S 2783 (2) _ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull,DIN;-ELECTRICAL - TERMI'1'NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMB Z'.-MECHANICAL C A Z Q?
BUILDING PROJECT]BEST IFICATION O G V J
BUI NGAI}fIR SS: A SANI'T'ARY NO, APPLICATION SUBMl'ITALDAIT
aef(JJ 9'i.C.Q s� 3
PHONE: r CO" CIORIS NA 1:: 1.1 O:
O .1- D N/C CONTHOLp
HCII ETIIiNGIN-[iR- nom^
"'W LIC :O ADI) LS.' /I - E] 9/237�39
ra. /
CON.yyy.AAACc PHONE. BUILDING PERMIT INFO
I/e I l �D�l� / fy/tytb ❑ Consultant Fecs Paid by Applicant(Initial) BLIT% ELECT , rLu M`C1
/�(' -� LICENSEDC RACfOR'SJDECLARATION d V V QTY. ELECTRIC PERMIT FEE LVC LJ LJ
1 Inauhy aremh mm l am Ticenxed Onto poohsiman nI Chapter 9 pcommoachig JOB DESCRIPTION
0o''Z mSMinn71XN0 r[DivisionJ of the Imlitievsoad Pmfestlnts Code,and mylicenmis RESIDENTIAL:
4 0 i'BRMI I'ISSUANCE
�W� ntfull fnrc�nJ a-: O 0 SFD H1 ❑PITCHING RE-PIP1.
UU Lsenxc 'ave LIeM nl'PLIANCES-kF.SIDIiNT1AL ❑ADI3ITION [I PLUMBING RE-PIPIT
F+Z BI Dalc Cnnlmdnr
Inds ❑MUCI'I-UNIT' ❑STRUIFICAH.
ppy A CHITEGPBDECLAR oo INNELS
Z O fn 7� 1 unrarnaand my plans that(be used ns PaMic reaxrtds CHIMN OA'I'ION
N ❑I'T021M]AMPS
OZ.-p ❑INTPk10R SWIMMING
It POOL
AIR
(=.`n.~,1+1 Licensed Prolcsnirnal 201-1000AMPE IMIROVEMFiNT �SWIAIMING IK301,5
�S4$v OWNER.BUILDER DECLARA'ITON OVER 000AMPS ❑RATA REMOI31iUREYAIR 0DEMOLITION
W tY d 1 hereby affirm that 1 am exenhpt from the Contrmo[a Licetsc Law for the
6 L U following reason.(Section 7031.5,Business and 1'mfcssinns Cnde:Any oily or mum SIGNS IiLECI'ItICAL C OTHER
�" which reyulma a pemlit to ennvtmd,Idter,improve,dclnnl'Ish,m repair uny son or - A"eµ�
to Prior In los issuance,also reclaims rhe applicam for such pcnninntileasigmd mnmme sSPI4CIAL CIRCUIT/MISC. '� O l�L
that lie i s licensed pursuant the provisions of the Convnemr's License Law(Chnpm
([mmimncingwith9cdinn7(NW)of Division 7ul'the lluvinussnnr Professions Code) .MR.METER OR POLE INST. '� COMMP,RCIAL:
a a c , that he is exempt therefrom and the basis for the alleged atemption.Any sing" _ NEW BLDG/ADDITION ❑DEMOLITION
N Sent ]031 S by eny applicam fora prrmil euhjecu Ibe applicant lou civil penal, I'( R DHVICI}5�,„ .4�` TENANT ❑FOOD SERVICE,
nal more Than rise hundred dollar,(551X0.
F Z> : IMPROVEM17NT
pSQ wi ldode,cer ofrddhe son mmye.incoseswithwredfaslheir cele tthmp¢ma IM NG 301.13LHC sIC O'PMiS
will dronework,Cort:The omoroa-,1endcdo Law
u(Sec]1W4,Busmms
63 and Jany who
b G,da:The Ghmmereo License Law Anes not apply m l owner of UUTLB'IS- I'T'CHES IX IRBS
pmpeny who wilds or impmres thereon,and who docs such work himself or Ihmugh
his own cnlPloyccs,prcavided Ihvt sn[h impmvnmenu are,aft intcndeA nr offcrcal for NP,W RG$IDEN'r1AL ELECTR S
sale.11,however,the huildingnr improvement is sold within oneycdr rfcompletinnnhe SQ.FT.FLOOR AREA $/SQ.Fr.
ownenbuilder will:uvc the burden of pmving lM1m he did sol builA or improve Bu pur-
pmc of talc).
