S 1287 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.CCECfRIGM, PEISn'NO. ����
BUILDING DIVISION APPLICATION/1'ERMI'P PLUMBING-MECIIANIOAI,
IIUIIAING PIIOAHCT IDIN'TIFICATION: "•t o ! f
BUILDING ADDRESS: SANIdARYNO. APPLICATION SUBMITTAL DATE
1 9 'LS
OW R'SNAMP_' - PHONE: ['pppNIP CI OR'SNAMIi: LIC NO:
t G /ern WG CONI'I2oLp
I Kr 1't{ t0 f•
lARCHI'IECTai NGNEER: LIC NI: ADDRESS: ,
f. r— �r Y L,C.�) S S , w Irl /bd
CONTACT: PRONE: • ILDINGPER
VIII p f.. ' MITINFO
' "
{ ❑ Consultant Fees Paid by Applicant(Initial)r '` •
BLDG ELECT PLUMB tF.cx
1 � r7k.�of1 . �
1.1NSED CONI KACfOR S DI CIARQTY Ar10N
PLECTKIC.PERMIT, '.-A'E'
Ih by n mall 1 : I 1 P : rum )(' s •, . ]OB DESCRIPTIO
o�Z d Section]000) fDoi+rn3o1Inela d11 hes',c,Coqdh,acd ryl is RESIDENTIAL:
F�� iv full lima Irff.m I'll.�d { I'LRMII'ISWANCf
y).. `�., _ ❑SPDWI. [D KITCHEN ItIiMODEf.
�UU Liccnsc Chis Lich APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE PIPE
G 1 Dat, Gmnaemr
ARCIII'IEC[S'DI!CLARn'I'ION ❑muun-UNIT ❑STRUCCURAI.
Z O N Z I undri,na my plmn ited bu axed as pabf,r,caNx PANELS MODIPICATLON
OZ�z UP 10200 AMPS f]INTERIOR C1 CHIMNEY REPAIR
<cnFa 1.iccmnl l'mfcssianel 201-I01JnnMPS IMPROVEMENT E]SWIMMING POOLS
OWNHR-ItIIILHHR DECLARATION OVER 000 AMPS El PAT RfiMODIi1JRF.l'AIR DEMOLITION
C
WW 1 herebyuHfir that I dn,exempt form the Cmaraemr's Licence Lew for the
W3 Cs F following Peson.(Section 1113 L5.Business and Professions Code:Any city or county SIGNS ELECTRICAL (y1HF.R
y which requ m: penota.commull,at,i.pm,e.demolish. m an, micance-
prior to itsissuance. q :th apmf' tf hl II fl I., Jane nett SPI.CI AL Cl RCUI'1'7M ISC.
IvvIyy� '�
bar licensed pars n II prv'sm : f,hCarl...an I ease Law(Chapter9
ad QC (comm...mgwilhliccl aT100)ofDivisionSofthe Busineesand Potassium,Cold or TEMP.MIi'CIiN OR Pf _2INST. COMMERCIAL:
. ca 'bet he is exempt therefrom and the basis for the alleged exemption.Any vhdalcm ul ❑NEW IILDG/ADDH ION -ErISEMOLITION
"N Suceon]OSI SbY anY applicunl linapermit suhjecu the aPPli,nnt n,;,civil lwnnity al POWER DEVICE" t]1'ENANI' ❑FOOD SERVICE
.f�.�Z 0ia ❑mancene
1II' h I Il : 5500
' IMPROVE
ECCkIC'. fthe p pent Y ply ll b:a:their npn:l n, SWIMMING ' )I,E
will) Ih k dN .l l t mnJd [f dt,:I (b 91k4,B
Ng- mdP fs, Core:The C t in,L I I Allyl msec or OUT f. -SWITCHES Iq%TURIN
pn,,ly 1 6 lds o p s❑ t t d who ders such work himself or through
his 0.11 ro"I"yers,providdoiffiet such im,reavernspe,are not intended or offered for NEW6S
IDI3NI'IAI ELFC'!'R SQ 12 -
ecle.IE however,the building or.imprecmenu,,.Id within one year,)unnpldinm the SQ. . '.IX)R AREA YSQ.Fn
n,rbuildef will have the burden of proving that lie did ant build or Improve forpur-
p e of sled. -�
0 I,as owner of the property, in exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.WMA,desires and Professions Coale:)Me Contractors Li- .: - F, ..
oro law coos not apply lr an owner of Progeny who hnilJs,.r hnpnwec in-coo,cod QTY. yPLIJVHING PERMIT `. 'I ,FEE
why contracts it.sudt pnjenx with a cna,", o')I wrosed princemnr
o the Gmemr4
Lirenee L:,w PERMIT ISSUANCE
0 I an exempt under See. ,0&1'C for this meson
- ALI ER—DRAIN ds VENT—WAq'17Rd A) VALUATION
. owner nam �1
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI'F.C.DEVICE.
