollar,(S510).
,ZO I.asownendthc n OTHER IV EMEN'1'
❑ property, ne ran,
ded or oacmc for
sol.enm.lmsaamq SN'IMMIN 1'HIC El
F will dutn,sion,Code:
Unt nummucto %License Law d( % o applyNice10 an. caner o • O
a3°�^° and coy wl nh cd.,4.r"contmeln a Livens.Law d«s no apply to l4. owner m ouru;Ts- cure-nxruREs
pmpuny whooyees.or sided that
t such apo who Joey m n tints deedhanor oreredf l
his own employees,pnrviJ.J ILm such impmvuwms em not intended lir offered for NIiW BESIDES'I'Al.11111i6i SQ Irl'.
sale ll:haw s.me huikling lir inhprn em iv Bald within oneycmofe ablmiun.the SQ.IT.ILOOH AREA S/SQ.19'.
ansmar-builder will have the burden of proving that he did nal M1uild lir improve Ibr pur-
$pmwnfstd..). (�q�•
dhd�,m owner at the pmpeny,,B ext ss and contracting will licensed contractor,ones
tinct the pn,iem(see.sal,Bnam.:.and rroresai fns cote)The commrn,rs u-
seLawAre.nm apply man awhhur of Property woo Huila.mringames mcrenn.and QTY. PLUMHING PERMIT PEC
who contracts for such projmd with v cc mrui licenwil pursuant Ire the Conarcmrs
Liecnsc Law. 1'IEIi MII'ISSIIANCIi
❑ I am ca.trtpt u der Sec. .B&P C Inr this mama
` ALTER-DRAIN&VENT-NATER(IiAI ^�VALUATION
owt - to U[�"I/
hL W(IRKEk'S COMI'ENSA'TION DEChARATION SACK FLOW 1'ROtliCT.DEVICE
XV
11 y affirm under penally of perjury,line of lire fllowing Jeclarullon.c.
1haveand will maintain aCenificatnof Consenttolelf-insure far Worker's Camper- DRAINS-FLOOR,ROOF.AREA.COND. STORK '1'YI'Ii CONSTRUCTION
scion,as poo iced for by Section 391X)of the Luhm Cale,fur the <,f ntr of the l O
work forwhlch this pemat is issued FIXTURES-PERTRAP L
C] I have and will maintain Worker's Clings elanion Invmranae,as required by Seelinn
3100ofthc LathanCode bombe performance of lie wild forxhichthispemtil is issued GAS-HA.SYSMEA-I INC.40UI'LEIT OCC.GROUP AI'N .�IT
My Wake,Cnmpvnsmlun lnvuruuce none,unit Pali.y number are CAS LIS'$YSTPHbI')NERA ' 3 //, I l -T
Currier: Policy N., 14l'/s//Ys (� 1
CI!R'Il19CAT11OPE%HMPII(1NFROMWORKICRS' UBE DUST S'B INTO' iPfOR
COMPENSAI'[ON INSURANCE tl TNG DIVISION FEES
(ILls section Bad not bccnniplcmA ifthe permit is formic treated dollar,(SIM) GHF RAI' � J l P ®�
or less.) PLANCIIFC til? -/
I certify that in the pertormance of the wart for which this fiction is issued.I shall r
nal cm In m become sub.cl lm lire Worker.'Coat 51" _S EN IiRGY ;E `
pram Iwnmh�m:hay mahm�r,n n. i pe'n-
,Z S:uionl,vwsof C.Iiknri,Drm WA MEATIER W/VENI'/EI. 'IR GRAM
Z Q Applicam
Z
NOTICE'I II AI'1'LIGNT:If,aRcr making min CeniOcam of F.xcmption,3nu ahoulJ µ S'I, TREATING S(11 I iii
bavnne xuljor Ire the Wadu's Counpensulion prnvisiuns ml the LuM,rCoda,you mull
� ,--, fonnwnh comply with such provisions or this permit shall be detailed revoked WATER SER
in PATI
7z CONSTRUCTION LENDING AGENCY NI2W RESIDIiMfIN,PLMI{, SQ.FT. Date Brecon
U O n:..cny:mmh:mill 11....is a.o umedna leading a,cac,blithe performance..
F-t the work ft whiehdas Nrtnil is o,aad(See.3099,Civ.C.)
O U Leaders Name St1
CP
IsnJer'.v Address lAl.. lit
r 0. 1 certify that 1 have read this application and stale that the shove information is BUII,UI l Flili Q a
FTA correct.I agree to congly with all city unit.a,.mynoinune.s:rd.staauw.ml:ling ,, QTY. MECHANICAL PERMIT FETE SEISMIC] I'
U Z building construction.and hereby numomc representatives of this city m enter upon the q i�
unavcmantiona i Pnq> 'y En Ia.pv..imm....""e, PERNH I'ISSIIANC17 . ELEM RIC L 3 v
(We)agree m save,indemnify and keep bamless the City rob Cupertino against �q
liubiliti...'.... awmpauso andc ,rmscs which may in any wry uecme against slid City ALTER OR ADD IO MECO{. PLOMB lit
In comailmenee of the'main of itis pemnit.
tAPPLICA -111NDEHS'IA DS AND WILT.GDAfPhY N'LTII ALL NON-1'OINI' NRfIANDLING UNIT RO 10,1)00 CPN) MEL'H, LFEIi Z 0'GLAfIONS, k. AIR HANDLING UNIT(OVIER 10.000 CFM) CONS�f . ION IAx
PPlicant2ontrumr me IixHAUST HUpU(WIDl1Cf) HOUSIN A11'1'LGA'1'IUN 1iB
IIAZAIi DOUS MA'L'I?WAIS nISCLf 1SUHIie applicant air l'murclwilAim6.........arc lir handle nvardnusmmenal , 1117A1'ING ON I'I'('101(11.1XX)1{'I'U)me Cup25532(0)? L_YNIIIIAI'ING UNITIUVER II1f1,IX)1191U)VENTILATION FAN(SINGLE RESID) PAID
nam Receipt a
Will the applicant or future building occupant use equipment or devices which If -COMP(3HPOR t0B000 BTU)
hI harurdoun air cnnmminants to de recd icy Ihn Itay Aruu Air Quuty M:tmmmncm O O
."whet? BOILER-COME'(OVER 100,000 BTU)
❑Yea ❑
I mvemajtlm he,;... nsmutmial mats mtdcrCh,pmrb.95obthe Cilli- AIRCONDI'I'IONI?k ISSUANCE DATE
fomia lI.allh&Safety Qak lions 50 3 and 25534.1 undemmnl that it the NEW RISIDENI AL MECH. SQ.FI'.
Sp m / ( `
haddun, nut un.uul�nvlaln Ij tI it,m,an,daitymnotby thc,ncupul
mfthe"tan menu , lhm I t.,ujavcculaccnl Pu�lf`'u
(/� (4.(p
Owncrnramhmrme 6cnl Ilam. A" ISSUED BY,
OFFICE 16