99090025 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY —l.V n0 h'A � ti
CITY OF CUPERTINO LUMBING-ELECIMECH-MECHANICAL ��-q �' BNMI N(
BUILDING DIVISION APPLICATION/PERMIT P]N(;13m'O-MRCBNIIFIC. S0001
NI111.DINC 1'ROJE6T'IDI:N'1'I4'ICATION
HUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITD\I.DAI'
1101131's-- n7 ' (_are'- i PL 2/16 — 4 P
OWN NAME:wsd I �� PIIONE: CON RACfO 'S N ME C O: /
L ti NIC CON'FROLIf
CIIITECDENGINEEK: LIC NO, AD)RE'S: J�D ,,.,r ❑
CONTACT. PHONE: ,/. BUILDING PERMIT INTO
/ /,r ed �p♦�y(/�(y'� ❑ Consultant FccP Paid by Applicant(Initial) RLDG Fill cr Pup,11 MECII
1/-1110." S O 7 V( ❑ ❑ ❑
LICENSED C N RACfOR'S DECLARATION QTY HLIECI'RIC PERMIT FETE
I hereby nation 1 am licensed under powislans of chapter 9(commenting JOB DESCRIPTION
k'a'Z with Section 7000)of Division 3 ofthe Be inched Pnefir"ons cls in, is RF II 1'
Ir:00 w' PERMIT ISSUANCIi
CWF to full force and ellen. --�� 'FUN'1. ❑KITCHEN RE-PI
H
aUU License Class Lick APPLIANCIiS-RESIDENTIAL pA Dll'ION El PLUMBING RI PII'li
F Z W Utm Cunlrxmnr
mQy ❑MULTI-0NIT ❑SODIFfURAh
)CHI I'IiCf;S DIiC1.ARA' N PANELS
Z O Z I undersmnJ my plem,l all be used an public rccoNn UP TO 200A MODIFICATION
ON
El ❑CI{IAINEY RIEI9\IR
(-.'!)/_'tern Licensed Professional 20141000AMP• IMPROVEMENT DSWIM,MINGPOOIS
OWNER-BUILDER DECLARATION OVER["ANE A'I'11 REMODEUREPAIR ❑DEMOLITION
C C 6 I hereby aflinn Thal I am exempt from the Contractor.License Law fur the
L O y U following ev,l(Section 7031 5,Bminess and Professions Code:Any city ar county SIGNS ELECTRICAL
a m which"Trims a peratit to"street,alter,hnhrove,demolish,or repair vny mructore
^�O�' prior to its issuance.also requires the epplicwn hamch permit in life. -audit swtemem $pEG1Al.CIItCUI r/MIS
that bets licensed pursuant tothe provisionsnnhe Conaumors lacenxe Law(Chandr9 COMMERCIAL;
�tYp� Ictiatmencingwnh Sectiun70000.f Divi.innloflhe Business.. l'mfcssions CNcl nr TEMP.METER OR IYII 5
d t c ly that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X�HSection 703 L5 by any applicantfor a gemnit subjects the applicantto u civil penalty of POWER DEVICES ❑TF:NAN'I' [I FOOD SERVICE
n more than fie hundred dollars(850X). IMPROVENIENI'
F=� Q I,as owner of the property.or my employees with wage%as their sole compensation. SWIMMING 11001,IILECfRIC
22CC,, will Ju the work,nul the structure a Dol intended or offered for wle(Sec.7044,Business ❑OTHIiR
gm and Professions Cndc:Ile Corramor's Lignac Law does not apply to an owner of OUTLE I:S-SW If'CIIES-ITXTURE
property who builds or improves thew.,and who dxsxuclt wad himself or though
his own employees.provided that such improvements are not intended or offered for NEW RESIDENTIAL ELF.CTR SQ FT. SQ.FL FLOOR AREA VSQ.FT.
sale.If,however,the building or improvemem is sold within one year of mmpleio.,.hc
couner-burlder will have the burden of proving that he did not build lir improve for put-
"m of sale.). TOTAL:
n I,as owner of the prapertY,am exclusively contracting wish licenced connectors or
instruct the preiccl(Sec.7144,Bnvincss anti Professions Code:)the Contractor's Li.
w Law docs urn:+arty to nnnwnee m'properly who buildsor no its lherelmoul QTY. PLUMBING PERMIT FETE
who commas for such p jecis with a colorations)licensed pursuant tit the Contractors
License Law. PERMIT ISSUANCE
1 am exempt under Scc, ,B k PC for this mann
ALTER-DRAIN&VENT-WATER(IIA) � VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
hnehy union under pcnni.y of perjury one n[the I'nllnwing Jcdtmtians.