s I hereby aRr under Penalty of perjury one of the following declarations: V
❑IM1ave and will mvinmina CeniOeme of CnnsemmnelGlnsure for Wnrket's Gmtp,o- DRAINS—FI.00R,ROOF,ARIiA,CONO. STORIES "fYPECON51'kU"c"r,
,.cion.ae provided Ino by Section 3700.1 he lata,Code.fur the perhnmunec of the
work for which his peon is issued. FI%TURIN-PF.R TRAP
❑ 1 hove and will maintain Workers Compensation Insurance,as required by Section
3900 of the labor Csdc,for the performance of the work fm It Jlhia r ilio sated, OAS—En,SYSTEM-1 INC:4OUD .'S OCC.GROUP APN
My Work Cut mora t INurynCe cauen;md Polley im u Q _ GAS—EA.SYSTEM OVER 4(' )
.arir ` Policy No. Q.^
; N fIITCATIi OI'FVEM ION FH OR RS ,V L
�� N INSURANCE GREASIilINDUSTRI.WAS" :BIT IiRCEPfOR
�.Q,MClIVP{ - BUILDING DTVI§ION FEIiS
IIMs s,x:eonominrlMnnnp aid "Ihepennit is cur one M1unNxA dnllna(51011) GR13AS13'TRAP -
nr le',) PLANCHECK FEE
I certifyt het price)erfurmanccubewrrk forwhich lhispemat izicwed,l shall SEWER—SANI'r Y—STORM I:A.2W IT.
sol employ any Person in any counties so as v,become subject to the Worker'Cnminn- ENERGY IEE P
OZ soom To ..fCalifomia.Date WATER HEA' JR WIVIdG/ElJ_'C1k
O Applicam - GRADING IIIE
hould
.N. NOli,mil1'U nl'PLICnMf:II;alwr ranking this Coni❑cmc a[lixempliun,you s WAI ER S YfEVicRHATINO SOILS Fl
become eubjcel lr the Wakets Compensation paremens of the Latin Code,you mull cii
fonhwith comply with such provisions or this am,hall be deemed revoked. WAIT: 101iCE
ap
CONSIRUMION LENUINGAGENCY N' RCSIUBN'1'IA1,1'LMN. SQ.P[ PAID r,JTY ur GUrtHIIIV
`7z Ihereb firm chat there is a construction lending c for the Blnmmce of Date Receipt#
U O rat .C.) ro
'he work Rn which Nia permit is izmeJ(Set.3(97.Cie CJ
{L, Lder
en 's Name DOTAL
U Lenders Address 'JOTAL:
>' ki I eenify th:n I have read this application and nae chance above infmwtion is .t f _ BUILDING FEE
VJ correct.lagree to cram with all city and coamy ordinances and arae lows relu0nsm QTY. 'MLCIIANICAI,PERMIT ' FF, .
U ,z banding eonsnunio a herby aulhori'r,rcpmenwlivcs errthiv city a,emar upon the
'f' sl?ISMIC P1313
ske oe entioncJ ,pe yfor n.speetinn pure.... PERMI'TISSUANCF.
(Wel ago to. indemmfy and keep hamdes Ne City of Cuperim against
[hECI'kIC PER
is Iiuhilitics,jndgt cols esu and expenses xhicM1 may in any way accfve againa nail City ALTER OR ADD'10 METH.
0
nsequcnc of a granting of this peril. PLUMBING FEE
AI'PLICAN I ERS'TANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNI'T('I'O N),000CFM)
MECHANICALFRE
SOU :B G LATIONR.
�� AIR HANDLING UNI'f(OVER HOW ) CONS'1'NUCI'IDN'I'AX
rat of APPllcanl/G ntmrr ❑vm E%HAUSTHOOD(WIDUCTI HOUSING MITIGA'HON IEE
HAZARDOUS MXIERIALS DISCLOSURE
Will[lie applicant orfumre building aceupam stns or handle hazarJrm material HEAPING UNIT(101Up,000 'll)
as defined by the Capeelno Municipal Calc.Chapter 9J2.and the Ileahh and Snflly
Code,Section 255321x)! HEATING UNIT(OVER TW)BTU)
Yes No
r' U VEN'HLA'I'ION EA :INGLEIIESID) PAID Dulc gremlinM
Will the applicant or future building occupant use equipment or devices which
.it hazardous air cuntaminums as defined by the(fay Area Air Quality Meagnnenl TOILER—CO (311P OR HXyflf0 BTU) r0'1'AL.
Dlsni,t" BOILER—C MP(OVER 100,000 DRI)
Yrs ❑No
I have read use hvrmdous radical......coarce,ander Chimer 6.95 of the Cull- AIR CO )ITIONER ISSUANCE DATE
facia Health A,Safe,Code,Smlonx 25505,25533 cord 25514.1 uadersumd that if Nc Nli RESIDI3N31AI.MI!CII. SQ,PT.
a "'Itingdocs na canently ha,ca nam,shot it is my responsibility to notify the ecrupinl
of the reyuimmens which conn h con prior to i�suanee of a Cenifieme of Oca,ryncy.
Owner or radm iced agent Durn TO'PAL: ISSUED BY:
OFFICE