S 1801 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.E.LECTRICA, I'Ii IT NO 1801
BUILDING DIVISION APP'LICA'TION/PERMIT PLUMBING-51EC'HANICAL
BUILDING PROJECT IDEN'TIF'ICATION
I1l1II,DING ADORES. I SANT"I'ARY NO, APPLICA'1'l(�:V SUB IPI'AI`DATIi
�(p�69 b S%�i/�NS < S I? 11 , 7 ///� 741 D?
oy ee O E; 4r COusAC.I R.. A a � LIC NO:
(�( \w ,K. L®.A/4�7 CGS- C NIC CO/N�TROhp
ARCHITECUIiNGINEER: LIC NO: ADDRESS: ❑ 4gQrL,5
CONTACT PHONE: EUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECII
< — / ❑ 21, ❑ G�
LICENSEDCONTRACI'QR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereh,afdnn had 1 nm tine d andLr nrnvhdnna or ch,mla 9 am,n,lemh'a JOB DESCRIPTION
DMZ thSectinn 2.NN))of DivisiunJof the Bo6ricsrunJPrnfession.a Caie.anderylicensc Ls RESIDENTIAL'
X00 xi �J'7y PERMIT ISSl1ANCF.
FU~ Lfiall kcmc Cle„nJ cf�.V-ZZv hicp '7/ Z- • ` �� ❑SFDWL ❑KITCHEN REMODEL
U APPLIANCES-RF.SIDEN'UAL ❑ADDITION ❑PLUMBING RE PIPE
HQLDate Gnolremo.
CHrrIiLTS UEL'LARADON ❑MULTI-UNI T ❑STRUC'ICATK.
Z ODLA
',0 K I under.. III my Plans hall he used us publie«costc PANELS MODIFICATION
CZ—,0 UI"TO 2WAMPS ❑IN'lERIOR El CHIMNEY REPAIR
F-4Fke Licened Profesi...I 201d000AMRS IMPROVEMENT C]SWIMMING POOLS
W. OWNER-BUILDER DECLARATION OVER I(XNIAMI'S ❑HA'TI{REMODEWRIiPAIR ❑DEMGLITIDN
C I hereby nllimt dem Iran exempt Gam the Cnntrue mr'a Liceme I.uw lotthe
Mu C 6 U following reason.(Section 2N 1.5.Basincss and Profczeinns Calc:Any city mutual, SIGNS ELECTRICAL ❑OTHER
N il O which requires a wood to construct,alter,improve,demolish,or repair any stmcmre
pnnnnits issuunre.v2n�Inirenlho applicant lar Bach permiun filensignal xhncnlcm SPI3CIALCIRCUIT/MISC.
fly
that he is licensed pursuant pexisiors ofthe Cmnrac.or's License Las(Chafer9
Colidusitiluxu—
WMMC) (enminencingwith See.inn70 ),,fEivision3ofthe Rusinessandl ,)fessions Cale)or "TEMP-METER OR POLE INS"r.
W c .hal hu is exempt therefroat airline basis fur the Arad cramp.ind Any vh,hdion of ❑NEW BLDNADDITION ❑DEMOLITION
x � Section 90315 by troy applicant far.penninxahjwM lhcappllcanu.a,A 1penuhy of POWER DEVICIiS yy• El TENANT CFOOD SERVICE
W..m not roam Oast five hundred dollars(E500).
F Z P IMPROVEMENT
6 ❑ Lasownernflhe protany,or my employees with wages as their sale con,wasmum, SWIMMING POOL ELECT C
Q wall do the work,and tha..dunumi.not intended or uttered tarsal,(SOL, Bueinaaa El OTHER
3 m and Professions Codc*11a,Commemrs License Low does no.apply Loan owner of OUTLETS-SWI'rc -FIX'G1RF.S
property who builds or improves thereon,and who does such work himself or through 0
hist own cmpinyeea,provided that ouch Intprovementa am nut imendcd or offered for NEW RESIDENrI 1 < SQ UL
sale.If.however,the building orintprovemen.is sold within one year ofcnmpletion,the SQ.FI',FLOOR AREA $/SQ.FI'.
