S 2490 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-h:LEC'pRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECIIANICAL [1
BUILDING PROJF,CT IDENTIFICATION J
2490
BUILDING ADDHI:SS: / ^ 1 SANITARY NQ APPLICATION SUII'ITAL DATE
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U 4 8 ill\1 f -
'NER'S NAME Sak ti i1S�l COMI'RACI'OR:S NAME: LICNO:
NIC CONTROLp
p RCIIITGCTI GINEh 1_ I I,IC�)-1 � ADDRESS: ❑ /'/�
CONTAFI 'JVJiO_`V�� PHONJ BUILDING PERMIT INFO
( r t-ry1�� ons ❑ Consultant Fees paid by Applicant(Initial)' nLDc ELECT PLUMB MECH
LICENSED CON'TRACTOR'S DECLARATION QTY, ELECTRIC PERMIT PCE
I hereby amen that I.m licensed sacs,provision,of Chanter v armmemeht6 JOB DESCRIPTION
SUlitlefiorc�sool 1)....bn3ofmoklteinaseanRv,ionrCodatmtnylicermie Fol � 131M11'ISSUANCE .• Be
TU
Um wClass Lic.k ❑SPD . [IKITCHEN REMODEL
Fzw Dam Compactor APPLIANCES-RESIDENTIAL ,DDITION ❑PLUMBING RE-PIPE
on=qaf ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
F PANELS
z O 14 z T understand my plana shall h:used us public records MODIFICATION
.Oz^ lll'T0211n AMPS
EPAIR
F4F-lli] Llcen.ud Professional ❑IMPROVNT 12 ❑SWIMMINRPOOL
201-1000AMPS IMPROVEMENT ay. at ..OWNER-BUILDER DEthe RAI PON
Commun ❑DEMOLITION I'OOIS
C Q I laminator.that 1 am exempt from the Communes Licene Law for me OVER 10(10 AMPS MOI]IiVREPAIR I31iMOLITION
lyj a IL F following moss.(Section 7031.5,13c,deva and Professions Calc:Any city m county SIGNS ELECTRICAL OTHER
E+^W wti(I Peru.... .t It r ' p I'.h,a wpaii,an,auu.m
y pnusloil,i...mor.alkonamne, he a,,IieaaIf 11 a file a,i,Fadvta,aaud SPECIAL CIRCUII'IMISC.
C�QE
that he licensed pursuant t the piravisions ofas,Contractors Liversc La (Chapter
((omit 8 Sectionth ]000)ofDivision 3oftha Business an it mfnsr oJe)of TEMP.METER OR POLE INST. ��1 .
d 6 ea the he is caempt Ihen4rnm and the basis Iva the nikgcd exemption.A ivlatinn of
N Section]ID LS by any npplicam for a permit suh'ecd then Gan 'I ❑N i LAG/A IDN OEM ION
1 pP vl penally of POWI3R DEVICES
nature than five h undyed dollars($511Ip. '1'?NANT OD$1?RVIGE
zQ I] [.;is owner of the pm,,any,or my employees with wages as th to cation, SWIM M INC,POOL E'LEC'TRIC IMP.. EMCN'1'
will do the weak,and the stmcture is not intended moffered forsa (Sm.T OTHE
W ro and Professions Code:The Contramors lumme Law does not apply to an o OU'O,ETS-SWITCHES-FIXTURES
property who huilds or improves thereon,and who des.such work himself or throe _
his own umpinyee..provided Ihit such intpl'ovnncnle ure not intended or offered for NEW RISIDHN'HAI,FLEC'I'N SQ FI'
sale.ll,hmwever,the hnilding vrimpnwcmcnl is svlU whhin one ye�ar��tIIR(�plan ,Lha SQ.IT.FLOOR AREA $ISQ.FT.
