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cool ICANT Tn FI I IN INGnRMATIDN WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL,
BUILDING DIVISION APPLICATIONFPERMIT PLUMBING - MF,CIIANICAL
BUILDING PROJECT IDIiMI' FICATION
PELW TT NO, 1262
BUILDING ADDRILl . /
�� �1 jl
$ANI'1'AItY NO.
AI'I'A'�N SUBMITTAL DAI'li
OWN�� fIONE: OQ
CON ACD/R'SNA E: LI
NIC
❑
CONTROL,#
$'704i
Q^
_O'� 1 i�+O
AR' OCT'/ENG 'A3R: CFlu NO
ADDRESS:L
tw�a MY� ��6t
CONTACT: PHONE:
DtHLDING PERMIT INFO
G/�,_. AnA _ \ _ _ ` /1 p.Q
❑ Consultant Fes Paid by Applicant (Initial)
II.CC'I' PLUMB MFCH
" y-/�Nrj(/` -Z"
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NP ❑
QTY ELECTRIC PERMIT FEE
LICENSED CONT'RACTOR'S DECIARATION
I hereby affirm that 1 am isenved ander provision. of Chamer 9 (commencing
JOB BSCRIPTION
PERMISSUANC17
IT'
with Section 9fAn) of Dlvi,mr3 of the lm,iness sna Profe,sions Code, and my beers, is
in full fnrcwmJ olreut.
RESIDENTIAL,
❑ SPDWI. ❑ Ell CIIIiN kEMOUTA.
APPLIANCES - REMIXING [A].
Liccn.e Class Lo#
Date Contractor
❑ADDI'T'ION [_1 PLUMBING RE -PIPE.
❑MUI.TLUNI'T ❑STRUCTURAL
MODIFICATION
El INH El CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITECTS DECL.ARNOON
1 understand my plans..hall be used as public reeoN.
PANELS
UPLO 200AMPS
hlccned Prof,load -
201.10nAMPS
OWNER -BUILDER DECLARAIDN
hat I am evemp, Brm the Cmumer's License Low for the
1 hereby affimt tm
fallowing reams. (Section 7031.5. Braises and Professions Code: Any city m county
❑HATH RCMODEIJREI'Alk El DEMOLITION
❑OTHER
OVER IINNIAMPs
SIGNS ELECBIGV.
which reopdre, a pemdt nasus mct. altar, improve, dmmtBsh, m renw, any structure
SPECIAL CIRCUI'IVMISC,
Prior I, it, kourrs.ol.o,evtdoes the aFphcam fm.ael.I"ouit to filen signed aamntent
dta, he i, fiecnsut pummmno he privi ions of mecommvams License Low (ChOal, 9
(commencing with Section 7000)ofDi,kinn Sof me Rn,inessand l'rnfessions Code)or
TEMP. MFJTR OR POIE INST.
COMMERCIAL:
that he is exempt therefrom and the hasis for the alleged exemption. Any violation of
❑ NEW BLDGIADDI'HON ❑ DEMOLITION
Section 7031.5bya.y applies., for a Pcmm,ubjem, ntc.,licamma civil pecan, of
na nuae than five hundreA ddIa,1($500).
I, acouncrol the prclpuny, or my enminyeas wish wegosus theirsnW cnl,tpensmion,
will do Tho work, and,hs,Vactam , net intended lir offend fm sale (Set. 7044, 11usinens
POW17;R DEVICES
NANT ❑ FOOD SERVICE
IN PkOVEMP,NT
❑ O'IHER
SWIMMNG POOL ELECTRIC
and Ihnfeecinro Code: Hot Coun sots License Law due, not apply m rat owner of
OUTI.I: S -S HCHUN-19XTURDS
property who builds or improves thereon, and who docs such work hintmlf or through
hit own employees, provided that such improvements arc not intended or offered for
sale, if hnwevec mebu'dding olimpnounnot i,,.Id within oneyear of cnrmlcfiom lira
NEW BE 'NTIAL EIEC`fR SQ FI'.
SQ. FL FLOOR AREA
$/SQ.FT.
tinviner-Imilder will have the burden oIproving that build not build lir Intpmve for pur-
Fposy„selene
owner of ,he #ropes,, am e¢lu.ively commcting wish IimnuJ mmmc,on m
TOTAL:
���'�9ajjll''
uel the project (Sec. 7H4. Business and Profession, Cale) The Contractor, Li-
soLaw docs mmapplytoanowner ofproperty who builds orimprove, mention, and
QTY. PLUMBING IF FEE
whocanback. for Inch I diems with a cvm"act ... IlcanseJPnva I,, the Commeon.,
PERM,F ISS NCI?
License Lt.
