S 0580 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY _
CITY OF CUPERTINO BUILDING-ELECI'RICAI, PP, NIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 0580
BUILDING PROJI'.0'1 IDEN'I'IMUNI ION
SANITARY NO. APPLICATION SUHMI'PIAL DATE
BUILDING ADDRI-ISS
D/D
IOW ?k'S NAMIiI PHONE!: CONTRACT R'S NAME: LIC NO: NIC ('ON'IROLa
J/�.s�ir/
•ARCA _C IENG;NI:ER: LIC NO: ADDRESS:
��� BUILDING PERMIT INFO
CON9'AITI: � VII(1NIi:
/„ �� Aim
77 /� ❑ Consultan(Fees Paid by Applicant(Initial) nI.OG 1H.rcr PI 0 n MO I
LICENSED CON'(RACTOHS DECLARATION QTY, ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby si inn that I ant licensed under pm,rOom;of Chuplcr 9(eml:ll:cneing
with Section 7")of Division 3ol he Polities and Professions Cede,end my license is R ID-NTIAL;
in full force and eRttt. PERNn r ISSUANCE ❑SFDW1 ❑KITCHEN RFMODEL
QUU LicenseC x Lic.is ������ APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUM BING RL'PIPE
mFi66 Decoy-� —Contrucmr ❑MUL9'I-UNIT [I STRUCTURAL
RCIII'1'ECT'S DEC,[,ARA'1 N PANELS MODIFICATION
~N Z 1 t ndecsmnmY d Plans shall he a,Od as public records
'ZOr4� UPTO 200 AMPS ❑INTIiRIQR ❑CHIA1NFY RIB'AIR
OZ—M
II—X Licensed Plomemnal 201-IUMIAMPS IMPROVIiMENT (]tiWIMMINGIKK)LS
�,1 f�, OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH RFMODELIREPAIR ❑DEMOLITION
IY C d 1 hemby affirm that 1 am exempt from the Contractors License Law far the ❑GHIER
X d U following rcaam.(Section 7031.5.Business and I'rol<ssinns GJc:Any city or counlY SIGNS IiI.ECTRICAL A ' T
,al
3 LL y which myuires a permit m conxwn.alcor.improve,demolish,nr repair any urvcmre M AJ
f"�:0-5 prion.it,ismanw,.hed requm,doeapplican,fnrsuchpermitto file a signednmehmenl9 SPECIAL CIRCUIT/MISC.
�Y that he is licemed putcmnunthe pn.skionsnf the Commit' 's -iceme hwlCapmr
114 C (<onnnmmiag with Section](XX))of Division Sof the limincsx:nd Pd,mssin.s Cod0or TEMP,N1 if 1'FR OR POLE I NST. El ly �]OIiMOLITION
ly GX e y that he is exempt Ihemfram and the hasis for the alleged exemption.Any violwion of
Wim Seninn 10315 M1y eny applicam furapcwil mhjens the applic.m t.acivil penally.(
POWER DIiVICFS A
AM ❑I'DQD SIiRVICIi
.t come than five hundred dollars($5(101. 0P`rVl JFTEH rINO
?G I,as owner of the prnpeny.or my employees with wages as their sole c.mpenw,ion SWIMMING POOL ELECTRIC HER
will do the work,and the structure,is ern intended or ott'cmd for sale(See.Jndq.[Insides LE'I'S-SWI' 'I1E5-19XTURES/
W m and Professions Code:The Contractor',License I,uw dors tint apply 1.an mono n
a3 pm petty who builds m improve, be....and who does such work himself or Ihnmgh NEWRESIDENT LP iCTR S
his Own employees.Provided that such improvements am not inmmk f m.(Toad for SQ.IT FLUOR AREA $ISQ.FL
sale,If,however,the building or improvement is )Id within one year ofcomplednn,the
e,la dder will have the burden of poising that he did not build or improve for Par_
C] IDs ode.) )J'AIJ
I.a owner rj the See 704,.B sine sivnd contracting with licensed conbaanrs to
Onowa @<Pot not apply to
Business and professions COdc:)The Commnon,and
<nselawdmanmapplytoan owner acu pmpeny whosedpor ant it)erthcmum.nd QTY. PLUMBING PERM FF.F.
