S 1421 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pl3k IT NO
BUILDING DIVISION APPLICATION/IllPLUMBING-MECHANICAL 1421
BUILDING PROJECT IDENI'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
r '-r� 2/All
UWNIiR'S NAME', I'IIONE: CONTRAMOII'S NAMIi: LIC NO
H1_OIfar. q. O NIC CONTROL W
ARCHITECUENGUsl LIC NO: ADDRESS'. AJ-/ ❑
I o IfrC c
CONTACT: PHONE: BUILDING PERh1IT INPU
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELE(7 PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONI'RAC'I'OR'S DIi(LARTITON QTY. ELECTRIC PERMIT FET?
1 hereby mGna that In tOrnWil made,providmn,of Chapter 9 Qaunnu ndog JOB DESCRIPTION
O y'Z will Section 7(RXBofl)ivisinn 3 of he Blssinevsvnd Pafevaons Code.nnd Illy license is RESIDENTIAL:
F W= n full farce and effect,,,r' OO e ^� PERMIT ISSUANCE
�V~ License Class V�It, Lic.p r3-)I'IJ7J El SCOWL ❑KITCHEN REMODEL
Q V
on<' Due-Commetnr
APPLIANCES-RESIDENTIAL []ADDITION El M
PLUBING RIi-PIPE
ARCHITECTS DECLARATION ❑M1fULTI-UNIT ❑STRUCTURAL
F�h PANELS
ZO NZ IundcrstanJ my plans atoll to ascots,public renMs MODHCHIMNIGYREPA
07_�O UP TO 21X1 AMPS El INTERIOR ❑CHIMNIiI'REPAIR
F�nLw Liccnad Professional 201-IIXX)AMPS IMPROVCMENI SWIMMING POOLS
d ydE; OWNUR-BUILDIR DIOLARA'NON
C a,COVER IIXXIAMPS ❑BATH REMODELIREPAIR Q DF.MOLI'fION
d I hereby mlti,m Ilan I am exempt from the Counctor's License],so liar the T Q^
X 3 Cc V (Sec
following reason . tion]0315.Business and Professions Code:Any city or county SIGNS FLFCTRICAL ❑ �6 OTHER �T�f",Sfa ,er
which reptiles a ar l to common,.Im,,impasse,demolish or repair mr,uructure byr ' 'raj
C, Which
prior to its issuance,also requires the applicant for such permit to file a signedsmmment SPECIAL CIRCUIT/M ISC
thin he is license)punuam m me provisions of the Cnntreclnrs Liccns law(Chapmr 9
W�00 (°"mmencing with Seninn]fNglof DivisinnJ nfthe Business anJ Pnafessinns Gde)nr TF,M11P.METER Ok PoLE INST COMMERCIAL:
d q a E that he is exempt thsamfoun and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLf DON
W..y Section 7031.5 by unya,liutm lorupe,,ail Objects the upplimntm a civil penalty"f POWER DEVICES ❑TENAMf ❑FOOD SERVICE
I more than nv"hundred dollars($500). IMPROVEMI?N'I'
�ydQ ,1.a,awne,of the prul>vrty,onoy smployces with urge,as Jwi,selc,lcu, matini SWIMMING POOL ELECT RIC
p. will do the work,and the structure,isot intendedn,offered fill-1.(Sri,T94,Basis— ❑OTHER
W se vad Proof..tons Code: Use Claims,nr's License Law docs not apply no era"caner of OUTUEIS-SW'IfCHES-FIXTURf•_S
property who huilJs or improves thereon,and Who does such work himself or through
his own employees.provided that such improvements art not intended or offered for NEW RESIDENTIAL ELEC-cR SQ Fr.
sale.If.however.the building or improvement is sold within one year ofcompletion.the ' SQ 17.FLUOR AREA $/50.F1'.
wo cr-builder will have the burden of proving than he did not build or improve tin pur-
pusc of a ile).