❑1 m cmpt under see. .B& P C for this reason
O n^„
AL'IIiR IN&VENT-WNF12R(EA)
VALUATION
12�'Op0e�
WOR KERS COM PE NS ATION DECI.ARATTON
RACK FLAW IiCrF DEVICE
I hereby afGmperjury one under penalty of perjuone o, the following dcclnmtions:
DRAINS -FLOOR.O('AREA, GOND'
move and will mainmina CuriDenleor Consem.tstf-l.... c for Worker's Compen-
salon, m provided for by Section 37X1 of ,he labra Cale, for the ped insane of me
weak rot which,his lrenni, is issued,
S'I ORIES
g
TYPE CONSTRUC'T'ION
I ^CIO
FIX'I'OR ES - PERT'RAP
❑ I have and will nwinmin Worker's Compensation mutases, as ,.fruit by Semen
37111 or Tho Labb, Cody. forme pe,fm.mouvof the work or which mix Fe r it is Issued.
C T�
GAS- EA. SYS'T'EM. I INC. 40 'LIT:
OCC GROUP APN
My Worker's Compenwtion Insurance carrier and Policy number arc:
Cartier: Put, No.:
GAS -EA. SYS'IAbb OVP.R 4 (EA)
GREASEIINDU$TRI, WASTE INTERCEPTOR
CER'T'IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
(' [VISION IT13S
(1Ink,eceionmulndhe con tiled if he pemti, is I, chundred Jullars($IW)
or le".)
GRIIASETRAP
PRF,
I certify shat in lheperfmmarecol the work mrwhich thispermi, is i,wed, Im.11
not employ any person in any manner so as to become subjen to the Workeri Comryn-
SEWER -SANITARY -STORM P. 2W FF.
sT
WATER HEATER WNEFUDELECTR
'
m,inn Laws of California. Date
Applicant
t NO[ CH DO APPLICANT: If, after ranking this Cmtilicam of P.sentptiun, you xhomil
bevomc auhjea m the Workers Compensation but the Labor Code, you must
WNI'F IR SYSTEMII'R APING
foMwith comply withsuch provision on his permit stall he deemed revoked.
WAIER SERVICE.CONSTRUCI]DN
n
LENDING AGENCY
Ihumby affirm thm stem isuumxtmmion lenJinguganey rot the Perfnnnanceofam
ReceiptI
NLWRESIDENTIALI'LMH. SQ. IT.
the work rnr which thispermit is Is,nu1(See. 3n97, Civ. C.)Lender', Name
AddmsTOTALI certify Nat 1 have read thisapplicaionand stem that the above information ie
'I'O'fAL:Lendds
Eranter.I
QTY. MSCI IANICAL. PERMIT FEF.d
l
agre,ta,mply with all city xndenmy Imllnerces and state lawerelaingtn
hereby authorize mpresenmtivcs nl'Joked, m anter apo. drat
PERMrI ISSUANCE
ELECTRIC FEE
abovementioned property lbs inspection purposes.
less the City of Cunino against
and keep rmpa
(We) agree ,o ,ave, indemnifyha
AIT ER OR ADD TO MECE.
PLUMPING 1'EE mon
liabilities,judgments, costs and espenses which may in any way acerae against said City
in .sequence of the gmming of this permit.
AIR HANDLING IINI'1'(1010,0110 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULAT'IUNS.
MECHANICAL. I'F:F.
AIR HANDLING UNI 'I'(OVER 1I,000 CITM)
CONSTRUC'I'[ON TAX
Signature of ApplicardCommmor Date
HAZARDOUS MAT17.RIALS DISCLOSURE.
EXHAUST HOOD I WIDUCT)
I BUSING SO I'IGATLON FIAT
HUNTING UNIT(10 IIghOW BTU)
Will lbo.ppllcamlir future htilding'mcupant smmor haadlen"folous mae,ial
as defined by the CuPv'rtlno Municipal Code, Chapter 9.12, and the Ilcnnh and Safety
Calc, Section 25532(x)?
HHAJ INC, UNIT (OVER 100,0101t l UI
VENTILATION PAN (SINGLE RP_SLD)
❑Yes ❑No
PAID
Dare Receipt#
BOILER -COMP (311P OR ID0,11(1011T11)
-
i Will the applicam a future handing oceupam as. emnipmem tar devices wblch
emit ha endrus air road brad, os defined by the lay Arca Air Quality Munagmmm�
O I
P011.13N-cUMP (OVER 100,000 1311,J)
Di ins'?
E] y,' 0 N
M
AIR CONDITIONER
I have read the hazardous neamials requirement., under Chapter 6.95 of the Calm
ISSUANCE DATE.
NEW RESIDENTIAL ME'CH. SQ. IT.
ronin Health & Safety Code, Sections 25505, 25595 and 25534. 1 understand the, it the
building doesnot cuncndy nave. m m.ma,t my I.I....Utility mmmryme occupant
rJ
7� 3 0 r` �JCJId
M the reyuiremenw which most be mgt #filo r m is came. of a Cenifie.te tf (kcunamy.
ISSUED ITV:
TOTAL
Owneror amhmized agent Date
OFFICE