/ h 1Jr will h' thebb fp gthth JJ tb It\a" par
P&?'],
�a/fk
owner (tel p pony d .' IYcontracting Id I' d ty' ��-
9I I'hep j ppl ]IF14 B : J P f:: Code)r 91 C t 1,-
sellwdoea nm tpplyl v wit rot p-+pony whtbl'laz o ' p sun thereon. PLUMBING PERMIT PCE
who ciarma is for such pmjmm with a Contortions)limnwd pursuant m the Contractor
License Law. MR ISSL NCR
❑I am emir" Sm. B&1'C for this recon
Inc AIME- A,VENT-WA'UIR(EA) - VA "IONN
iter WDRKIi r Nn IT PPNSATION DECLARATION ]it
CK FLOW I' i RI ial al®
\1 I hereby sreallder penalty of perjury ens of Ihe following Jcdnmtivns: ICV�IC�'J
I have and will maintain a Ceniticam of Consnn nl elf-insure for Worker's Crmpem DRAINS-FLOOIC 13A,COND. STOR .. '1'YPEC RUCTION
sation,us provided party,Section 3]1X1 of Ihe Latur Gda,far the performance e1 the
work Iia which this payout is issued. 171X'I ORES-PER'1 RA
❑ T have and will maintain Worker's Co.raw.......Insurance,as required by Section
37W oflhe Labar Code.for the performance of0e work bnwhich lhi.spemtit is issued, GAS-EA.SYSTI3M-IINC.JO OCC.GROUP AI•N
Ca Worker's Compensation Insurance carrier and Policy number arc:
Cameo Policy No,FROM
OAS-EA SYSTEM-OVER4(IIA)
CER'I'INICATEOFBAI[ONII NFRAN WORKIiRti'CE GRI3ASEANDUS'1'RI,WASTE IN I'ERCEP'[OR
COMPENSATION e .hit iNfut
This motion need run becomPlcled if the permit is fomite hundred dollars IS I W) BUILDING DIVISION FEES
nrlssl GRI3ASE'fRAP
I certify that in the performance of the work for which this munit is issued.I shall PLANCHF:CK FEE
notentpiny any person in anymennerso as m bevomemJnlmfto the Wurkem'Con rem SEWER-SANITARY-STORM PA.2W IT. a
Z saliva,l,nwa of Cnllhania.Date 1 ENERGY FEE
zC Applicant WA'I'[R HLATIiH WIVENIIIJ.EC'B GRADING PEE
.N. NOTICE TO APPLICANT:If.after making this Cenificme of Exempti.......b.old WATER SYSTEMRRFATING
a > become subject m the Worker's Compensation provision.of the Labor Croc,you must SOILS FEE
ELI forthwith comply with such provisions or this pemnl shall be deemed revoked WSJ ITR SERVICE
Q
z CONSTRUCT LENDINGAGENCYagency
NEW ftESIDEN'IIN.PLMB. SO.PC PAIDIj. r m
I..J I hereby amthi that there ixacn (Sec.3nlendin6 a6ency for the Performance of Dae Receipl6
U the work for which this permit is issued(Sec.309],Civ.C.) /� 0
Q U Lender's Name v 'f(YI'AL'
aLender's AdJrcss 'I'O' I•
I certify that I have read this application and slam Cost the above information is BUIIA NO F
lA somal.I agree to comply with all city and county ordinances and sem laws relatingh, QTY. MECHANICAL PI2RMIT FEE
(J z building mrounction.and hereby amhorize representatives ofthis city tomeruptm the SEISh E dam
,bele-mentioned propmy far inspection pcarries. PERMIT ISSUANCE(We.)agree to save,Indemnify un I keep Iosnnlu.the City of C.penine against EL ' it PEE
liabiliticx.jmlgments,enols and expenxcx which nwy In tory way metmugaiol said City ACI'IIN OR ADD 10 MIiCII.
inamscyra
uance of the mining mark parson. PL GIBE a
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH At.].NONPOINTAIR HANDLING UNIT(TO 10,000CFM)
SO' ULAT M: 1 NICALFEE
/ Od A1I211ANDLING I1Nl'f(OVER 111,1100CPM) CON."RUMON'rAX
'gmnure nl ApplicanUGmlmemr Date EXHAUST HOOD IW/DUCT) HO 'LNG MITIGATION PEE
IIAlARDOUS MATERIALS DISCLOSURE
Will meapplimin future building ecerawalamreor handle Immulous material HEATING UND'G'O W.Ml ETC)
= as coined by the Cupenin)Municipal Code,Chapter 9.12,and the Ileulm and Supply
Cade,Salton 25532(10'? HHA'I'ING UNIT(OVI3R 100,010 It'I'U)
❑Yes ❑Nn
VEY CATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant use eynipmem ereevices which Dare Receipt p
1 huzlNous air contaminants as der,red by the tiny Arca Air Quality Management BOILER-COMP O HP OR 1(X1100 BTU)
strict'!
❑Yes ❑N. BOILER-COMPMVEIS 100.0110It'1'U)
I have pad the hamper., led.[,,mryiremems trader Chapter 6.95 vflhe Cali. AIR CONDITIONER ISSUANCE DATE
forma eahh&Safety Code,Srctivns 255!15,2551]and 25534.1 undcrstunJ Lha if Ihe NEW kESIDF.NI'IAI.MECH. 5 /T_ .+f
buJU tot cumnd a n.Nul it i+mymepnu'ibility to nullly the ncnlpunl / f'/
.I'll 1ui 'ments I mel tufaccrnk,uleotl( yyeCy. - C
rofad mizM a'em Data /
ISSLFDBY:
OFFICE