1,mos owner of the pmpeny,am exclusively contacting With licensed comnmurs to TOTAL:
mlmel Ile pm,l¢I(Sec 71,43,Nus unJ 1'mles Ix Cndc I file Com, Li-
w+law des mol applYmnn owner of pn:peny who huildx or lmproven thnnm,nnJ QTY, PLUMBING PERM IT PHI,
who cmmmO,for sten pmjecls with v corn ccon(O licensed pursuant Ice the Conwnnrs
License Law. PERMIT ISSUANCE
❑1 am exempt under See. .B&P C for this mason
Owner Ila¢ ALTER-DRAIN&VENT-WAIT:R(EA) VALUATION
WOR KHR'S COM PENS ATION DECLARATION 13ACK FLOW PROTECT.DEVICH Q�
1 hereby affirm under Penalty of perjury one of the following Jec Emotions:
❑ I have and willonlinvlin it Ccnificntc of Coas:mnomlf--invum for Wmkcds Comp...- DRAINS-FLOOR.ROOF,A R HA.CON D. S'fORll!S TYI'I?CONST'RUC'TION
smion,as provided hr by Section 3700,41h,Lahnr Code ler the pert onionsf th
oe
I monk fin which this perulit is issued. FIX"TURES-PER TRAP
❑'lase and will maintain W'orker's Compensalion Insurance,as required by Section
3700 addle labor Code.for the performance ofthe work lir which this permit rs issued. GAS-EA.SYSTEM-1 INC.a OUTLETS OCC.GROUT' MIN
ICvaymWcro.,ktULwli'rcmvc�me,and Pny`ar, 9pcUPolicy
GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEM[MON FROM WOR KERS'
COMPENSATION INSURANCE GREASI%INDUSTRL WASTE INIERCEPI'OR
DIVISION FEI3S
(This section nccA not hcmmplcmd iDM permll is Tatum"hundreddnllurrc($11X) Bull
E[RAP
or less) I'LANCHI3CK 1111!
cenifythul in lila pcymensa w,.,ewmk Rrwhichthi,,permit isissual,aball SEWER-SANITARY-STORM I?A.21X1lrf.
not cnnploy any pe:�nn in any manner so as m hconm wbjecl m the Waders'Cnnnpeln- ENERGY Pule
Z2Z. nation Laws of California.Dale
A locant WATER 1113A1ER W/VENT/ELECI'R
pP cknuLNc air:
= NOTICE TO APPLICANT:If, for making this provisions
ns of of Exemption,you ahold WATFN SYSTEM?BEATING
>
become subject to the Waders Compensation permit
shal oedo labor Cole,you meq SOILS FEE
�
forthwith comply with such provisions or this permit shall be deemed revoke). WATER M7RW1GE
Po Q
� 'z CONS'I'RUCI'[ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
V 0 IheaebYutlirnulul Iheaiauumswction lending agmey has lbs pcA'unn:metnf Dote Rca::plis
Fthe work for which Ohio pe nnitis issued(Sw.NKUCo,.C.)
O U Lender's Nance TOTAL:
Lmrdera Addmxs TOTAL:
f-' G I cenify that 1 have mad this application and state that the above information is BUILDING PEE
VJ correct.l agree to comply with all city and county mdinamces and suite laws olatingto QTY. MECHANICAL PERMIT FEE
V Z buildingcommu nn,anA hembytinhorize rtprcmnhtive.of this city mercer urymthe SEISMIC FEF.
above-mentioned property for inspection purp:nes.
(We)agree Ice save,indemnity vad keep hannluss Nc Cay of Call against PHRMII'ISSUANCE ELF.CI'RIC FEE.
II"hlitics,jtdgmcnw.costs nnJ expenaa which atop in any way occas a,lar,taaid City ALTER OR ADD TO MECH.
Inco
roo,.um¢v of the grunting Wilds pc mil. PLUMBING 1143
APPLICANT UNDERS'T'ANDS AND WILL COMPLY WITH ALL NONA'OIN1' AIR HANDLING UNIT(TO 10,000 CFM)
SOURCL REGULATIONS. MECHANICAL Ila?
•�7
1 � xKK I 1J AIR HANDLING UNIT(OVER 10gq ClN)
CONSTRUCTION TAX
Signture ofApplicant/Clracmr
EXHAUST HOOD(W'/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lheupplicaiter future buddingmecupumdonor handle hazallous mIDenal HEATING ONE I(To I00,000 BTU)
as defined by the Cusco.,Municipal Corse,Chapter 9.12,and the Health and Safety
Cade Section 25542(a)'! HHA'I'INC,UNIT(OVER 100,(XI(1 B U)
E3 Yes K",
V ENl'I IAOON FAN(SINGLE RES 11H J
p
Will the app..... or furore building occupant me equipment Qu or devices which BOLI ER-COMP(1HPOR IN)NE,b'LU
mit huurdous air cnnaminams ss dehneJ by the Hay Area Air Quality Management )
Uintnm? TOT l
❑Ynjfv: B011.13k-COMP(OVER IfAI,fNM1BTU) 1999
I have read the hamnbm materials repuirenmms under Chapter 6i95 of the Cook- AIR CONDI'DORER
ISSUANCE DA '
lirmiu Health&S lmyme CAEOd,ca e o errs 25505,25511 mid 255]3.1 m notay the
that if the NEW ItCSIUI3N'TIAL MECH. SQ.Pr.
building docsnmcummly is"II 'neral,that lt'wmyicol 2, mcIfimOaf ,c occupant
nr me regniremnntl wmcln Iatm be Ism Pon,I')iXamtnnn ora c�inam nronnnptnmy. B y
Owner On amhonzW agcm Doc TOTAL: IS -
OFFICE /