owner-builder will have the burden of pfnving that he did not build or improve her pur-
i, p G
r0
E] L ns owner or the pmpcny,ant exclusively contracting with licensed examine,
.cu rra the project(See.201,1,Ravir Las and Profeasime,Cale:)The Con.....is s I.i- -
aeLawdoesnenapplymanownerOfpropertywhobuildsorimprovesthereon.met Q'N.. PL.UMBINGP FEE
whit eon¢ana for such p Jeanwitha omma,Oup)licensed pm,a,n1to the Canoncmr'a
Licence Law. PERMIT ISSUANCE
❑ I am exempt nnder Spa. .B&P C for this mason
Owner Dole AI:I'2R-OI<AIN&VIiNf-WA'I'T?R(EAI VALUATION
•
WORKER'S COMPENSATION DECLARATION BACK FLAW PRETECE.DEVICE
I hacby Illlinn under penAy of parJnry one al the following declarations:
❑I have and will munwin a Cerlidicaleul Consent to self-insure fnr Worker's Cnanpen. DRAINS-VLOOR.I EARHA,CONE. STORIES TYPE CONST RUCTION
cation,as parOded for by Section 3200 of the Lahm Cale,for the porfnmtance of the
work In,which this panni,is issued. FIX'TURFS-I'. TRA'
❑ I Lane and will mainmin Worker's Compunsa.ion Ia,mmm,n.required by Section
3200ofthe Laro Cad,fnr.hetarfnamanccof the work forwhidt his pLanal is k,pad, GAS-EA.S TEM-II 1'r TS .GROUP APN
My Worker's Cnmtamation Insurance canter and Policy number are:
Carrion Policy No.: GAS-P.A.SYSTEM-OVER 4(17
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASEANDUSTR1,WASTE INfERCIi R
NUtLDING DIV[ ION DIiFS
('I7tis satins neLJ no.ce ctmgilemd it thepemtin is fnnnre huMrad Anllors($1110) —-
--"—
mlesn) GREASE.'I'RAI' PLAN UK',
I cemify that in.he tartom,ance nfthe wnrkf xhlch this permit is awad.I Shall SIiWER-SANOTARY-S'FORM IiA.2001 FT
no.employ any TO tin any manna was eco crapiec.In len Wnrkers'Compnn- ENER THE $?, #0
zZ sunioh Law (CIiiaa {� WAI ER HF.AI'IiR W/VIiNTlE1.I1CTR
Q Applicam Of I r 0 GRADING Flipale
h
NOTICE TO APPLICANT:It,.ftc.making this Cenilica c of Excramum,you should WN1 ER SYSTENIUREATING SOBS FEE
hes,..n.n.hlau n,the Workers Cangwnsndon pmvisio Out fl a Luhnr Code.you mos.
fanhwith comply wbharch pron.dure,mda,paint shall hl decmedrevoked. WA'I ER SERVICE
a o -9-9 OS is
CONSTRUCr1ONwains INdingaeCY NEW NF.SIDIiNf1A1.('LMB, SQ.PI'. PAID
U� Thereby offnn that there isuconnruc.innlendingngenvy for the tarfirmtnncc of Uum Hcaipp
.Its — be weak far which this permit its issued(Scc.3092,Civ,C.)
I"I Lender's NameTOTAL: 20ys
U Llndcr's Address 'TOTAL:
1 unnify that 1 nave mad this application and state that the above information is BUILDING THY /77.00
to correct.I agree to comply with all city and county ordinuncesmtd state laws relating to ('-y. MECHANICAL.PERMIT FEE
V Z building consume 0.a hemby mnhorize a'eprcsenmtivcs nl'this city m Lane.uponlhc SINSMICP 2,
above-ohnsioned Fantasy far inspection purposes. PERMIT ISSUANCE p
We)agree m save,indemnify and keep haemes.the City of Calamine against ELF.(TRI .li 7 I, riQ
liuhll mics,j•Wgmanl,are1,end expenses which may In any way name against art City AIT 2R OR AT)])TO M ITCH,
in asequence of Ne granting of this permit. PLUMBING tai
APPLICA T UNDERSTANDS AND WILL COMPLY WITH ALL NON-POI 'T AIR HANDLING UNIT(To II) M CPM)
SOURCE MECIIANICAh tEID
AIR IIAN DLI NO ON['I'(OVER I(),oa CPM) CONS'I'RUCf1ON AX
Signature nl AppEc.11d"oRono EXI IAUST BUILD O ''GON PEE HOUSING MI
IIAZAGISMATERIALSDISCLOSUILE of
Willthe applicmn nr fumm hnikh_wcupam store or handlehurardou.v material HEATING UNIT TO 201,000 B I'U)
as appeal by the CuNnino Municipal Codc.Chapter 9.12,and the Health and Safety
Crxlc,Salina 25532W)l HEATING UNIT(OVIiR]WELL)RTU)
❑Yen MA
No VENTILATION PAN(SINGLE RESID) PAID
No
Dam Receipt If
Will the appbnmdarfmam h definedbytheant BayA a AirQnlor Acviceswhent BOILER-COMP(311I'OR IT0,OWBTU)
enill Lumrdous air commninana as Ju6nLd by the 13hy Area Air Quality Mentrgcnrenn L
District?
❑VCs ANn BOILER-COMP(OVER 100.000 BTU(
1 have mad the havaNnus materials taluircnutns under Chapter fi 95 of the Cali- AIR CON DI'HONER
ISSUANCE DATE
(..in Health&Safety Calc,Spelions 25525,25533 and 25534.1 understand that if the NEW RESIDENITIAL MECH. SQ.lel'. 6
building mn0yhavcatennnt.Ihnt i.Lc my resltoncihility to nodfyA nc nn. �-- -7 - 71% -7 _ Q
nf,he rc9 - nwhicnmunbCntcI prinnn issumccofaceniftcmeol( apa1e
Owner roan m TAL: ISSf IIiD HV:
OFFICE