S 2164APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO IUILDING- ELECTkICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING, PROJECT[DIRbO IFICAI'[ON
PEB\�ipNO
P'S'NO
BUILDINGADDRESS: s
SANITARY NO,
N'1'LICATION SUBMI'1']'A1. DATE
/L) -s--_ 9
U I'(fS NAME: PHONE
CONTRACTOR'S NAMB. LICNO:
1rct`D_
N/C
CONTROL#
❑
FCL 3ER; LIC NO:
ADDRESS:
CON'PACf: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (initial)
BLDG, ELECT PLUMB hi
❑ ❑ ❑
I.ICENSED CONTRACTORI III ARA'D(N
I herehy III!,. mal I am Ennrvd under provisiens of chapter 9 (mmmrncing
QTY. ELECTRIC PERMIT FEF;
JOB DESCRIPTION
PEkMIT ISSUANCIi
antiSection 7000) of Divixian 3 of the Business and Prol"ussions Code, and my license is
c
in lull lora and s.
RESIDENTIAL,
❑SFUWI, ❑KITCHEN REMODEL.
APPLIANCES- RESIDENTIAL
License Cia.M Itilli s
Uac-- .e -\gip C S DEC r
A CIIIT[CTS D[CGRATION
1undersand myframshall beused aspublic records
❑ADDITION [I PLUMBING RF. -PIPE
❑AfU1.T1-UNIT ❑MODCIVRAI.
AHON
CHIMN CHIMNEY
(j INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E]SWIMMINGP00LS
PANELS
UPT02(X)AMIlS
Liccmad Prntcssinnol
1201-I000AMPS
OWNIBt-BUILDERDI!CI.ARRI'IONOVER
I hatch, ME on loan I ren exempt floor, the Cournana'.c License Law far Ill,
otiming narrow. (Scctinn 7031.5, Rosiness mad Prof Bions Cale: Any city or county
0 BATH REMODEUREPAIR El DEMOLITION
rFER I�
In(ll)AMI'5
SIGNS ELBC'I'RICAI.
which requires a permit to constrict, alters imports, demolish, or repair any stmcmre
prier as its issuance, also requires the applicant for such p:rmine file a signed statement
SPECIAL Cl RCLA17MISC.
V
that he is licensed pursuannu the previsions of the Comment's License Law (Chapter)
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
TEMP. MEM:R OR POLE I'VE
COMMERCIAL:
that he is exempt handrail anti the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 70315 by any applicant for a permit subjects the applicant a) a civil penally of
POWER DEVICES
El TENANT ❑ FOOD SERVICE
not uaua than five hundred dollars ($500).
❑ 1, ns owner of me prnpmy, nr my employcen wish wnga:n lu their vola to ansalino,
will Jo (he work, and the structure is not memad or oul rel hassle (Sec. 9034, 11 all,
IMPROVEMENT
❑ O'Him
SWIMMING IH) .IiLGC'1'kIC
:ail profession, Code: 1lie Cnnmmml's License Co. docs not a111Y In an owner of
OUTLETS- II'Cl11iS-FIXTURJ(�)
NEW R IDEM'IAL 171 -EM R
property who builds or improves thereon, and who docs such work himself or through
his own employees, provided that such improve areas am not intended or offered for
salt. IL however, the building nr improvement is sold within one yea of completion. the
SQ. FP. FLOOR ARG
SISQ. 17L
-builder will have the burden of proving mal he did not build or improve for put.
rya of sale^).
I, lu owner of the propcny, ran exclusively contracting with licensed cwnaacmrs to
emntmel the project (Sea 7044, Biomass and Prelessions Cadcp The Conaachv's Li-
o:rnitractoty who bandana ioopro
causeonwdwes sol ap"oic",
QTY. PLUMBING PERM/1
-
the Coumamnt,and
calm contacts fnrxuch pmjccn wilhawnnraemr(n)Ilceued Purxuum come Cwnaudnl's
ill
PERMIT IlSUANCI?
Licence Law.
❑ l and exempt under Sea . B X P C for this cameo
Owner Dar
ALTER - DRAIN dz VEMI'-WATEVALUATION
I 1]I
� ��jj ATION
Ufm
RACK PLOW I'RU11:[T. UF.VICF.1I
wIherlunJerRKEIV!ry.nOMidpesjury uncATION
fill ing dedaratinns:
Emeand will roninmin aCarificmrofConsent losclf-ime. forWorkersCwmpam
for by Become 37IX1 of the Lnhor Ctde, lirt the performance of the
roan. as hick this
work This permit is imuad.
