S 0592 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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BUILDING-ELECTRICAL PIJITNO
CITY OF CUPERTINO mMECHANICAL 0592
BUILDING DIVISION APPLICATION/PERMIT , IUILDINo;PROJEE.IDENTIICAIION
BUILIIING ADDRESS: - - ;SAN[ RYNO. APPLICATION SUBM I1'$At,DATE
30
0 NE 'S NAME PHONE: CONIRACfORSNAML': LIC NO CON'fNOL�
6 -� SS 6 0
ARCHITECfIIiNGINIWR: _ LIC In, ADDRESS: / '
LZ`31 S.67iP•A-C'f//UN B S
CONTACT: PHONE BUILDING PERMIT INFO
5'6fpt,/CALZ 4�/1L�f..tiS ��� ❑ Consultant Fees Paid by Applicant(initial) It,li. - PLUMB MEE1
041"127—
LICENSED CONTRACTOR S�RATION / ` 1 t fI a"' t .
QTY. '( LCCTI2IC PCRMI'I', + I LE ) •/
I hereby firm that i am licensed orderp " f Chapter 9(con n no
JOB
DESCRIPTION
D�Q my license RESIDENTIAL
withSt t1 . vsonowune -
I'ERMI f ISSUANCE
n fullforceand efTecl - ❑SIDWI. ICfiF.N RIiMOIl1IL
U F' LiccnNc C I.tc.q
Q U APPLIANCES-RESIDIiNTiAI. ❑ADDIi'ION 1'LUhiBING RE PIPIT
F 7Q-W Date ConmuI _
RCIIITECT"SU A"PION ' PANELS El MULTI-UNIT [I STRUCTURAL
F 7 y MODIFICATION
zosonz
lundonotandmyplamidatilheueedas uhliclecnrds UP TO HO AMP'S
El INTERIOR ❑CHIMNEYREPAIR
�.� Liceo.ud Profcoinded - 201-10011 AMPS IMPROVEMENT EjSWIMMING POOLS
Q -a OWNER-BUILDER DECLARATION
C .! OVER 11100 AMPS C:1 RATE EIiMOD131JRE1'AIR El DIiM01.1'I'ION
W Q I hereby affirm that 1 am exempt from the Contractor's License Law for the ❑OTHER
O E U following rcusrm.(Satrion 70.31 S,Ilmincss and Professions Cade:Any city or county SIGNS ELECTRICAL
V3.WO ti which requires a permit to cmnwct,also improve,demolish,or repair any stmmurc _
FFCC prior to issuance,also rtquiresthe applicam for such portion to filensgnnlsmlement SPECIAL CIRCUIT/MISE.
2p�i Ihul hu is linnsal pumuum to the Drmvimans of the Contrunar's Liccnsc i.vw lCM1.p¢r9 ,
W�QO (commencing with Section 98111 of Divininn3 lithe❑ceincan and Pmfensions Code)or TEMP'.MBTER OR P01.13INST, COMMERCIAL
d o yy Nat he is commit thcmfmm and the basis for the alleged connotation.Any violation of ❑NEW BLDG/ADDIi'ION ❑IIIiMOLI'1'ION
iC m k, Seainn]Olt S by anY applicant lip a Ponnh subjects the applicant to a civil punnhy of POWER DEVICES ❑TENANT ❑FOOD SIiRVICP.
Fyy monntire than rise hundred dollars Wild. IMPROVENIRN'I'
C
11 1.as owner of the progeny,Or my employees with wages as their sole cmncreedinn, SWIM N7 ING POOL ELECTRIC
will do the work,and(he structure is not intended or offered liar sale(Sec.7044.Business El OTHER
and Professions Code:The Contr'actor's Licence Law does not apply to an owner Of OUTLETS-SWITCHES-FIXTURES
progeny who builds or intpmser thereon,and who does such work himself Or through
his own employees,provided that such improvements art not intended or o0tired for NEW RESIDENTIAL RLECIR S
sale.IL however,the building or lmponxncml is sold within one year of completion,I he
$Q.IT.FLOOR AREA SISQ-PI'.
