S 2584 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BOB LDINO-BLECiRICAL PERM]'T NO.
RNG.MECHANICAL
BUILDING DIVISION APPLICATION/PERMIT BUILDING PRHdBCrIDENCIFICATION S
2584
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL PAT]
19TVZ- How-q D CougT wzem0 GA (Lojd! 9) 2�2-Z g
OWNER'S NAME: PHONE. CONI RAC I OkS NAME: LIC NO'.
5 A/LEY WOall "0-118-19128 X!L (AI.;I NIC CON"1'µ0L#
ICI - ?NGINLLR: LIC NO: ADDRESS: ❑ �• / O
y+r C-2/23c
CONTACT PHONE:: BUILDING PERMIT INFO
M1kE CHEW W-2ZS-2 7*Q ❑ Consultant Fees Paid by Applicant(Initial) BLDGELECT PLUMB MUCH
L, LE�f—
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FIFE
I hereby ofnrm mw nn
1 am licensed ander provisions of chapter 9(cm, eneing JOB DESCRIPTION
0z2 with Seetion70(XHof Division 3ofthe Business and l4ofessions Cale,and my license is RF
WOO PERMIT ISSUANCE
10.1- in full force and effect. DWI. O KITCHEN REMODEL
2UU License Class Lie# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
l-zW Date Corrado
ARCHITECTS DECLARATION ❑MUCf6UNIT (STRUCTURAL
PANELS MODIFICATION•2 O N 2 I understand my phos shall be used us puhl'm words
024- UP'10200AMPS 01 N1ERROR ❑CHIMNEY REPAIR
F`3CW I.icatwcd Pr "n 201-IIXIHAMI'S IMP ENT GSWIMMING POOLS
OWNER-BUILDFIR DECIARSHON OVIiR IIXNIAAIPS O BATAµIiMODEURF:PAIR ElDENOLITION
C Q 1 hereby of rte tial I am exempt front the Contractors License Law for the
L Xtil 30ILUfollowing meson 1Sueiton 7031.5.Business it 11ndesslons Cade:An ciy a suroy SIGNS IiLECTµ1CAL
❑OTI{IiR
0 to, which requires a rt to construct,,alcor,improve,Jemulish,or repair any su
0.0 prior to its issuance,also nowines the applicant for such permit to file to signed statement SPECIAL CIRCUIT/Mgc
that he is licensed pursuant a the provisions of the Co muffles License Law(Chapmr9 -
q�0 (camrramr. gwith SuuJon 710X)of Division Sof the l{usinessead PricloWom Code)or I EM P.M ETGR OR POLE.[ASTIC COMMERCIAL
but he is exempt t ban fi stn aW be basis fur the nllegcd exmnption.Any violation of ❑NEW ItLDGIADDITION ❑DEMOLITION
4X1 W Sect...90315 by wry tq,shewafora per tnit .hi""the upplicum ma a lvl ,nalty of TOWER DEVICES ❑TI:NAN'P (-1 FOOD SERVICE
�at naturnme than five hundred dollars($5W). IMPROVEMENT
1 0 1,asnwmmul'11,NoTary,onny employees with wages as lheirsola compensation. SWIMMING POOL ELECT RIC
7F0 will do the wod,wnd liffeeucure is not intended nn award for.1e(Sec7044,Husiress 0OTHI7H
W-m wood Professions Ca1e']lie Commerce,Licerwe Law Jets not apply to an nwner of OUTLETS-SWITCHES-FIXTURES
C 3 Pmpeny who builds rr impmvcs thereon,and who does such work himself nr through
his own employees,provided that such improvements not not intended m offered for NEW RESIDENTIAL ELECTR SQ FU
sole,If.however,the building or improvement is sold within nue ysarof cnmplmion,the tiV 1-r.FLOOR AREA E/SQ.ITI'.
