S 3122 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P1i ITNO
BUILDING DIVISION APPLICATION/PERMITPLUMBING-.MECHANICAL 3122
BUILDING PROJECT]DENT IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
2 / 70 ,- 't1E�Yeou) V/Eu/ Lf7i✓E (('�(o- Q,d
All OWNER'S NAME �I 9 P�F. 133 COYfRA' >k'�A �O „r'J�NSNoif
KK fpm NIC CONTROL.
ARCI 111ECUENGINEER: LIC NO: ADDRE ❑
9
/3 �JN�o�yJ�. S .J.
C'ONTACI': PHONE: BUILDING PERMITINFO
pg�/e ❑ Consultant Fees Paid by Applicant((..:lisp BLDG CI' PLUMB MECH
,. 9JgH011el- 95 g'1 f q 193 /
LICENSED CONTRACTORS DECLARATION QTY 13LCCTRIC PERMIT lalili
C C Z I hemby union that 1 am licensed unde........ions of Chapter 9 banameneng JOB DESCRIPTION
Wp lh Section 70(1 of Division 3 oOhe Business and Professions Code.and my license is PERMIT ISSUANCE: �1 RFSIDENTIAL: ,�,�t
�,e0 nt full force and effect. 2 61g Q (!�3 r / v ❑SPDWL �LfDICHF.N REh1(lllil,
QZU Liccnsc illi !� hiaN > APPLIANCES-RIiS1D1iNTIAL [I ADDITION C1 PLUMBING R6PI1'li
F uI Dme Commetm�/�+�M' KiPUPeN1
r zw ❑MULTI-UNIT' El STRUCTURAL
'D m ARCfII"I I'CI'S UIICLARA'I'ION PANES MODIFICATION
zoatzl undeomml myplms shall heated axpublicrecn.de UP TO Its)AMPS
❑INTERIOR E3 CHIMNEY REPAIR
O Lwrnmal Pndc,,acll 201- IMPROVEMV,N'1'
te,C IOW AMUS E]SWIMMING 1'(I(ILS
a ee=:i OWNER.,I..tctranRD na,ConT1ON OVER 1000AMPS ❑BATH OTHER ❑DEMQLI7']ON
C Q 1 naso err dint I um cBusin loon No Contractors Liccnw r is for dna
3 F- whichingreason.(section 7031.5.onHasiner. and improve,
Code:Any carts, SIGNS ELF.CTRICAI. ❑OTHEk
r� which iN isos n perms al the alter,impmsu demolish.or reps any tmmmre
F LL.pNq hen rmibiensed..also.......he powmliwntfor Coatsch tsar Lircmeo file a Law(ned] hapternt SPECIAL CINCUI'1'/MISC.
at .; tha he is licenced.ursuanunthc provixinnx of the Commewrs hicenw Law(ChaPterY
IW�a00 (Commencing with Section"!(If )of Divi.sion3 of the Business and Professions Cvdclnr TEMPMETER ON DOLE(NST COMMERCIAL:
a a Q C that he is everrim Oercfram unit the Imak far the alleged c.empuor.Any GrAitllon of ❑NEW HLDG/ADDI"TION ❑DEMOLITION
W l e- Section 7031.5 by any applicant fora periall subjects the applicant e a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
sol more than five hundred dollen(55011. IMPROVEMENT
I,ac nwncnsfthc n
❑ pmpcRa.ntyc Tplayccs wllbwngomlale Selmnnpnsmiaaa, SWIMMING POOL Ii1.liC1'RIC ❑OTHIiR
g., ;,will ad "ofcwmk,Carne he C..sasnatlnlcnJedu Law doseal svlapply to at,
s ID D
497 pro ery,who
CnJc:Thooses deco Law does such
work
hi toll rthrouof OUTLETS-SWI'TCIICS-FlXTURI?$
6 his ,.y wM10 build,or improves t such.., an who docs e m work heed a orthroughfor
his own employees,mmiJCJ Na.each impmvnnent ate ern .,ended lir nlfemJ lin NEW kF.SIDENI'IAI.IiLIiCfR SQ FT.
salt.If.however Oe buiumsor impmvement iswld within one yew.Romplctina Ne SQ.F'1'.FLOOR AHI'.\ 81SQ.1d'.
owner-builder will have the burden of proving that he did not hand or improve for far-
pose oC.wle). 'OTA L:
El 1,a,owner of the property,am exclusively contracting with licensed couracmm pt
mime,the project(Sec.70-W.9mincss and Professions Cade:)The Cnmmcmr's Li.