ma iter-builder will have the burden of flowing that he did not build or improve for put- P
perof.mle.). TOTAL: A + D
n I,us m,m,.f the popeny,mn exclusively contracting with hcunscol,,aiIcemrs w
construct Chep I t(See 7044 B dP f Carl Th Cntmct 1 •,_ - - - '- r•
c W I Iapply t fprogeny h b'IJ. -improvesthere QTY. ) • !;PLUMBING W'Rh11T i' FEE/ ��JQ 'I
wb t t'f alpneell itha oamtrls)Iwn Ip tt (heCmnmctms - " - Y/w.L REC
Licenaelax. I PERMIT ISSUANCI. Tlas {I(�
Ej I am exempt under Sec. 13&P C for Ihic reason 1 I
ALTER-DRAIN&VENT-WATER(EA) j%AM'rlON
Owner Dam V
WORKERS COMPENSATION DECLARATION RACK ROW PROTECT.DEVICE I
1 her.Ii,allion,under pcnulty Of wrin,Inc of the following declurations:
[have and will maintain a Certificate of Cnsnl to sell-ineure for Worker's Carmen- 1)RAINS-1760OR,ROOP,ARIIA�COND. S'I'ORIHI 'I'YPECONSTRUCI'ION
sadcn,as provided for by Section 3900 of the Labor Code,for the performance of the-
it Inch this permit is Issued. _ FIX'I'ORES-PER TRAP -
QrThnew and will maintain Worker's Compensation Insurance,as required by Section
](0 of the Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INCAofffLE'B OCC.GROUP � MEN
My Workery n Pens,nio Insyy ice comer in A Policy nwnFe y�`y �•b -
Capim: Policy. GAS-
EA.SYS EM-OVER 4(1iA). ,
CERTIFICATT.OF EXI!MFION FROM WORKERS' GREASININDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need no twenmpleted fthe permit is fellow hundred dollars($UXb GRI?ASE TRAP' -
or Is,,.)' PLANCIIECK FF17
I certifythat in lbeperfommanceef the work for which this permit iskscro,l shall SEWER-SANITARY-S'FORM EA.20(1 F..
an employ any Penson In any manner in,as to become snhjcd to the Wmkcr:Camlen- EN17RGY 10313
z Nation laws Of Coliform.Date WAIT.R HEATER WNIiNT/ELECT?
O Applicant 1 GRADING PEE
G7 y
NOTICE 10 APPLICANT.It.a0ef nmking this Cenilirnc of Exemption,you ehnnld WA'I'1iR SYS'I'IiM/fRI NTING SOU's FEE
henwte Nubi m the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with.such miscount or this permit shall he deemed revoked. WATI7R SERVICE
Q PAIU
z CONST RUCTION LENDING AGIINCY NEW NGSIOIiNTIAI.PI.Mly SQ.IrL Rc PIM
I hereby affirm that there is a amwomfion lending agency for the performance of
W0 the work for which this Permit is Issued(Sec.1097,Ci¢C.) -
Ql"' 1<ndefs Nano TOTAL: -'fO'fAl.:
>� LU41 Leader's Address
tT Iny thin I 1 I this 111 I m' l"are that dinformation ia DULL FEC
.F.r Van
cancrect,1 agne tcomply with allcD and crronlyardfiand state Inno,nelatin,to QTY. MECHANICAL,PERMIT i " 1t' 'FEL:' `
U hull' gcommunion, ad h by threpresentatives f this city o enter upon the SIHSh C THE
aM)ve nent ned pro Pemy for lsNction Puq)n es" v PLRMIT ISSUANCE 11 1 NIC -:E
(We)agree m save,indemnify and keep hatmlexs the City of Chpmito.,.,a,( _
lin
iabilities,judgments.costs and expenses which play in any way mime against said City ALTER OR AUD'I'O A/ECH, PLUMEE GFEE
tmequcmm of the,man ng of Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(TO I)'NOCI'M) MFCH LI'i,
S 'RCE REGULATIONS
AIR IIANDLING UNIT(OVER IgDO CFM) CONS9'11GG1'10 'AX
Si amrc nfApplicant/Commcmr Uam EXHAUST Ii(>nD IW'/DUCT') HOUSING A1ITIGA'F NPER
IIAZARDOUSM ERIALS DISCLOSURE
Wm lire ap,licamormmrc bpi functional Nunn nr huodlu halm'dnuctmncritl H17NI'I NO(I N I'I'(TO I MAXI 111 Ul
as defined by the Cupcmm,Municipal Code,chapter 9,12,and he Health and Safety
Cods,Sweden 25572(.)? HEM ING UNIT(OVER 100,0101 B'UD
❑Yes C]No V CIS I'ILA'1'ION PAN(SINGLE RES I D) PAID - _ -'
- Dote tcceipl M
Will the appllcam or future building occupum use equipment or devices which ROILF.R-COMP(7HP OR 111(1.1X0 R'f0)
emit incurious air con creation;es defined by the Bay Are Nr Quality Wangemm�t 'TOTAL:
•�Oistdct7 ' 100.000 BOILER-CONIP(OVER 100.000 BID)
El YO. ❑Nn
I have the hazaNnus materials poomrmords under Chapter 6.95 Of 0e Cali- AIR CON DI'I'IONEH
read ISSUANCE DATE
fnmiv Health&Safety Cole,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ,EL
houldngdoes not cur tdyhwatt u:m6 that 1'sntyi xpnnciM111ytnnntifylbeoc npnnt
of the r;nimments which must Its met prior to issuance of a Cenilicate of Occupancy.
Owner-o,authnrired agent Unm MEAL: ISSUED BY:
OFFICE