r-builder will hove the burden nfpnming that hu did nm hold or Improve for or- �` ,S 4aa
cacnf2la.1. ` }S Lwly# AIZ
0 1,m owner of Elm P....wi,ran uxulnxivdy enntntcting with licensed eontrnemcc to AI' `V h'
canswet the project(Sec.7044,Business and Professions Cola)Ttte Contractor's Li- S
cense Law does not apply to an nwneroTeforry who builds or improves thereon,and QTY. PLUMPING PERMIT FEE A
whocommets for such projeen with a comranorts)licensed pursuant athe Commorma
License Law. PERMIT ISSUANCE w /y F
0 I am eiempt dYet Sec. =N--,
N--,B&P C for this mason 4
Date ALTER-DRAIN&VE Al ER(EA) VALUATION
WOItKFR COMPHNSAII1 y'.CLARATION A e I RACK FLOW PRO( )EVIL" �^
ntmeny mnrttt tamer penalty orperim�lro or mo rnunwing e�wranon: L J 88�
(have and will tnuinmin uCenifrvta Of Gmsenno self-insure for\4rrker's Cntnpcm DNAINS-FLOOR.ROOF. H Y STORIES T'YI'13 CONSTRUCTION
station,as provided for by Section 3700 of the Labor Code,for the perfnmtance of the
work for which this permit is issued. PIX'ILHGS-PER TRAP
0 1 have and sill maimain Workers Compcnsminn Insumme,as required by Section
37M ofthe labour Cock,for the performance of the work for which thismbit is issued GAS-FA.SYSTEM-I INC.4 Ol LES DEC.GROUP APN
My Worker's Conmpensation Insurance carrier and Policy number we:
Carrier: Policy Na.: GAS-IA.SYSTEM-OVER 4(Ad
Cliff]I FICKFE OF EX EMFHON FROM WORK ERS' Gµ1iASIJINUUSTRI.WAS'T'E IN'FIiRCEFfOR
COMPENSATION INSURANCE BUILDING DIVISION EEHS
(This section need not be completed d the pernti(iw our one hundred dollars($100) GREASE TRAP
orless) PLANCHIi KFEE iO
I certify that in the performance ofthe workforwhich this Permit is issued.)shall
SEWER-SANITARY-STORM IA.2ft0 FT
not employ any peasm in any manner sr as m beermc zubject vt the Weirton'Compete- IiNERG IE /
O z scion laws of Culifomia.Dae WAITiR HEATER WNENTIELEC IR GRA) liE
2 Applicant
i..t FN-t NOTICE TO APPLICANT IL after making this Cedifewe Of Eacmptinn.you should WATER SYSIHM?REATING SC
F resume subject m the Worker's Cmnpen',dim'answnns ol'the Labor Cook,you must
forthwith comply with unch p usidou,nr Wis permit shall hu deemed mvokal. WAI'EII SERVICE
as CONSTRUCTION LFNIDING lend AGENCY NEW RIi51UGNTIAI.I'LMIi. SQ.FT. 1'AI
❑ 2 Date eceipt a
U p k fr%hich nn tbauhcrc issue(Sec.30 lending agency for performance of
0 'he work for whim this permit is issued(Sec.3fy)].Co.C.) T I
U Lender,Name
WLenders Addcerayt TOTAL: BUI )INGI iE
1 cenify that 1 have rend this application and stem that the above inbmnmien is
rFi hcnrrcet.l agree nt comply with all city and county ordinances anA store laws relating to QTY. MECHANICAL PERMIT FEE
V G hunlihmgumswetiun,and lerchynuthnrirer.Ptesemmivcsofthis city,,cutcntpnoo the SEISMIC II:3
7
shove-mmntinned p,O,,,iy for impectlrn pu'q,n... \ PENMI'I'ISSUANCE. 2
(We)agree to save,indemnify and keep hatless the City of Cupenino against ELECTItI
liabilities,judgmems,eusts and expenses which may in any way accrue agaiml said City ALTER OR ADD TO MSCI I. PLUMBIND
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00 CFM) .: O
SOURCE RE("/II,A'TIONS. M NSIR[ .
"EC.it AnDONS AIR HANDLING UNIT(UVEH III,IXXI CFM) CONS"I'Rl T )NTA
Sig—nvmm/-t1 ApplintnllCu vcnrt Dem EXIIAUS'I 1 IOOD(WIDIICI'0 HOUSING MI'1'ICA'1'I FEB
HAZARDOUS MATT rLS DISCLOSURE ut
Will the applicant or future building occupant store or handle haumdous iawenal IIIAI'INC,UNIT(1'0 1(Man B 1'U
as defined by the Curydinn Municipal Cale,Chxpmr 9.12.and the Health tend Safety
Code.Section 25532(x)? 1 HEATING UNIT(OVER 100,000 BTU)
❑Yes ON. VENTILATION FAN(SINGLE RESOD) PAID
Doe Rmeipt no
Will the applicant nr furore building oe the[s use equipment or devices which
Int haeweum
ds air commninns ns Aefinesl by the Hay Arev Air Qn;dily Munugontunt BOILER-COMP(3HP OR 100,000 BTU) TOl'AI.
Dixmlct9 HOR.ER-COME(OVER RXIOX)BTU)
❑Yes 0N
I have real the hmallous materials requirements ualer Chapter(95 of the Cali- AIR CONDITIONER ISSUANCE DATE
frown Health.&Safety Code.Sections 25505,3533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. SQ.Fr.
building dors nn¢urrently have a tenant,that it is my responsibility to notify the occupant \'
of the mquiridemsw ich in be meAcear in a of a Cenifaateof Oveupun9.
Owner m amhoriied a,,W
Y. Doe TOTAL: ISSUED BY:
OFFICE