S 0178 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1 7
CITY OF CUPERTINO BUILDING-ELF.C'I'RICAL PEy ITNO. O1 1 H
BUILDING DIVISION APPLICATION/PERMIT PLmnHNG..MECHANIC l\7
BUILDING ADDRESSBUILDING PRO '1
JECr IDENnilc ' C: SANITARY NO. APPLICATION SUHM111"rl'AI.DATE.
l o g 93 N C{1o��z RD ' G -zit
�'NIiRS AMI:: , / -'1� b�5-,- C1;1 R16 'fOR:S NAM[i: — N�n� NIC CON'1'NOLp
ARCH CT/ENGINEER: V LIC NO. ADUjtFE$: � �( ,Se s� ❑
CONTACT. PHONE: BUILDING PERMIT INFO
r—A ,r '`X q 32. ❑ Consultant Fees Paid by Applicant(Initial) HLD 1:1.1iCr PLUMB MECCH
LICENSED CONTRACTOR'SCDECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby dlGrin that 1 am lexam'ed under prnvoimI,of Chapter 9(cimnrncing
M=Z with Section 70fXBol Division lofthe Buxinesand Profeaians Code,ind my licen.¢is RESIDENTIAL
W p PERMIT ISSUANCE
�WD in full force and elf5a �.-/'��p ❑SFDWL ❑KITCHEN REMODEL
QUID Liana Class —Lies#�.l / 7APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RH�PIPE
F Z W Der Cimm S�uS
va<a ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION
J__V,z l understand my plamshall W.oxI ase public record. PANELS MODIFICATION
OUPTO200AMPS [I INTERIOR [I CHIMNEY REPAIR
1. W A,rawl Prnl'nssion.I 201-10KOAMI'S IMPROVEMENT C1 SWIMMING POOLS
C6 p� OWNFR-BUILDER DECLARA9'ION OVER I000AMPS C]BATH REMODEIJRFPA[R E]DINOLIHON
0N 1 hereby affirm that I am exempt frm m
othe Coraclnrs License Law for the Ej
3 a.F following reason.(Section)031.5,Business and Professions Code:Any city it county SIGNS ELECTRICAL OTHER
lady which.quite,a permit m cim rmt,aloe improve,demolish,or.,i,any snietwe
F': ,< He,1.its isuartce,al.I m,mrx, wapplicantfor such Permit o file a signclslatemenl SPECIAL CIRCU IT/MISE.
} 'hat he is licenced purwoutto the Provisions of the Contmnors License Law(Chapter 9 COMMERCIAL:
W C�0 (commencing with Section7")of Division l of the Business and Professions Code)or TEMBMETEROR POLE INST.
a y o y 'hat he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑D1iMOLITION
W..m Section]071.5 by any applicant for a permit subjects the applicant to a civil Ivenally of POWER DEVICES ❑TENANT CFOOD S17RVIC17
FFC..0 not more than live hunireddollre,($510). IMPROVEMENT
2yC �I,as owner of the property,it my cmployta,with wagcsas their role cmnpensmiml. SWIMMING POOL ELECTRIC
F. will do the work,aodtheslimame is not inanded it alfeted forsale Sce.7O ,lousiness El OTHER `� 1
W and Professions CreditThe Caran corn License Low dors not apply to an owner of OUTLETS-SWITCHES-FIXTURES 1 /�
a 3 prav rty who builds or improves thereon.and who does such work himself or through
his own employees,pookbil that such improvements arc not intended or offctcd for NEW RESIDENTIAL ELECTR SQ IT.
.sale.If.however.the building or improvement is.sold within one year mcompletion.the SQ.FT.Il(x)H AREA SISQ.FT.
