S 3939 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY .
CITY OF CUPERTINO BUILDING-ELECTRICAL, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3939
CtP I"Ij!I B1MPINC PROJECT'IDEN'TIFICATIONif:('.:;i?il,Tri
BUILDINGADDRESS: SANUFARY NO. APPLICATION SUBMITTAL DATE
223 ne o _ Q _q
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NAMEe PHONE: C&pITRACR R_'S NAME: LIC NO:
COecieliNi&" IKCC•.e NIC CONTROL#
ARCHITT:CI'/F.NGWEER: LIC NOESS: mTN'�{c9Lhi ' jnU /'�.� ❑
T 1JW
.gl
CONTACT: PHONE: i>U6U !J'P{i?:'!l1fiBUILDING PERMIT INFO• i',;
3-5 �^�� ❑ Consultant Fees Paid by Applicant(Initial) RLDG ELECT PLLUUMMBB/ MECH
LICENSED COMxACTOR S DECLARATION QTY. - llt II ELECTRIC PERMIT,') II t -FEEIij
lhvrehy,fr lhat l a,lcenseda l y � I Chapter 9(envme g r ". 11Ii ( I ail .. ..x,t ._-z.D _LJY �.. t#n,- . JOB DESCRIPTION
WIZ with Section]O(MBof Divtstan 3ofthe Must sand Professions Codeand my Teem,is gESIDENTIAL:
N Oaciti full forecanJ ofect PERMIT ISSUANCE
<—U License CWss_�_ljn"a ❑SPDWL ❑KITCHEN REMODEL
F APPLIANCES-RESIDENTIAL
NQL Dme�.v- -- .-_moi-6—Comructn ADDITION PLUMBING RE-PIPE
`"� �A�CHITECI"S DFCLARn N PANELS ❑MULTI-UMT ❑STRUCTURAL.
Z O N Z 1 understand my plans shell be used ass public records MODIFICATION
OZ—, UPTO?BBAMPS [I INTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-100(IAMPS IMPROVEMENT 0SWIMMING POOLS
qY �,
OWNER-BUILDER DECLARATION n OVER 1000AMPS ❑BATH REMODEIIREPAIR ❑DEM LITION
E C Q 1 hereby u(Scer Ibm I um exempt from the f2ita,Cqc I: c Law fur the , 9
It13a following reason ISmion 70315,Business and Professions Code: y my or uny SIGNS ELECTRICAL ❑OTIi IiB !
4 vFi which requires a Permit to enn.swch:drag improve,Jemolistf��s([[re r any dare
��OQ that
s Invokdpursarequlrce the upplicam forsucM1#Boni tat mmmenl SPECIAL CIIICUI'I'/MISC.
thm he is licensed pursuant to me Provisions oI the Cnmmgols \\VV" w(Chapter 9
OO (oemmencing wish Section]fhllp of Ulvision9of the llu.' cxs Profc.sinus Cale)ar TEMP.METER ON POLI?INST, COMMERCIAL:
a a e mat he is exempt memom and the hasis fur m IegeJ c apo Any violminn of ❑NEW BLDG/ADDITION []DEMOLITION
iC Suasion]O3L3 by any up mamfor u Ptrmit suhje 1, Bopp cannoacivil Penalty of POWER DEVICES ul�tn ❑TENANT ❑FOOD SERVICE
1- 0 n marc than live halal,d dollars(15110).
❑Lasowncrofthcpr ry,ormy emplo tts with ages as their sole compenmtion. SWIMMING POOL ELECTRIC IMPROVEMENT
Wp. wllldmhe work,and tl ehmnule i.not luta ed ontl reA for sale(Sm.A144,Business El OTHER
im ..it Professions Cad The Contractors Litt Law does not apply to un owner of OUTLETS-SWITCHES-FIX'1'GRES
pmpeny who builds rimprove,the mo and se o does such work himself or through
his own empinycvs. r That uch improve ons arc not intended or offered for NEW RESIDENTIAL EhIiCTR SQ Ir'.
sale.If,fewevem the Build
tiding, ' proveramissol wiminoneyemofcompletion,the _-„SQ.RrFtOOR-SI I EISA.FT.
awnerh lir will h theh f tail dd tb 'IJ - c �' I 1
,rase r 1 ) L.l
❑ I Rh . ty , r Idcontracting d I t t t t TOTAL 1
h P J t(5 , a d PG d ,Th G t t L 91999 f
seL d t apply to an ownerfp Peny h builds th n d QTY.;,fl .II PLUMBING PER li ' i;�fEE I� JUN
- wclose
oc tlmLL'fnrsucltp 1 is wnhuvonw t OIicLnseJ pursuam to the Cantruemra I .a cn,.t DJt.IUv F .4t.; '!'�' U
License Law' PERMIT ISSUANCE
❑I am exempt under Sec. ,R&P C for this reason
Owner Date ALI'12R-DRAIN&VENT-WATER(HA) VA N�-
.