DRAINS- FLOOR, ROOF, AREA,
STORIES 11'1'YPECONSTRUCfION
tel
FIXTURES- I'ER'I'kAP
hma ave
have and will Ioai, bin Ire ad's Counpermor.(if the n r knmce, h myuiwri by Scctinn
and
3]1111 of the Lahur Cadc,I'ormc performance of the work for which lois permit lx iounl.
/�
CAS-EA.SVS'fl!M-I INC.40U'ILE'I'S
OCC. GROUT'
AFN
C Workf� y�mon j( it Polity nun r
My Wo - Pit, ort zoor YyJit PNot t\x-\f'12
rj
k
GAS-G.SYNI'IiM OVER4(F.A)
CERTIFICA'1'Is. OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GRGSPJINUfISTRI. WASTE( I:NCEI9OR
BUILDING DIVISION FEES
(This sectionneeJ nota mmplclM if the gamut is bureau, hundred dollars 011011)
nr Icss.)
GREASE'I RAI'
I'LANCHECK FEE
I carflymm inthc perfnn),im, at the work I vibachmis permit is imicd. I shal l
ploy any person in y Innet so us to become nohiao,, the Walker,' C isen-
,air emanun
SEWER-SANHABY/]ORM EA. 2001T.
ENERGY FEE
WATL'li HIiA'flat VBN'i'113LP.C'IR
GRADING TGE
swion Lnwx of Culilinni. Dam
Applicant
NOTICE TO APPLICANT': If, afar making this Certificate of Exemption, you should
u Luton Cade, you nue,
subject Rome Worker's Cumpeusadon provisions of mto
WATER SYS'(' /IREAl ING
SOILS FEF
Ibthwimanmply wahxuch prockwmm this permitxhall aeecmed m-lod.
WATER SF ICI?
CONS] RUM [ON LENDING AGENCY
I hereby alrrint,a0min is a commerce landmgagro, forte perfwmmes, of
NEW SIUENI'IAI. PLMB. SQ IT.
PAID
Dae Rn<ip11f
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lender', Name
'TOTAL:
Lank,', Addaucs
BUILDING FEE
I certify mut I have anal (his rpnumium and tam that the rave informminn la
contact. l agree m comply exult all city ad cmmonimmeex and mute lawsrrlmingm
hulking construction, and hereby authorize representatives of thistaym enter upon the
QrKy. MEC( IANICAL PERMIT F
SCISS F-
PERMIT ISSUANCE
Ii1.liC IC FE
1'1 (NGF '
above mentioned property for inspection purposes.
(We) agmem same, indemnify and keep harmless the City of Cupetinw against
liabilities,judgments, costs and expenas which may in any wayaccmeagainst said City
I. consequence oflhe tiou of this penult.
ALTER OR ADD'10 MECH. Ca
AIR HANDLING UNIT (TO 10.000 CFM)
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN"I
SOURCE REGULATIONS,
MI!.I C -5-7,1
AIR HANDLINC UNIT(OVP.R 10.000CF Up❑
CONRI'RUC 'AX
Signature of Applican✓Comremor Date
IIALARDOUS MATERIALS DISCLOSURE
Will the applicant or future building metanot score or handle hazardous tomerial
F.XI IAUS'I I fooD(WIDUCT)
GMITI ATION pini
HEATING UNIT LTO I(g),INM) BTU) Ok(
as defined by the Capetian Municipal Code, Chapter 9.1 2. and the Hcahh and Sufmy
Cade, Section 29532(d?
E3 Yrc Nu
HEATING UNIT (OVER Ifi OIM) BTU)
PAID
Dam RcmiplN
VENT LAI ]ON RAN ISI NGLE RESID)
-
BOILER - COM(' 0HP OR 1(111.00) BTIO
mcwn n
JR nayr� me • s r fulum huilding occupant use cyulpnlcnl or devices which
nnunnlnnntx nx defined by the Bay Amr Air Qmlity Mmmgenmm
Uisnid?
❑Yes r�No
]yyfA4 0
BOILER-COMI'(UVHR 1110,04 11111)
AIR COMDR IONER
(have readthchedic.Sctio ntequi
ISSUANCE DATE
NEW RF_SIDIiM11A1. MGCIt. SQ. Fr.
that Ba,
fumia Health & Safdy Cade. Satires 25505, 8533 and 8514. I undentard Bim Ban,
533anumler understand
gdme nm currently have a tenant mm it is my mspmsihility m notify me acapanl
't n
air ems whichmuslhcnmtpdsnmissuamazfaGsilicate of Occu Banc,
—\le,.
ISSUEDBY:- Min i�N7-A-UCC,
TOTAL:
�
Owner or Blob zedagcnt Date
OFFICE