S 1591 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
1 e CITY OF CUPF.RTINO BUILDING.ELKCIRIC,AL PHft�b+III No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J ' 1591--
�- BUILDING PkOJECTIDEN'FIt'ICATION
BUILIANG ADDRESS: SANITARY NU. APPLICATION SORMI'ITAL DATE
20 6 6vpvrzlL
1JIO-yfF.�J—2441 C(INTkAC10R'S Nr\ME: LIC NO: NIC C(1NTROI.p
I\JCHITECl/ENGINEER: LIC NO: L ADDRESS:
CONTACT: PHONE: - BU ILDING VERMITINI70' —
J>p C" Eit aX � ��24/I t ❑ Consullanl Fees Paid by Applicant(Initial) ELECT' PLUMB MECH
LICENSED CON I RACE ORS DFCLARATION QTY ( CLGC7 RIC PERMITJ,FIiE
I t br'fl (he? r :l d P n: rcM1ann-.v¢.crone -ng JOD DESCRIPTION
'8Z with. i ',OXp Ib nt3 nfmv lku ons cull nl : is Code.tdmylev : .x PI!RMII ISSUANCE! a l^a RFSIUENTIAI:
FCI-F. in fall forevind effect J ccc❑ISS'F'''DWL ❑KITCHEN RF.MODFI,
4UU License Clan 1.ic.N APPLIANCL'S-RESIDBISITA, ?Q41 T10N ❑I'LfJS1RMG RF.-PIPIT
h Q L Dale Cmtlmclnr I❑MUI:I'I-UNIT 0SRUCTl11tAl.
Dy ARC]11 FECPS DECLARATION
PANELS
~,t)Z. I understand my,kine shall he usedre,public recuts ^ MODIFICATION
��,H„O 2 UPT020BAMPS V ❑EST PRIOR ❑CHIMNHY REPAIR
Fa4tiW Lieenseti P..feesinnol 21)1-LLgOAMPS IMPROVF.MENf SWIMMING POOLS
C Q I ocher,a01mt ha`I. exn.npl fro v 1 e Comnctor',License Law for the GVHR RXXI AMPS
ON ❑IlA9'I I REM(llllillRliPA1R 0 DHMOLI'1'ION
apyx5,O L O loll.wing mason(Section 7011.5,Rosiness and Poorest is Code',Any city or county CIONS ELIiCTRICAi. ❑01 HF
W 3 a H which requires a permit to ennclrucl,aller,improve demoliso,or repair any ameture
.~..�0g pro.r to usu Lso requires the applicant fsuch permit file a signedstatenent SPECIAT.CIRCUITIAiISC.
ray Fath I' I, a Ih p fill Contractors' l I (Chupmr9
p0 (utmntete'tgwth lection 71d0).fl)vitn3 I'IhcH s dl I ' 'Code)., ('LMP.NIF 1'1?I RPOIEINSr �'e.Zf MMBRCIAI:
6 a C tbar he is exempt darrefiewa and Ne basis for mos alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Xm" Section 7031.5n applicant for permit they applicant to a civil penult f POWE ES
Y any perm: pp Yo ❑IMPROV El FOOD SIikVIGE
not man;than filo efao,o l dl.lhtrx y amp. OTHERVF.MIiNT
ce dothewoas r ,and pmpeactur myemployeeswith wages as otelr solc(See.w1-4,Bafdon, SWIM GPOOI it ; TRIC
(.. will dahewons and the he Conte fors intended Law
rest for doers not apply it an Business. -1 OTHER
L 3 mW property
Mile b Gale:Th.Contractors License Luw dna.not apply In an owner of (3UTLE'IS-SUIT IE I ES s
his o ny who milds or sided t s thereon,and who obex such work
te on-Vol moron l vote.
own however,
the provided That such improvements are not intended or doriod for NE; 1;. )ITN AL ITL 't SQ PIl
svle.lf.hswever.the building ar improvement is,old within one yemafc.mpldinn,the , SQ FT.FLOOR ARIiA USQ.IrI'.
ow tel'-builder will have flue ardlo of proving that he did nal buildo,improve for po
❑ c nl.sola).
