S 1838 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUU.umc-a:LECI RICA I. - PESIENO.
BUILDING DIVISION APPLICATION/PERMIT I'L1LSUDNG-MECIIANICAI. J
1838
BUILDING N O.IECT BEEN'[IFICATION
BUILDING ADDRESS: SANITAIXI'N( N'1'I.ICAt ION SUBMI'PIAL DAI
0 l�v < <ra- A-r� 'mob
ON'NP :SNA :� PHONy�- ONTRACIOR'S NAME: LIC NO:
NIC CONTROLp
�0 ARCER I'I!CIII3NGINEB LIC NU'. AIIIIRFS.S: ❑
CONTACT: PHONE: BUILDING PERMIT INTO
A4j _^, /n i ❑ Consultant Ems Pain by Applicant(Ini(ird) BLOC ELECT PLUMB MECCH
�- LICIIIEJSSFIDCONTRACIORSDBCLARA'I'ION QTY ELECTRIC PERMIT FEE J013 DESCRIPTION
ffi
I hereby,arm ohm Earn licensed unbar pmvisinm of CM1uple,9(commencing
CCS rich Seaion](XXgaf DivisinnJof the Boniness nnJ Professions CFdc.and my licenseis RESIDENTIAl.
WO p p PERM]I'ISSUANCIi
F�a,,F in all force and ellect. ❑SFOWL ❑KITCHEN REMODEL
QUU License Claw Lie# APPLIANCES-RESIDENTIAL ❑ADDITION [:1 PLUMBING RE-PIPE
1,7,W Dane Gma eon,
n� d ARCHITECI'S DECLARATION - ❑MUCO-UNI I' ❑S'I'kllC Nlt AI.
I„p m I'ANIiLS MODiFICAI ION
0_Z I unka
. ,br J 1ny plans sha116e usedm Public recoNn
OI1PT0 XM)AMPS
` ' El INTERIOR [I CHIMNEY REPAIR
F-�Fa Licensed ProfeWouti 301-1000AMPS III OVEMENT C]SWIMMING POOPS
CYC;
OWNER-BUILDER IIECLARATION tlV1iH I(XXI AM1f PlS {•l, UkATH REhf(lDE1JREPAIR ❑DEMOLITION
C{ay sc I herchy arErnt chill I mil exanpl[Film tire Cnntmemr'x License Law fur the
p G OTHER
U followinmaron.(Sentlon]11,11.5,liusino:.,um l I'ntresions Code Any oily or n..or, SIGNS ELECTRICAL ❑
g
3 h which eamms u permit 1n cunemun,seer,Improve,demolish,on repair any alruclum
F't='C j prior to its issuance.also requires the applicant Br such psnninn file v.signed statement SPECIAL CIRCU[TIM ISC.
� } that he is licensed pursmnt to the provision of the Contractors License Ww(Chapter 9
taala�0� (coencing with Section]0(Xnof Division 3o[the BusinaamW Proftsdnar Code)est TEMP.MIITER OR POLE INST. ' COMMERCIAL
mm
tL y o y' thm he is me:npl therefrom and the basis for the alleged uxemptioa Any octal of ❑NEW BLDG/ADDITION ❑DEMOLITION
W N Section 0031.5 by any applic:nn for n Pcn.at"am"',the uppl'nanI to a .,I'er:Jty of 1.OW IFR DHVICES ❑'I'IiNANT ❑FOOD SERVICE
not more than rive hundred dullnrn(S50). IMPROV EMI,NT
=� I]Lmnwncr of the Progeny.nnnyemployecswithwages auheiraJc rnmpensatiolt, SWIMMING DOLE,ELIiC1'RIC
P. will doth.work.and thenmmum is not imm�JeJ onsRemlfor sale(See 10,14.Business �QTIIER
63 m and Profession Code:The Contracwh Lieenxe Law doer not apply m an owner of OUTLFI'S-SN'ITCHILS-FI%TUR13
property who builds or improver thereon,unit who does such wark hinnclf or thmugM1
Ell own e11111orycu,provided Ilan'rich 1lnpmsummots are not intended of nffclvd for NEW RIISIDF,NfI AL IiLECTR SQ FT.
.-1.111 thbBlg"I 11111allaullank,add vrothan....c Year oI ' pli he - SQ.171 FI.00RAREA $/SQ,PI'.
ovsiuemilder will have[lie suadcal [pboving that h did not6 II(it improve bar put-
Lose
p e f-1 1 TOTAL:
..EIT as owner oftct pru,way am exclusively contracting' with licensed contract-, In
,una 1 I IS al1 1 -Cal I l,r Contractors 1
y 'c1w.1 t PPIy1Fanwan p P 1y n n lI: I x
QTY. PLUMBING PERMIT FEE '.566.4
�/�
h 1 Ins ornuehnlw Cnnmw I
Licemc Law. PERMIT ISSUANCE .S"'
❑I am corn i under Sm .BNe I'C4n1 ssa.