WOR KER'SCUM PENSXHONDECLARATION BAC KFLOW PROI'PC'I'.DEVICE By-
1 hereby infirm under Penalty of Perjury one of the following declinations:
❑Ihave:md will maintain a Certifcnre of Cnnsemtoself-iomm fur Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYpfi CONSTRUCTION
cation,us provided for by Section 3](10 of the Labor Cale,for IIIc performance of the
work for which this Permit is issued FIXTURES-PER TRAP
L] I have and will maintain Worker's Contpcnsallon Insurance,as required by Section
37M oflhe labor Cale tonne performance ofine work for which this permit is issued. GAS-EA.SYSTEM I INC.4 OUTLET'S OCC.GROUP APN
My Worker's Compensation Insurance caricr and Policy number arc:
Carrico Policy No.: OAS-P.A.SYSTEM-OVER 4(IIA)
CERTIFICATE OP EXEMPTION FROM WORKERS'
COMPENSATION INSIJRANC12 GRHASMNDUS'I'RL WASTE INTERCEPTOR
(ITis action neN not he comPlcteJifthe pennitisfrrone hundred Jullars($100) NCHECK°ME DING DIVISION FEES -,
loss) GREASETRAP pLANC1IECK PEE
leemylhminmeperform ase ofthew kfnr which this Permit is iswnl,lshall
I emPlo an m oasm& 'm1oo,'Com SEWER-SANITARY-S'1'ONM EA.2fq P1'.
Z moon laws of Caf IM1ti .I tlm,m ��V//yL pen- ENERGYING Fli
O Applica t c s WATER BEATER WNI3N'GELECi'R Rl, GRADING FIiGNOTICE T)APPI. A T:Iflaroodon this Cenificmoof Excro tion,you should g P WATER SYSTEM/IREATINOMco ith suecnnme Wurrkemovoiommthis Provisios of thelahor Caleynu must SOILS FEEforthwith complyilhsuchpmvirinremthis pertnilanvil hedeemedrevoked. WATER SERVICIiCONS"ac is.rIONuaru. IGAGP,NCy NIiW RISIDENIlAL PLMB. SQ. PAIDU 0 Iharebyafiirnl thanbere ixuconsmmtion lvndin8 u8ency Brrlhe purforin:mw of lata Receipt#the work for whichthis permit is i...ed(Ser.309],Civ.C.)
I.cnd N TOTAL:UIxnda:Add TO 1 n fy th t I h d th. ppli a t J t t th t th bo f a t - - BUILDING FBI"y cored I g IIv n II 'Iv 1 tv I' Ia t FIsl QTY,"r' '1{MCCHANICALI BRMV Z hold' 6 ompaction andh rcb)authorze representatves of thisctyt enter upon the vs SEISMIC FF.P:move-mentioned Prolmeny for inspection purposes.(We)agme m rave,indemnify end keep hennlesx lie City of Cupenino againstPHItMITISSUANCE fi1.HC'I'RIC I:Iiebilities.judgments,costs and expenses which may in any way aceme againstsaid City ALTER OR ADD TO MECH.
In mnsuluerovof me gin 4 tg nl mi.,,-; PLUMBING FEEAPPLICpNyyNDER. '/.NUS AND WILL COMPLY WITH ALL NON-POINT pIR HANDLING UNH'(T010,11f1(I CFM7SOURCMF.CNANICAL FEEAIR HANDLING UNIT(OVF.R 10,000 CFM) CONSTRUCTION TAX
Signature dApplical /Commcmr hJ Dale HXIIAUS'P EnoD(W/UUC) HOUSING Mi'I IGq'r10N FFF
HAZARDOUS MATERIALS DISCLOSURE _
Will maapphcnm or nomehoilding orculam store or handle hazardous material BEATING UNIT(TO100,000 BIUU
as defined by the Cupenino MumcipaI Ct .Chapter 9.12,and the Health and Safety
Crde,Section 25532(10? HEATING UNIT(OVER 100.000 BTU)
❑Yes• PAID VENTILATION PAN SINGLE
Receipt#
Wdoursll the air continuations
d fl I by the rt Bay Area
Air
naemitk ent BOILER-COMP(3HP OR I OO,WO IITU)
emit havvdonx air conlaminanLs a..Jef�pwl by the Bey Arcn Air Quality Management T l.
District? !M-tv// BOILER-COMP(OVER 100.000 B'I'U)
❑Yes
AIR CONDITIONER
1 have rend the nava ns nuvaivlx rcyui,onlents under Chopin,n.'J3 of the Cull" 'ISSUANCFx�ATf1 P(2p,
labia Hal &, fety Ca Sections 255(15,255J3 and 255M 1 understand mat if the NEW RESIDEMI'AL MECH. SQ,FT /`!J_ G(�x—V
building ra s c tly aamnunt,mm it is my rexPnnsihility to notify the acopum T
nl me ngtlir n nl r�hid asst be uonw nfa Ce/Ali=yf[nl�My!}Isy.
Own,,l mharized agcl t rj 7 ••D7me TOTAL: ISSUED BY:
OFFICE