01.uv ter of the property,vin esclmively counclin,with licensed c rtractors m IO
utouum the protect(Sec.7044,Bahner,and Professions Cou-,The Cnntrmrrk G- t
,se Law docenotatp,I,to owrernf....peny who milds or impmves o:eruct,and QTY. PLUMBING PERMIT FEE
who contract for such projects with v contractor%)licensed pursuant to the Contractor',
License I.aw. PERIOD I'ISSUANCE
❑ kine,ca �I under So'. ,Ii&PChrrllrsrcasnn
_ AIXER-DRAIN A,VENT-WAI'ER(EA1 VALUATION
Date _
Wali BR'S O .NSATION I3ECLARA'HON HACK PLOW PROTECT'.DEPICT:
I mreby aftrte under Penalty of perjury one of the following deslurtiom: ��• Q�V
❑InaveandwillmainminaCcnifhwmof Crnsnntosclf.insur G,r Woreces Cn, pNOr DRAINS-FLOOR.ROOF AREA.COND. STORIES TYPII CON S'I'RUCTION
sitinn,us poccidod Ga by Suet inn 3700 of the Labor Code,fur Thu perrormmice of the
Wo tivwhich Chictmunn,ismed. ITXTURIS-P13R'IRA['have and wills mai main Workers Crone uiot Incumnce,as required by Section
hofohe .ahnr Gmu,fonhe perPoranunceof the work fnrwhich this parmit is insned. GAS-Hl,SYS'1'HM-I INC.40UTLETS (ICC.GROUP APN
My Worker Co mit�ra r ncc[aria mW Policy nu
Carrier: Policy Nu. rill GAS-EA.SY51'IIM-OVER 4(GA) p
CG I:ICATIi fIF EXIiMPT1UN FROM WON CRS' " J
COMPENSATION INSURANCE GREASUINDUSrRI.WASTE.IN'TERCEPT'OR
BUILDINO DIVISION IBs.6ti
fnno,etirnnced not IN compineJ iftnepermit is furore hundred shill...(SIM) - -- ---_--
GR, SE'1'RAP
nr lu,.) �,,..� PLANCIIECK FET? e "
IcenifytbatintbcperfnrmmwcofIhework rte list' dlshall SEWER-SANITARY-STORM EA.ANI Fr.
sot employ any person in eny an;Naes subject( th Wurkt open- HNERGYPEE
0 z scion Laws of California.Date WATER I(EATER WNENI'/ELECI'R GRADING FEE
z O Applicant
NOTICE TO APPLICANT:If,: :a kii
i.,Cenilicam of Haemp Auld WATER SYSTEM/fREA'I'INC,
F Mnnnc subJam to fhc Worker's(h sapnwisl hlhel�od[ u oust S(31L5 PI?I:
Lakl (rnnwim comply wish ouch prop lFT�ls I dcd� nk WATER SIeRVICE
qEPnu) /14�
CON'STRU IONDING AGENCY NEW RESIDEN'1'I Al.PLM. SQ.CL
.�1 z Date Receipt b
V Ql Inrchyullirm fn.,dome is mstmetion lnndingugency fonhe perfn..be of ��•5}�
the work for which this Pemhif is is ucr(See.9097.Civ.
Leader's Name
'TOTAL:
V Isndcr's Address —^'•�- T
I cenify thin 1 have read This a,hcanon and state ohm the above ini notion is BUILDI , 'T
r�A concef.l vgrcemanhply 04th all city and comny oNinancet mA vine lute.,rmmingm QTY. MECHANICAL PFR IT FEF,
U Z building crnAmninn,and hereby authorizerepresentativesofhhis city toemmup:m the SEES I 1 !F. ?o
ahovenomair I.]properly f p"opow'. PERMIT ISSUANCEO
(We)once to save,indemnify and keep harmless,the City of Coleman against GLI?C 1 hEE
liabilities,judgments,costs and expenses which may many way acerae against said City ALTER OR ADD TO MF.CIL
in nm pump nOil gnantng ufohis(mon". I'LI1M GI2E
APPL •A UND' AN hS AND DLI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10,QMICFM)
SOU .EEG. TION h1ECHA.'CAI.ITiG IL
L S-a7-f� AIR HANDLING UNIT(GVHR 10,00007M) CONSTRUC NTAX
li-n arc of Applo,or or ale GXHA- THOOD(W/DUCT) HOUSINGMI'G HONFEE
I IAZ DOMARRINS DISCLOSURE
Will the applicam or rebuilding a<upum snhm orhmdk hezuNnus mmmial HEATING UNIT(1'0 100.00 BTU)
as defined by the Criterion Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 2553200!Yrs HIiAFING UNIT'(OVER 100,000 H'I'U)
0 VENTILN'IONI'AN(SINGLE.RILSID) PAID Date Recu"#
Will the applicant or furore building ncmapant use epuiptam or devices which
emit haralloux
air
undef by the Ray A.Air Quality Mamgentem BOILER-COMP(3HP OR IOB.U(O BTU)
District? f MIA
Yc 13011 -IRI1NO(A RTU)
AIR CONDITIONER
1 nave nvd Nc hveuNons mmerials rmlalremnna mhdur Ch:apmr 6,95 o[tna Cali- ISSUANCE DATE
fnmiallc hNe Safety G,re.5eniens25505.25533 vnA 25534.1 undemtund ohno if the NEWRESIDENTIALMHCH. SQFE
and i�macm� �m
n'. roibilitymn tify lheoccupam -7
•� / p
of , colo nillal fVsnupnney. - ('
n `me TOTAL: ISSUED BY.
OFFICE