ALTI3R-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORK.Jrr 'f p,al 'ION DECLARATION HACK PLOW PR(YI'IiCI'.DEV ICE 7 0 0
..by ubirm under ix of pct j111Y m:e n[Otc lollnw:ng dcebtrahnns
nIlurvc nnJwillmvinlu:nnCenlli.nm of Conµcnnnscll-imumfrWorkdeContpen DININS-IlOOH.ROOI(AREA,CONU. S7 D: 'I'YITC1lN5'IItUCfI(l
.,union,as pntsidsd for by Section PW of the Iron Crate,for the wri nion.of the
work for xhiub this gamut is issued. FIXTURHS-PER TRAP
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700if theLuhor Code,Far the serfnmmnce nl'lhe work for whiitrahis lormil L+iswed, GAS-Eq.SYSTEM-I INCA DOI[.[IS APN
MWnrAcr'n Colnpensmutricrnul Pulley number are:
G
C Frier'. Policy No.: AS-I3A.SYSIHM-OV 17R4GiAI
CF,RTIFICAj E OF EXEMPTION ITOM WORKERS
C(lhil'ENSATI
ON INSURANCE GREASI91NDU5'I'Ed.WASTE IN EURCHFIF BUILDING DIV]SIIIN Il1F'_S
('ntisamion need nm hecompletWifthepcond is fortune hundred dollvrv(Sltgl GREASETRAP
P1.ANCHF.CK IFlili
mless.)
cow
Ion airy Ihanoilhc Purinrnnlnccnrlhe worA for which lhi,per.)h is ioucJ.lehall SEWER-SANITARY-STORM BA.2[X1 FL
nm a 11 Y' Y P ^ Yykt .� o h Isp./mt kQC1V k Co:rlw t IiNI1HC'Y FI'1.
Z [snit 1 f Cr111K a � ! lS WATER I{ggT1iR N'NCN TIF.LECIR GRADING FGI'
O p mina t v /DIA
'zr y_ NOL ICT TO APPLICANT If. B ka,di L r f ate off npt yen should NAIFR SYSTEMO REAL ING SOILS FEE
F reelable subject nil the Warkux C en.m a i ,of he Labor Code.you malt
a+ Bmhwid,comply with vcch,ra,kiln or this Inrmii shall be Jeclvcdrevoked. WA'l'17R SERVICE
J Q
0 RIJ
CONSTC'1'ION 1,13NDING AGENCY N13W kCS1UEN'i'IA1,1'I,M13. SQ.T. PAIDU
J 111embyvlfirm0unbercis.c...trial ion lending agency fon be cafommn.c of r Dam HecciP
ULT
GP the work for which this pnmtit is issued(Scc.3091.Civ.CI IYTAL:
C) U Lenders Name,
Lcndch AJdivST
OTAL, X
I eerily 1111111 have mod Ibis opPliculiun rind®ire that 1be above inlinnmtion i, 1 11UIhIlING PEh
Acrrec1.Ingre to comply withall city andsounly nrdlnunccs and 'are lawn relining tit ECHANICAL PERMTL l IFF. - SHISMIC FIRE
Z building conswction.andhemby nummnr<reprcommkes of Nin city to enter upon the
aMrve mentioned property for inspection partuaev. SUANCE ELECTRIC ITE
IWU agree nr sora indemnify and kep han dewsthe Cityof Captain,,againsthimilitie,balgmm,......ound es,n,r,whibbey'in any way am me agaiml,md CityADD'1(IMIiCH. PLUMBING THE
in oequcncc of the In nling or I...p"nnh.APPLICAN'1'GNDERSI'ANIIS AND WILT,COMPLY WI'I'II ALL NONd'ONILING UNIT 11011,(X)CFM) MECHANICAL 1931[
SOURCE REGULATIONS.
LING UNI'1'(OVER 10,000 CFM) CONSTRUCTION TAX
Signature ill'APPIinmUConuuctor Dme GOOD(WIDUCT) HOUSING MEI[QAB'ION FEE
IIA''/.ARDOUS MATERIALS DISCLOSURE
Will the applicant or nuarc buildinguacnpal alre ur hail 11,harrN..n:namniaCHI I('10100,BW B'I U)dclined bythe Cupeninn Mun al Crate,Chapter 9.12,and the Hcailh and kdMyHHAIING UNIT(OVER ill B'I'U)
Coda Senlom 25532(u)P
F IYes VENTILATION RAN(SINGLE RCSID) PAI1l
Dune Reecipt#
s� s Will the npplicum nr olue building Wcripalt Use e9uipnmnt or devices which BOILEk-COM P(3II P OR I coop)it 1'IJ)
oril hasanlnu'air con,.... ins n eI oil by the Buy Area An Quality Mon l,rueal 'I'(II'AL:
Diaria! Yes No I{(111.I1R-COM PI(IVIiR IIX).lKKl❑TI)
I base read the hoydens mall ra,mment,mde,Chapter 6.95 of the Cal i- AIRCONDITIONER - ISSUANCE DATE
fnmia Iknllh FV Safety Code,Seni...25505,25533 unit 25534.1 unJumtvnd in,,it theNHW RIiSIDENI'IAI,MECH. SQ.FT, �7
611ud' ,n al wn.Fly base v le:a... barlira . .....i Khly ln,aJy me 00.':1 1 /
oft re Ig c IchnisIten poor ora Ceni or : nc.
Owner or mranood,gem ft m TOTAL: ISSUEDBY:
OFFICE