S 1201 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUH,DINt;-ELEC'OUCAL PE IT NO
BUILDING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL PEI
1201
BUILDING PROJECT IDEN'1'IFICXf((IN
BUILDING ADDRESS: SANITARY N(1. APPLICATION 1111111'If F
104(,,) M14oE2A DQlVC
OWNERS AMEL: E. C RA(G)R'S NAME: LIC NO:
AH SIVA, MJ1I'H(IN .—n o ):t GuA/sTie Z776x✓ 9995/ ""
�I "ADD
°NTN Lx
CII ':'IFNGINFER: LIC NO: UD S5: ❑
0 M<Made-J Ay2 C,A%4wk PA 4cT, CSS 9.5l7-
CONTACT: 1.11ONJE: yc4 oS12S BUILDING PERMIT INFO
UDA`j R- S I M A M 172 (f�0-9 ❑ Consultant Fees Paid by Applicant(Initial) H; II
Cf PLUMB MEC
LICENSI?DCONTRd code,resmo RATIOofCh.N QTY ELECTRIC PERMIT I'I%E JOB DESCRIPTION
1 hereby affirm.hot I ran licensed under provi"inns ors Caper 9(cam.mnse is
woZ with Sccrion]gp)of DivisinnJ of the liusincsv and Pmlcscinns Crdc,unJ my license is PERMITISSUANCE RFS IDENTIAI:
F1-0 irld116acand cDiyl. y9ygs-/ ❑S'DWL ❑KITCHEN REMODEL
�UU s In,, 40 COn�S - APPLIANCES-RGSIUIiN'I'IAL UUITION O PLUMBING hit PIPE
F Z Dam • 3/• T o Comrtcu r JJs
.�¢y CMUI.TI-UNIT OSTRUCTURAL
ARCHITECT'S DECLARATION
1,,,to N PANELS MODIFICA]'IUN
ZO O=2 I undersand by phos xM1all h meJ m public rett.Ns UP TO 200 AMPS
[I INTERIOR CGHIN1NIiY REPAIR
FLt:ac LLamed It levsional 201-1000AMPS IMPROVEMENT ❑SWIMMINGPOOLS
OWNIiR-BUILDER UECLARAI'ION OV I(XNIAMPS O BAI'It REMODEIJREPAIR CDEMOLI'I ION
IY C< 1 hereby affimr stmt I am exempt from the Cansaaor's License Law for Ibe
X..i Ct following reason.(Section 7031.5.Emboss and Professions Cae:Any city or county SIGNS ELECTRICAL ❑OTHER
W a i7 which requires a Flom,.a)construct.der,improve.demolish.or repair any wacture
1_'.4--0< pro ht ,h ,pfc tt hp in fl , J.emmcnl SPECIAL CIRCUIT/MISC.
fly man dp xu d I m Id c t r l [Clptcr9 COMMERCIAL'
w_mCo (mom b.,in 7gN0 fDi .i. J lithe Business dP Professions Code) 'I EMP.ME[HRORPOLE1NSl'.
a
W—
C but he is exempt mercfmm and me Nasis name alleged exanpuoa.Any violatmn of ❑NEW BLDG/ADUI�IQry, ❑UISMOLII'ION
mom Section 7031.5b applicant for 't subjects the applicant to a civil It f POWER DEVICES {{..//
y hundred
prmu 1 Pp emilly O'IMPRO S CFWUSERVICIi
not more man Esc hundred Anllms?SSW). IMPROV h11iNT
❑.t C cr lithe ,,ndt.d propcoy,or.,lot de left,thwagmastMirse. (94.Business SWIMMING POOLELECTRIC
a will do mo work.C d e:The Com n sol sJccad a Law docs sato(Sly ,,all ILtner If C Ol'1IER
aim and Pnffoxinns Code:The Cintmmir:v Liana Low dm:n not apply n.un owner of OU'll,l?TS-SWITCHIiS-PIX'1'URES QA.
propcny h h ld. in ib,nova,in J b does:such to al nsit�
k M1 If through —LY�tf
his ply provided that such imp I. not intended BBmd for NEW RESIDENTIAL CLEC.R SQ I.T. ypBT�
Ic If,h ,hbli dig p .n t Id withinun Y f pletion he Cl 17 VId.�I y\QHA(ITV $ISQ.IeI'.