x Lawdar, at apply manownerof pmparty who builds or improves mane...and QTY. PLUMBING PERMIT - FEE
who canners for such projects with a convaanrtO licensed pursuarnn the Comontaes
I.iccrsc Law. PERMIT ISSUANCE
❑ I um exempt under See. ,B&P CGa Otis reason
Al:Tlik-DRAIN&VIiN'I'- ATI' sA VALIIAI'I(IN
Owner Date OD O
Wm under perp y l perim1y ten DECLARATION BACK FLOW PItOI'EC'I'.UIiV IC,E
I hand w affirm under Certify of perjury one of the fallowing Welds`ion.,
(]Iltwe and will for bynatan3700al(ifConout to
Labor Codeawrcforerformace of the
DRAINS-Iy,OOR,HI%IF.AHFA.COED. STONDIq TYPE CONSTRUCTION
wti If r provided for by Ss ion 31(X1 of the Labor Code,for the performance of the
work for oil ill marten is is lket FlXTURI?S-PER'TNAI'
1 have and will ode,fin wends Croce of the
work
hi as rephis per itt i Section
71W of the or Code,far th vfnnnunce of the work for wish this permit is issucJ. GAS-EA.$YSTEM-I INCA OUTLETS OCC.GROUP AI'N
Carrier:worker �lipn to ppyp eraldY NoY numb v7i dG9 t� GAS-EA.SYSTEM-OVER 4(EA)
CIiRTIFIC it:OIFEEXXESIPITON('ROM WORKERS' GREASLUINUUSTRI.WASTE INTERCEPTOR
CO�PITNSAT'lON INSURANCE. BUILDING DIVISION PEE$
(Ihis section d mab 1Ef,cOt,Ic I "at is I or art,hundred l llurs(ItIIXB CREASE I RAP
I I PLANCHI:CK PEE
I tfytht' lh pct t' kl h h this p t '': al'l shell SEWER SANI'T'ARY-S'IORMEA.2XIP1'. �p
not employ any Person in ar'nama,.oasl bes bleat h W k .'Copan- ENERGY FEE W
Z sudorl-n—of California.Dme WATER HEATIR W/VFNT/ELLCTR
z Applicenl GRADIN R;
h N(TI'IC13 TO APPLICANT.If,after nroking Chic Cenihcv¢of Exemption.Y^u shuulJ WATER SYSI'IiMOREATING SOILS
home whj¢t m the W'orkc(s C..mpenmtinn Provisions of the Lahr Gale,You muu
C Q LrnM1with comply with zacM1 Proviunn.lir thi,pcmut sM1ull be Jarman revoked. WATER SERVICE
GONSTRUCI'ION LENDING AGENCY NEW RESIDENT IAL PLMI. SQ.14. PAI
UO I lately off rte than here iso ennsuuetior lcodingagency for the perfamtance of lite Reactor#
W F me w...k for which his permil is s,mal(Sec.3097.Co,C)
O TOl'AL:
Isnders Nene TOTAL:
r {U>•1 Lender's Address
G 1 cvnily that have recd thin agytlleatian vnd nude tial the abase inlitmm�ian is ItU I GI .. Q
aF. N otrmel l agree teem ly with a city rnd county ordinances and nae laws renting In QTY. ML'CIIANICAL PERMIT FEE SEISM 'Pini (2.
Uz huilJing nsretmnio , dherchy amhorim rLprcncmmivcn..f thiscitynt enmrupm the
uMtve.nrcmioned p for inspection pupows. PERMIT'ISSUANCE ELF. RIC THE O
(We)agree 'ndennify: it keep homeless the City of Cupcnino against
liabilities,judgments, nu despe s which may in any way acerae against said City ALTERORADDIOMECH. PLUMBING FEE
inconuquenccoftheg no oft permit.
APPLICANT'UNDERS 'A NO WILL COMPLY WITH ALL ON-P 11 N"1' AIR HANDLING UNI'1'('rO II1.WUCFN) MECHANICAL hlili O
SOURCE RE ULATION
/(� AIR HANDLING UNTr(OVER I0.000 CIsb1) CONSTRUCI'RIN'I'AX v
Smnmaeol Applicaa/C..nma r D.A. EXI(AUST focn)(W/DUCq HOUSING MI'I'IGAI'IUN hI!li
IIA%AIRDOI. MAI'(RIALS DISCLOSURE
Will the apphtealal Panum builJing oscapwn smte in handle hxsanlnux mntaial HEATING UNI'I'(1'0 I(IDIXXI II'RU
us defined by the C.1,linv Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(.)'! HEATING UNIT(OVER❑XI,OXI BTU)
❑Yes [-I No VENTILATION PAN(SINGLE RF_SID) PAID
Dam Reuipt a
Will the applicant or nature building occupant use equipment m doviees which BOILER-COMP(31111 OR I000f1u BTU)
emit hmmdou,air contaminants as defined by the Bay Amea Air Quality Management TOTAL:
t Dion" HOILER-COMP(OVER I01.0X)BTU)
❑Yes C]No
have read the h:vunhn...nvrorials rcyuiremem,under Charner 695 ad the Cali- AIR CONDITIONER L,IJANCE DA16
litmin Ilexlth&Safety Code.Suction.,25505,2553):vW 25534.1 nndetuunA that if the NIiW kESIUIiN'I TAI.MliCll. SQ.1'1'.
building des notcvmmlly have a tenant,tM1m It is lay alpaasibil'IY,,slily thcxuupant l ,(
at ne arIniremees was"an't be met prior to ismanec Ilia Cel iBeate of OCCatpmlCY, U
Owner or imermiveingcnt Dale AI` ISSUEDBY:
OFFICE