I a. f t1 p puny m ly contracting with licensed . n ,I /79 'AE-o-1
on l t the pr l 't(Sec.7044Ba,rrm,and Prom.,iore,C dI top Cumertlar:1'
acme,Llwdocsu l a r-o' r.y who bud hethe eo I Q'fY..`.' ' I'LUMHING P:RMIT'
who umlmals t uch cls ithvunn nor6)IlIF to (pursuant ml he flref,.I ' � w
License Law PERMITISSUANCE v � _ ALN,
O latae ' Sec .B&PCfmlhisrmsnn 02A
LN,
R-DRAIN&V];.W-WAIER(liA) VALUATION
Ow c
WORKPENSATION DECLAR
! 'S COMATIUmON HACK MAW PROTECT.DEVICE by
emby often under pcnvlly of N,ory one of the I'ollowing dcd.ra.lons,
❑ Ih cend will maintain.Cenificale rrCbnwm to.velf-insure for Workers Courtlier- DRAINS-FLOOR.ROOF,ARCA.Cool SEE ONIIIS TYPECONSTRUCTION
sail..,us provided for by Section 3701 of the Labor Cele,for the performance of the
work lo.whieh,hiv porn..is issued. IIXTURHS-PHR'TRAP 89
[:]1 have vnd will initiation Worker's Compensation Fusion".is
reyuimd by Section 3k
3700ofthelabor Code,for the performance of the work for which this profit its issued GAS-IA.SYSTEM-I INC.4 OUTL1?IS OCC.GROUP APN
My W.rkcr's Compensation Iasumnce carrier and Policy number are
Carrier. folic,Nn.: GAS-ITA.SYSTEM-OVER 4 07N
CBRUFICATE OF E%EMP1'TON FROM WORKEiRS' GR6\51%INUUSTRL WAS'IP,INI'ERCiiI'1'OR
COMPENSATION INSURANCE VW. AM B _ (i ISI_ON FEI•_S _
1'Ihix xraalnn need nut J,maadcmd:talcPermit i'tor on chundreddnll;...(SI(Xu GRVASIi'fINP /
or loss.) Xs i'LANCHFC 14 -
Icenifythat inthe performanceofrhewark for whichthis Permit isissued.I hall SHWER-SANITARY-STORM EA.200 FT I Vit
v l
not einpl.y any punas in any mvnncr.n ns In beennte suhjcd t.Ihe WnrIm"''Courtlier.. A NN�f'-ytr+S FEE
OZ say..1 La"of C.hfnion.Dare WA'TrR IIHATER W/VEMIII7I.11C'I It U V D
r'z.Q Applicant GRADING FCii
h NMIC17 TO APPLICAMP If,ager ,nvdting this Cenificale of Exemption,you should WATTE
ER SYSMO RENTING
? hemn.0 rabbet l..the Wn.kcls C.ntpenantion IF...visiuns of the Lama,Gide,you mass SOILS FEE
{Ta fonhuith comply with such provisions or this permit shall he de voted revoked. WATER SERVICH
Q
a' CONS'i'RUCI'ION LENDING AGENCY NEW RESIDENTIAL PLA113. SQ.FT. PAID
VQ Iherehy of firm that the,elsamnswnion lcnding ngoncy l'ur thcperfnnnvnceaf Pum p
H thewtak far uhich this p[rmil is issued(Sec.JIW9.Civ.C.)
W Lender's Name TO'V.L:
Lender's Address QI'N.
G I certify that I have read this application and state that the arrive,Information is - BUILDING p11'
.H.. tq correct.l agree comply with all city and county ordinances and state laws relating to QTY, MECHANICAL-itERMI'I PF:E
V Z hunitfi.g....locoion.and hereby autonrire representatives of this city menter upon the s SEISMIC :F.
above mentioned pmpeny for inspection pm pnscs. PHRMIT ISSUANCE:
(We)agree to save,indemnify and keep harmless the Ciry.f Cupcnino against ELECTRIC rl:E
liabilities,jud,narov,caavand ov,ei whivhntvy in any way deems,rrminslxaid City ALTER OR ADD TO MECII.
PLUMIIING 'Eli
....mRuene,it he gating of This permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(10111,0(1(1 CPM) O
MHCIIANICAI.IEE l
SOURCE.REGULATIONS.
' . AIR HANDLING UNIT IOVIiR 111.IXXt CIM) CONti IRUCI'[ON'fA%
Signature of ApplicanVContranor Date IIXHAUST HOOD(W/DUCD HOUSING MEI IGATION ITE
HAZARDOUS MATERIALS UISCLOSURF
Will ll a opPlicart ur pfu®hnllding ncn.panl snm,,handle haaualnns material 1117ATING UNIT(10 100,00)BTU)
an defined by the Cupertino Municipal Code,Chapter 9 12.and me Health anti Safety
Code,Scot)..25532(.)7 IIHATING UNIT(OVER 100.001 BTU)
Ves No F-1V[IN'1'ILAE'ION PAN(SINGI.Ii REM D) PAID Laic Recciia9 -_
Will the applicant or future building occupant use cyuipmenl or devices which - ,.
,.it lmmrlbus air cbmaminants as defined b the Bay Arca Air Qaalit Management BOILER-COMP(iNP OR[00.000111T)
Y Y� 'IOTA L: 1
D.stncll BOILER-COMB'(OVER 1,,(X)0 IP111j)
❑Yes E]No
I terve rend the IFnus materials ov,do pre's under Couper 695 ul the Call AIR CONDITIONER ISSUANCE DATE
fomiv health&Saficty Cove.Sections 25505,25513 and 25534.1 understand its,,Him NEW RCSIDEN'I'LM.MECII. SQ.FI'.
building dons not curtenlly have a tenant that it is my responsibility to notify the occupant
.f the n'MirerwnR,hich must be met Her to Isx.con,of a Cenificate oro«ttpancy.
Owner or art horired agent Date I I TAI.:'j ISSUFD BY:
OFFICE