S 3045 APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.EkEurRICAI• 1'E IT NO
BUILDING DIVISIONAPPLICATION/PERMIT PLUMBING-MECHANICAL 3045
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'15\RY NU. APPLICATION SUHh11'I'1'AL DAIIi
cA c" �
OW :RSNAMI!: PHONE CONT'RACTOR'S NAME: LIC NO
G tg— 6 2E a-1 NL 5/SpS� NIC cON1ROIL
�<CHITECT/ENGINE LIC NO: ADDRESS: ❑ Q IC q
CONTACT P
,. / HONE: BUILDING PHRMH INFO
•G,„,,,� / Lfx. 9117 ❑ Consullanl Fees Pail by Applicant(Initial) BLDG LIST PLUMB ME li
L.+ 14,
LICEENNISIiD I
CONTRACORSDECLARATION l/ /
I lmreby akin mal I am Ifecnsed under par,h,ions at Chapter 9(com:meneims Q PY ELECT RIC PERMIT Viii JOB DFSCRIIYI'ION
wc1 tDah Scevon>IXIII)uf lTvii con nonunrl l'ralcxaions Crdu,:nW my littnxc is F D TIAL'
�Z a,n 3albe Bus
W O 1'Ii12Ml'1'SSIJANCIi
CWF' nfail one ClassJollcct. 'DWI. ❑KI'I'CHHN k1iMOD131,
aUU
License Claw Lica APPLIANCES-RF_S IDENIIAL ADDITION [I PLUMBING RI PIPIT
naaor
AItCIIITECI"S DECI,AItATIpN ❑MULT1.UND ❑SI'RUCI'URAI.
�t-Z IundcrsmndmY phmsslmll betwed.publicmcords 1'ANIi1,S S10DI19CA1'IUN
Q'Z�Q UP TO 200 AMPS I [_1 INTERIOR ❑CHIMNEY RIYAIR
F+411".,W 7,,n..I Nodasximud 201-IIXMAMPS IMPROVEMENT E]SWIMMING POOLS
OWNE:R�BUILDER DECLARATION OVER IIXXIAMPS ❑BAT'A REMODEL/RF.PABR ❑DEMOLI I]ON
C C Q I hereby affirm that I am exempt from the Contractor's 1.iccnse Law for the
ka U p,U falbwing mason.(Section 7031.5.Business and Professions Code.Any city or county SIGNS ELECTRICAL ❑OTHER
a aT'Q which mount.a Ivermil u+cunauel,idler,Improve,dcnud labs or mp:dr any rmctnrc
F`-O.] priorto its issuance.ma,occurs,the applicant lot nucb varand to file a brood'rate or, SI'I_CIALCIRCUIT/MISC.
} that he licensed pursuant u)the provisions ofthe contractor's License law(Chapter 9
C,C> (s'omneniing with Secaam](XX)of Division 3a411hc 1lusincss.nd Promoian,Cadu)or '117MV MET ER OR POLE IM1 COMMERCIAL:
=a.e¢ than he is memmficrelron and the basis far the alleged exemption,Any violation of ❑NEW 1{hUGIADDITION ❑DI!MOL1'1'I(lN
Section 7031.5 by any applicant for apermit subjects me applicant mucril penalty of N)wlik DEVICES ❑TIiNANT ❑FOOD SERVICE
nut more than five hundred dollars S5(NB. IMPROVEMENr
,=Q D huv owner of tbu Prolerly nr my cn:plryccs wllh wages uv their arta enmpatsudnn, SWIMMING POOL ELECTRIC
E. will do the work,and the orinm
uoi,not intended or oR'erad food,(Sec.WlkLB.,ineca ❑01'111?k
s.