owner Wilds,will have the burden of posting Lha be did not build or improve for Net,
Piave of svleJ. TOTAL:
1,as owner of the property um exelucivcly conameling with licensed contractors to PA
l D
mdmet the pnrjc,,(Sat.7144,Bmarv,,and Plotesniens Codeq The Com ruaur',Li- II
Tia law does ern apnlylolmowmr of pm,n,who Wildsor lmprnves damon.Tied QTY. P ING IT FEE M
whncomracts forsuch projcns with ucomrador(s)licensed pucsuannodhc Commcuors AN 2� REy n
License law. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this reason V
r ALTER-DRAIN&VENT-W TPR D: CITY VALUATION
Dae Lr L'urera.l.BgU
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVI Ii
1 hereby affirm under penalty of perjury ane of the following declarations:
I havemal will maintain.Certificate if Cement m mlLinsurc for Workers Ciml T DRAINS-FLOOR.ROOEARI: CON.. S"IX)RII?R TVI'l1 C(1NSTRUC'CION
saden,as provided fort by Section 7700 if Ne Lmos rCode,for the Dalonnancc if the
/'�k fir which this pcnnil Is i.waeJ. FIX'I'URI;S-1'IiR'IIiAP -
I]1 have and will maintain Workers Compensation Insurance,as required by Section
77Mof the latex Code.for performance of the work fir which Nis permit is issued. GAS-EA.SYSTEM-I INC.q OUTLETS OCC.GROUT' AI'N
cym xy.L g notion lnsum came P^n1d Io `yryt9gv,ns)as 9! GAS-IiA.SYSTEM-OVER
- CERI'1/RI'1 CATS QP EXEMPTION FROM/WOORdKF.[R3'j GREASININUUSTRL WASTE.INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION PIiES
(Thnseaiin need not becameletedlfdat punnh is loom,handreddellm,0111X1) GREASETRAP
PLANCHECK Ir1Ui
m Icsn.l
I certify tbot in the perlirtmancmdthe work l'or whichthis pemlit ix iswrA,l.Ar.JI SEWER-SANITARY-STORM HA.2000E
not employ any person in any manner so us In become subject li the Wmlare,Conifer- ENERGY Plili
Z sation laws of California.Date WA'ITR HEATER WNENf/ELECTR GRADING hili
Z O A,fivum
y NOTICE TO APPLICANT:If,After making this Certificate of Exemption,you should WATER SYSTFEM/1REATING SOILS FEE
I--' become subject to rise Worker's Compensation provisions of the Labor Code.you must
[a forthwith comply with such provisions to his penit,fidl bo deemed revoked. WATER SERVICE
n
.Uti. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ I7 PAID U;nc Rccciplp
Up IhcrwhichirmflimtM1emixnced(See 11097.Cing agency for ciliaperlonnunaof
Ibc work for which this Irrmn n inured ISuC.PINI].Civ,C.)
TO'IAL:
Q U lender',Name TOTAL:
r LcndeLs Address BUILDINGFEE
fy 1 certify that 1 have react his epptic.li.a and slate that the fl n to information in
FMA emeect.l agree tocamply with all city and county ordinances and state laws relining m QTY. MECHANICAL PERMIT FEF. SEISMIC FF.E
U Z budding coiswaiin,and hereby nmbome mpreaonafvew of this city m enter upon the
above-mentioned property liar inspection per stars. PERMIT ISSUANCE ELECTRIC Flili
(We)age=m save,indemnify and keep harmless the City of Cupcnino against
Iiuhilillc,juJgmcm,,cus..and expeases whichmay army way ream,against Trial CT E
id City AR OR ADD TO M ECH. PLl1hl I II
In amscquenev Til dbc granting it nn
thin pcil.
APPLICANT UND IRS UNION AND WILL COMPLY WITH ALI,NON-POINT AIR HANDLING UNIT LTO 10.000 CFM) MECHANICAL.PCC
rp
LA' Oy,S� ,r
s E/' AIR HANDLING UNIT(OVEH 10.000CFM) CONSTRUCTION TAX
licanUContmctor Dale FEK IiALIS'I'HOOD(W/DUC3 HOUSING MO'IGAI'ION FEE
rHAZARDOUS MATERIALS DISCLOSURE
applicant...future building occupant store or handle hazardous material HEATING ONI'T(TO 100.000 BTU)
e'uperatio Municipol Chole.Chnptar 9,12,unci the Hrahh and SulayH[Aq'ING UNIT(OVER 101,1X01 R'1'll)
55J20a1I ❑No VEN'TII.ATIONFAN(SINGLIIRI?SID) PAID
Date RccciPt p
Will the applicant or future building occupied use equipment or devices which BOILIiR-WM11P(lHP OR EXLhou HTU)
mit hmardaus off annamimems as define)by the Ray Arca Air Quality Management TOTAL:
Dison? BOILER-COMP(OVER 100.000 BTU)
❑Yes E]No
I have read the hverdous nadenal,esIs under Chatter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
air
fomia Health ni Safety Coda a«bons 25505,2s my and 25554.1 understandredly
the
than If the NEW RESIDENTIAL MECH. SQ.IT.
buildingJarsern currently have o me,
ll,o is Inalle of aClftiymc'IF Iheorapom
of he myuircmcma wM1ich nntxl he med poor li issunnca of a Cmifratc of(kcuponcy.
Ovocamamhodzed agem Dole I
TOTAL: ISSUED BY:
OFFICE
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««All shrove sign dwWz&artworks m belong to SWYNS EXPRESS MFG.CO., Any duplication is prohibited. ALL R101fr RESERVED."
mam cmxp-i nm. co. Scale : Noted Drawn by :
4166 AVM=AHL,COVIN IL W)IM,CA 91733 Date , 5-21-97 Drawing#
810-"3.3333 • a18-643-I&II(FAX) APPROVED BY :
STAT[YC#554097 • U.L AFM WID#6119SE6
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n � 10893 N. WOLFE RD. GUFERTINO
Scale : Noted ICI i Ex?:m nrG. (0. Drawn : ^
Date : 6-11-97 Drawing
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2446 MERCED AVE.,SOUTH EL MONTE,CA 91733
�Ou 818-443-3333 ' 818-443-1615(FAX) APPROVED BY :
�j STATE LIC.#552097 # U.L APPROVED#E-119586