I have and, v Cenifianc ofCunvent to nelbimure for Wmkcds Culpen- DRAINS-PIAOR,ROOF.AREA.CO STORIES 'fVPI?CONSTRUCI'10
sa.i m,sax provided f o by Section 9700 of the Lobar Code,for the performance of the
work for which this pemtit is issued. FIXTURES-PER'rRAP
n I have and will normal.Workers Compensation hourroce,is required by Swine
3700 of NehMrG .tonhe perfnrmana lithe work for which this permit isissuN, GAS-FA.SYti I'EM-II -lib OCC.GROUP J/ r�f� '
My Wo r. on n fu' n r '"-rtiI/ani Polio.-pptnWV ffi_W__ C (� sayrr
Cartie ".ady n /7 YCJ GAS-F.A SYS 117. VE EA
CERTII'ICATE OF EXEMPT ION FROM WORKERS' GREASIVIN E Itclll
COMPENSATION INSURANCII BUILDING DIVISION FEES
(This neeion need not be conalned it theproub is for tine hundred dollars(11100) GRE
PLANCIIECK lyili
ort s.)
/comfytlmin in any nrmance N the work Por wiffica to the it is Workers'Camper, AVE SA -STORK 200 I'll
not employ any person in any manner v+us it)become subject.o the Workeri Compete ENERGY Il3E
Z xminn Lawxof California.Date WA - TER :NT/ELECfR
GRADING I
zC) Applicant ( 'lili
N NOTICE TO APPLICANT:If,of el making this CWu is.end Exemption,you shit- TF.R. "I', t'ING
abeconm subject to the Worker's Co oNntalu n provisions M the Labor Code,you trust SOILS Ilii
0. r fM1 nrtbwith......Itby with... provivnnn nr this peropi.shall M created revoked. A']ERS ICI?
PAID
Z) z CONSTRUCTION LENDING AGENCY DENTIAL PLMB. SQ,FI'. Dale Ne<eip.N
L) O (hereby affirm that hem is a mmuuction lending agency fit the performance of
D. F the work for which this permit is issued(Scc.3097.Cm.CJ
Olenders Name �s'�OI 1
L) Ldmfr`s AJJma TOTAL: s1
dI cvnity thin I hove rad/his app emiou unit state that the naive iN- orneur In BUILDING PEIi
to emrcd.l agree to colony with all city and county ordinances and state laws relatingm QTY. MECHANICALPERMI'T FEE SEISMIC MIR
CZ building conourcierand hereby truthnrlre re,mewemivos of this city to enter upon'he Oe
above-mentioned property for inspection purposes. PERMIT'ISSUANCE ELECTRIC FEE V JCN^
(We)agree to save,indemnify and keep harl the City of Cul:cnino again.-
liabilities,judgments.costs and expenses which may in any say accom agamn aid City ALTER OR ADD TO MECH. PLUMBING Plili !/�1 � 70n
in consequence of the 6rm in this permit.
API .1 \ TUN \NDS AN U WILL COMPLY WITII ALL NON-POINT AIRHANDLING UNIT(TO I0dxXICFM) MECHANIC\1.PEE J
SOU C I
t AIRHANDIANGUNI'/'(OVER 10,11S)CI'M) CONS,RUC'HONI'AX
1�
Sigwmrc of Applieunor Dare EXHAUST IIOOD(W/DUCI') HOUSING MI'OGADON TLB
HAZARDOUS KINITRIAM DISCLOSURE
Will the applicant or future huuldinilJing xcupum store or humJle haaallous material HEATING UNIT CFO 100.000 BTU)
as defined by the Capitation Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0(X1111'11)
Code,Suction 25512m)7 -
(- 0Yes [gry VI?NTI I,AI'ION PAN(SINGLE RES I DI PAID
Deur Recen l N
Will the tapir....or future building,,,upoa use cgmpnwmrsm devices which BOILER-COMP(IIP OR 10300)III'U)
it h mous air uommninan.s ax Jetined by the Bay Arca Air Quality Management 'TOTAL:
..satin^ / )OILER-COMP(OVER Radial li'I'U)
Yo rullt
Jly(
I ha .h h -Nruts requirements unite Chapter 695 of the Gnh- AIR CONDITIONER ISSUANCE DATE
mums He It ' lie o a255x5,25513 vnd 2551-I,I nndcmm�d.hat if the NEW RESIDENTIAL MECII. SQ.Pf. '-' �•_
building 'nrz l on1,lhm mis myrugmsihany lite I ythroe'puntnnhe rg r n�uta npronto is.vance of t l:.1.
Vill
Owner or cath ]N Bcm Da TOTAL: ISSUIiU BY:
OFFICE