L 3 and Pmfo,,am,CMC The Carrlmemi,License Law dors not apply u+an awncr of OUTLETS-SWI'rCHILS-FIX'1'Ukl'S
property who bulldo rr iaaproves thereon,and who dors such work himself or through
his own annployees.provided that sm r infor,r arm,arc sol Treaded rr ollcmd Int NEW RESIDENTIAL 1!I,ECTIt SO PT,
,ark.If.however,the building ar imPmvement is sold within one year ofcampleliot.the '\ SQ F1'.PLOORARHA $ISQ FI',
erhuilder will havethe hurdenofproving that hedW not buildoUrimpre'rTorpor- J# x
Palo al,al..).). fj )Kp f
L I c p .T exclusively b y withl 1 t T: : i- ` ( sc
3 3�
consumer Lathproject ISa t)TW.6 . -and P f. Cud Th ve Imnor Li- /1� •] I,..rljl`�
eco
m1 I It()[apply tar pony h b dju p .eC m and QTY. PLUMBING PERMIT FEE, O 7
who en mutsfnrsuch prVwl. m' vat 111 Jpu. II m C vu I r'
Liccn,c law. PERMIT ISSUANCE �Q
I ani exempt under Sea. .B&P( for this reason
AIJTER-DRAIN A,VI!N'I'-WATER BA) A
D:IO
Wm under'penOMP1iN rjory on DECLARATION BACK FLOW PROTECT.DEVICE
1hereby illllrai.na pcnalyofperjury one()I the fallow ins,declaraWork,,,
�Iheve and will mairmen Section llcme of Crnanlr soc .forthe WnrkedxGeopen- UIINNS-PLO(Ik,ROOF,AREA.GOND' 4HNFkM4EH
'TYPE CONS'1'NUCfIl1N
smirk, r pash fli for by Section 37lNl of the Lada CnJc,li+r the perlkrrmoncc of the
work for which this permit is issued. FIST'ORES-I'IiR TRAP S T Q
37 I have Luwill:aainmin Worker's Cumprns:nion Insurana..a,le,,rad by Scotian r '
pr+ permi MS-EA.SYSTI!M-11NC.4 UIJTLEI:S
3](Nl ufthe Labor Crxlc.for lLe tionnance o(dm work for which this lis saucd. AI'N
MywarkclsC pcsti�n umncdcamcrand l'olicYnube z7
Carrico �6A..(, anne,�1'—/l—/ Policy Nu.: GAS-EA.SYSTEM�OVER 4 BEAT
CEk'I'IFlCAI'1!OP I!XI!MI'TION hkOM WORKIiII.' GREASIDINDUSTRI.WAS 117 IN'ILRCEI"IOR
COMPENSATION INSURANCE NG DIVDION FEE, _
IThi,.¢nirn rend nut hecompleted.fthe permit is for aochundroddullan151W) GRE!ASEI'RAP
or Icxx.1 2-
I
b
I ccoi fYthin In the poffamateat the work liar w'hicb this permit to lswed,l shall SEWER-SAN I rARY-S JORMIIA,21X11'1'.
not employ any perssm in any manner%r re to beano subject Ir the Workers'Camper- D
Z salion Lav,s of Caffomia.Date WATER BEATER w/vEN-DELECTR
zO Applicant Gk IN(I PF,E
=
NO]ICU TO APPLICANT If.after makingthio Cenilicmeof Exemption.You should NATER SYS')IiM/1'RI!ATING
F' become subject llm
o the Warkees Compensation provision,of the Loar Curb.you ust SOIL IgiE
turns 1111 comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
7Z CONhem isa'IONLtion leGAG1gNCY Nii\V R1!SIU131VTIAI.FILMR. tiQ.FL PAID Dam Rcccipta
V � Iherehy xltirm thin there i,aconswmion lending agcnry for the performance of /\
{L F the work for which thispooh is issued(See.3119],Civ.C.) F p 3 8 J e TOTAL:
V1<nJer's Name 2 ,. x
Lender',Addmxo -/
1}� I cti-of that I have roud this application and e,am that the above intonation 1{UILUI
coned l agree to comply with all city and cm d,ordlnunccs I ,I'
Q-1 Y. MECHANICAL PERMIT PET;
V Z buildingcswctioaanJ hemb,mar im repirwid.ives of upon SI!ISh - 'I': x ��
on
above-rownianedpmpeny for m1pacian purpaseo. n 1:
(We)agree m save,Indemnity I I lace Larndcon the Y nTCupour a / ITL[ 1.PEE
liibilitie,,judgmms
e ,coolant]expensanwhichnuy many air, try IID T( E I'1 E 1 NO IT
in consequence of thegmming of this permit.
APPLICANT UNLESS?ANDS AND WILL.COMPLY TI,ALL.NO NT AIR NI T( CI 1 MEC ANICAL FEE
SOURCE RI;CIJI•A'TIONS.
• AIR N 16G l T lik IILIN I+M) C S'1'RUCTION TAX
Signora of AppliImUComnuTnr Duro f!XH US I(JOD /1 IIOU. GMITIGATION
HAFARDOUS MA'IERIAIS DISCLOSURI!
Will the applicant of future building occupamumre or handle harmlom,national IiEAfING UNIT(TO 100.000 ITT U)
as defined by the Croatian Municipal Calc,Chapter 9.12.and the Ucalth and Safety f
Crile,Scainn 25592(.)? HEATING UNIT OVER TXrIXXI BTU)
pre. 0 N PAID
VI!NTRATION PAN(SINGLE RISID) Dae Rcccipta
Wi11 Too upplicamnrpiano building occupum use cynipman o,dcvimo which HOILER-COMPpHPOR I0JE013'1'UI
-mit haaardou.s air comwninanls its defined by me Buy Area Air Quality Mnnagemom
Disniciyes ❑No! BOILER-COMP(OVER 100.000 BTU)
I have read the htuaous inrcdals requirements under Chap6.95ol the Cali- AIR CONDI I'IUNIBe IS: ANCE DATE
fnmia Ilcalth&Safety Craft,Sections 25505.25533 and 25534.1 umlmrand that if the NI!W RISIIE!NTIAL MECIL SQ.PI'.
building docs sol ramor ly huva a wfaut Thal d is any to.pansibility h:notify the rcevp.nt
of the ngri s ch must bcmn pear In I....accafa Cv0;I +laaf(kn:,�,nt�}�>nn , o /\ 3
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