h II llhaveIl burden of proving JJ nhold,), p ,fill par I7 {/��
""O I'ad ) ��V ti
C1 1,as awncr of the property,am exclusively cantmcting withlicensed cnnlracmn t,I ll
construct the project(Sec.NW.business and Prafessions Code)The Confiscate I.Li-
came,lawdoes not apply to an owner of property who builds or improves thereon.card QTY. PLUMPING PERMIT FEF,
who contracts for such projects with a contractods)licensed pursuant In the Contractor's
Liceme Low, EDRAINS
ANCE '�
L] Lan vxmpt under See ,13&P Cl al'his rcamn
IN&V1iNI'-WATER(HA) \I
• Owner Dote
WORKIiR'S COMPIiNSATION IIECLARAr10N PRfT1EC1'.DEVICE
I hereby Office under Penalty of Ierjury one of the following deductions:
❑I hove and will Tmnwm a CrnlBwmil Consent nil whGinvnm far Workcr'x Compen- OR,ROOIAREA.COND' STORIES TYPE CONS'I'RHCTION
cation,ax provided for by Section 3700of the Labor Code,fur the perfomwnce of thek for whichnis permit isisuW. 'I7R TRAPW ad will maintain Workers Can,,ed ation Insurance,as requited by Section3p] )al theLaMrf CWc,f..the perfournmeof the work for which thisry:.it ix issued. STEM-I INC.i OUTLETS OCC GROUP AI'N
My Wnrkcry Com n'lion 1.arrive rimier and Policy n arc
rrivr J)"A7 'FOrT� Policy Nlr,:dGAS-IiA SYS'rF.M-OVHRJ(EA)
CHRI'[FICA112 OF EXEMPTION FROM WORKERSGREASH/INUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE I _ I VISION FEES
(This.section need not Becompleted,fare pcmtit is forone nodded dollere($IW) GRF,ASEAKAP
or Iris.) PLANCHEC
I certify that in the performance of the work for which mi,permil is issued,(shall SEWER-SANITARY-STORM EA.21X1 FT.
hmcnr eu '' ENERGY FEG /.
not cnq:luY try ninon n any tnunner settto ill I, h.cnndm W..art,Campcn-i
Oz .ration law",,Callfomia pale WATER((EATER WNEN'UELECIR GRATING FEB.
Applicant
h
NMICETO APPLICANT:IL after staking this Certificate of EW.Ni n,You should WATER SYSTIi tTREAI'ING
F become'a e t m the Workers Com tion f the Labor Cold,you mud 50115 FEF.
jw n-a con.,oro o
CYt + LrnhwilM1 cnnrply with such pnrvixinna of this pcmril shall be dcemcU rcwAcd WATER SERVICE
0.Q
� z CUNS'1'RUCTION LENDING AGENCY NEW RESIDEN"f1A1,P1-MB, SQ.En PAID
I hereby random mm there.,a emstmcnon lending agency for the perRrmrance of Dae tplx
Ul Q mil work fit which this permit is issued(Sec 3097.Civ.C.)
T(TTAL:
C) a
I vad ',Name_a fr
W Lcadur'e AJdmcv
1}. a I eerily Ill.,1 have read this application and state that the above information is
BUILDING Plil: —�
LN conal l agree to comply with all city and county oninunees and state laws relating to QTY. MECHANICAL PERMIT PhL SHi SMIC FL
V Z building com.vection,and hereby amhorim repmsnmlives of this city m enter upon me
aMme-nmmioned p,I,,ny fill
r im,deian purposes. PERMIT ISSUANCE ELI:CTR( 'Eli
(Wm)agree to,ave,indemnify and keep boneless the City of Cupertino against
Iinthda..c iudgmcnts.onntc and es,was, 1,,,h,,,.y inan,way ommc ngninxLwid City ALTL'R OR AILD TO MFCI I. I'LI1MI{ING FEE
.nvrgaence of the granting of this perp'.
APPLICANT UNDERSTANDS AN 'LL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL ''.
Sol JRCI,kE�L\TIONS
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCT'IIIN TA
Si vol AppllonJCnmml �J 'lino J( EXI INIS'f FOOD(W/DUCI) IIOUSING MI'FIGA'I'ION iE
HA%ARIN)US MAI HRIALS DISCLOSURE
Will the applicant or future building.ceupont little or handle broader,material HEATING UNIT(TO 110,005 BTU)
as defined by'he Cullom,Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1W.000 ETU)
Cade.Section 255321a)'.'
�Yet, ❑NuVENT LAI ION I AN(SINGLE RESIII) (NIU fill, R.cdplx
Will the applicant or future builJing.wcupanl use equipment or div Ices which BOILER-COMP(3HP OR S 11X1.000 RTU)
taman
mail hazardous air connotations as defined by the Buy Arca Air Quality Management 'I'(YI'AI.:
District? BOILER-COMP(OVER I W.0(s)BTIB
[-1 ties El No
I have read the hamnlomauariulx ruryirmnagx under Chapter 695 it rise Cali- AIR CONDITIONER ISSUANCE DATE
form.Tenor&Safmy Coke Seenom 25505,25533 and 255311 understand mato the NEW RESIDENTIAL N1ECH. SU.IT.
buildo,doas not comedy have a retmng mm it line,msrymchiloy,,ratify the occupmr
of the requirements which moa be act prior as issuance of a Ccnificam of Ovculidrw. I CDT
0wncr or amborold agiol Darr 1 ISSUED I{Y.
OFFICE