who mmrucu for xucb projects with o mmmdor(q licensed pursuant m the Contracmr's
License Law. PERMIT ISSUANCE
❑1 am exempt ander Sec. .B&P C for this at
ALTER-DRAIN&VENT-WATER(11. VALUATION
Owner Dam
•
WILL KER'SCOM PENSATIONDECLARA'1'I'll BACK FLOW FIRM ECT.DEVICE �Go
I hereby nftinn under penally Of perjury One it the out hawing Jcclarmion,c CJ
�Iheve and will maimein aCenilicum of Cnnscnuo mlf-insure lin Wmkcfh Campcn- DRAINS-I'LOOR,ROOF. CUND, STORIES '1'YI'ECONSIRUC'HON
Wlian.as provided far by Section 371X1 Of the Ia1+a Cade,far the ped omunle of the
work far which this permit is issued. FIXTURES-PER TRAP
[] I have and will mammin W.rkerx Compensation Insamnce,as rtyuired by Seeli.n
3700al he Lala¢Code,for the onlormance Ill the walk for which mix- Perot l is iwdeJ. CAS-I!A.SYS'I'EM-I INC.q WTI.I?1-5 OCC.GROUP Al
'N
My Worldn'aC peso na career and Policy numhr_ O GAS-EA.SYSTEM-OVER 4(EA)
Carrier: t T` �ED Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCEB L) C )VISION PEES
(This secllnn need not becompletediflhcperaid IS fofallclluPldreddallms'($)(qI GREASI!'TRAP PLANCHEC
or lost
leenify that dnrmancanf the work for which this permit is insueJ,lshall SEWER-SANITARY-S'FORM EA.210 IT. ENEHGI'Iji
nolcmployanY Y:X^,10�c,),7�c� N'nrkm.'Cnmpen-
z onion, WATER HpATER WIVI:NTBLECTR GRAM IT,
z 0 Applied —
y NOTICETO APPLICANT:If,alta making this Ce iricat<Of Exemption,you should WAFER SYS'IEM/TREA'ING SOILS -
I-' hecmne.mhjmpm the Wmh pr Cnlnpcor this pmvisions of the Lahr Cede,yw must
a� fonhwilh comply with Such pmvisions or this pcnni,shall MJcemed mokeJ. WATER SERVICE
0 Q PAID
CONSTRUCTION LENDING AGENCY NEW RI!SIDENTIAI.I'LMB, SQ.I-T ate Receipt M
U Z I hereaffi
byrm that lsa em.dm,h nleadingageney for the perfommnc<of
the work far which this permit is issued(Sec.3099.Co,C.) TOTAL:
O1" Lenders Name TOTAL:
r WLemkr's Address BUILD] GFELE /
IL I certify Ind 1 have read ibis application and scam that the alave ml'onnminn k
F TA correct I agree la comply with all city and county ordinances and stale laws relating to QTY. MFC H ANICALPERMIT FEE SEISM 'PF.E
U z building conswetiun,and hemily.mhomm representatives of this city to enter upon the
thave-memioncJ pmpcny for inspection mard,ox. PERMIT ISSUANCE ELEC IC PEE
(Olde)agree to save.Indemnify and keep harmless the City of Cupcnino.gains,
lnM1ilhics,ludgmens.coils died cxl'<mms vehielnmlylnany waynceruc.gainxtsald City ALTER OR ADD TO MECH. PLUMNINGI '.
msequeoce of the granting of this permit.
APPLICANT U NDERSTANDS AND WILL COM PLY W ETH ALL NON-POINT AIR HANDLING UNIT(TO 10.(NIfI CPM) MECHANICAL I'-'
SOURCE,REGULATIONS.
AIR HANDLING UNIT(OVER IILINMI CPM] CONSTRUCTIONTA
Signature of Applicunl/Cnnlracmr Dam EXHAUSTHOODIIVIDUCI'1 HOUSINGMI'HGAHO TF,
HAZARDOUS MATERIAE S DISCLOSURE
Will the applicant or future building Occupied stole or handle M1azaNaus mamlial HEATING UNIT(GO 100.0)(10 BTU)
as defined by the Cupcnioo Municipal Call Chapter 9.12,and the Health and Safety DEALING UNIT(OVER 100.000 BTU)
Coole,Section 25532LIC
❑Yex PrNI, VENTILATION FAN ISI NGLE RUMP) PNU
Dale Bee Ipd a
Will the applicant or future building neempant use equipment or devices which BOILER-COMP(3 HP OR 100,000 BTU)
•emit hamrdaus on,contaminants us defined by the Bay Area Air Quality Management TUI'AL:
Disvid'! � HOII,lilt-COMP(OVI?k IIXL1XM)H'TU)
Yea
AIR CONE]HONER ISSUANCE Din
1 Health
mad the Code.S s tions is 5,25533 an under Chapter 6.95 of the Cili-
lhuddi Hcahh ray Code.c a jinn 25505,25533 va12553q.1 unJersland that if the ,NEW RESIOIiNT1A1.MECH. SQ.F3'.
buildingd urrcndy havcal<nunt,mut it is my respnmiMlllymn.,i(y lbc wcupam
ofthe ui or
or ammumo d agc.t ¢ IDl'AL: ISSUED BY:
OFFICE