B 0411 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI RICA]. PERMIT No.POSH
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAh pg)pp,� `1
RUILIISG I•ROJECT IIIEN7IF'1CATION
SANITARY NO. APPLIUATION SURhfITTAL OAT
IIUILDING ADDRESS:
102 '94- ORANGE AVENUE, cuPERTINO,cA 95014-
NIR S NAME: PIIONE: CON'TRACTOR'S NAME: LIC NO.
A?LURI g•Rr kUMAR 8bS- 0802 Nrc coNreol/.a�
ICJII'ECT/ENGINEER: CALL AO RESS: ❑ �36�
rCON�
HARLES cGORVIN X000 ` V
7T. PHONE: BUILDING PERMIT INFO
ETE Lr D)MACU LANGAN ❑ Consultant Fees Paid by Applicant(initial) tLl ELECT MAJOR MECH
�6 - 77
LICENS IID CONTRACTOR'S DECIARSI'TIN QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
ems,affirm Thal I am Recordander provision,of Chapmr 9(communeing
QOon 70(N)of Divisi ire Ruxinesv and l'ndbsslous Code..m my license lx RESIDENTIAL;
"° nt i'IiRMI I'ISSUANCII
F��F in lull Informal cffcaA )WI. ❑KI'I CIIIiN R13MOOliI.
aVV License Claes Lic.a APPLIANCES-RESIDENTIAL, AUDITION [I PLUMBING RE-PIPE
HGi Dat, Comracmr QMULETUNIF ❑STRUCTURAL
ARCHITECT'S DECLARATION PANELS MODIFICATION
ZO p oiZ I understand my plum Shull he used as public record. UP TO'_IU AMP
❑INTERIOR 0CHIMNEY REPAIR
Fa,H.,�'W Licensed Professiunu. 2111-I(NpAMPSirw IMPROVCM'NT 0SWIh1h11NG POOLS
CY C OWNER-BUILDER DECLARATION OVER 10(X1 AMPS .� ❑bill 11 REMODELfREPAIR [D DEMOLITION
C
O L 6 I belch,aff.n that I ant exempt frons the Convacmr's License Law for the ❑(TI'DER
V following remun.Netiun 7031.5,Basins Intl Prnfex..all,,Code:Any city nr county SIGNS ELECTRICAL
which nucleus a rwrmh ser construct,after.improve.dcl a fish,.r repair coy nmmnre
F'LLO.] prior to its issuance.also requires the applicant forsuch inromit,filenxignedsmtemenl SPECIAL CIRCUI'1'IAtISC.
f } mal he is licensed purse-alio life provisions of the Contmnors License Law(Chapter 9 COMMERCIAL'
I+liC0 (commencing with Section]IXxp ofDivl,sion3 oath,Business and Professions Cole)or 'TEMP.METER OR® i
a a C that he is exempt therefrom send life basis for mxe
The allege)emption.Any.....tion- WNG [I NEW HLOG/ADDITION [I DliMpl,l'FION
W=T` Section 903 L5 by an Secs ❑T'CNANT ❑FOOTESERVICE
y applicant fnrapermit suti t the vPPlicannn.civil penah f POWER DEVICES
I- not mate than five hundred dollan($5Wk IMPROVEMENT
E2� ❑Las owner of the property.or my employers with wages as their sole compensation. SWIMMING POOL ELECTRIC ❑OTHER
F. will Jo the work,aodmcnmcame is nm intcndedorolTcrcJ for vale(Sri,7041,Business
Wint and Professions(1dc:'Thu Convector's License Law laws not apply To an nwncr oa OUT'LETS-SWI'I'CUBS-FIX"TUBES
property who builds or Improves thereon,and who does such work hinself ser through NEW RF,SIDEN'HAI,ELECT R SQ PI'.
his own employees,puo Wedal msuch improvements all nun intended a offered for SO.IT 17LOOR AREA VSQ.171'.
sale 11,however.the Emitting,,imprnleaent is sold within...ar, n completion,she as
ousincr-builder will have the burden of proving mat M1c did nal buil)or improve for par- �j
pwufmlcJ.
I,vs owner of the prnpeny.am exclusively reflecting with licensed contractors m
nnstmct the Rural(Sec.](FW,Brahma s and Profexsions Com:)The Clareart—Li'
Genu taw Jcesnol-pPN nr-n owner of property was bui.ds or improves thereon.and QTY PLUMBING PERMIT FEF.
who contracts for such projects with a contrvcams)Ilcensed purmannn the Comr l
Usem,law. PERMIT ISSUA
I am exempt under Sm. ,N.@.'C Mor this reasno
AATER-URA IN'I-k 'I'ER(EA) VALUATION
our Dat,
WORKER'S COMPENSATION IlEC1,ARA1'ION RACK RAW PROI'FC 1 .i
1 hereby affirm under penalty of Irerjury one of the following Jeclaraions:
t []Ihavennd will maintain aCenihcam of Consent ulGimurefm Workers C.mpem DRAINS-FLOOR,ROOF AR ND. STORIES 'TYPE CONS'I'RUM 1
cation,ac Provided for by Section 3710 of me Lahr Cade,for The perfnranre of the
work for which this permit is famed. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,vs required by Section GAS-EA.SYSTEM(INCA OUTLETS 39.X1 of the Labor Code.for the perrmnce
foaof the work for which this Permit is issued OCC.GROUP
My Workers Cmnpcmation Insurance easier and Policy number um: GAS-EA.SYSTEM.OVI!R 41EIG /1I
Carr '. 1�Carter; Policy No. _A V 5
CERTIFICRTIs OI'EXEMPT ION FROM WORKERS' GREASEANDUS'I BE.WAS T;IN'I'ERCEP'IOR
COMPFNSA'I']ON INSURANCE; BUILDING PIiP,S
('This section need not The completed ifine Permit is fortune hundred dollars(S TIN)) GRCASETRAY PLANCHIiCK FEIi "
or lc,,)
(certify that in any numnc,of thebecom which thio pre Worlars'Copen-all SEWER-SANITARY-STORM EA.200 F1'.
urn employ any person in any runner so as m become subject m the Workers'Campcm ENERGY Igili
Z union Laws of CWifomiu.Date WATER HEATER WNEM'/ELECI'R GRADING IEE
C) Applicant I
FZo — NOTICE TO APPLICANT.If,after making This Cerificme of Exemption,you should WATER SYS'1'EMOREATING SOILS FEE
Froutines wbjet to the Worker's Coinpenmtinn pro.sinm nl the Labor Cade,you most
Q Innhwilh emnply with such prov savoor this CONSTRUCTION LENDING Ilial.he deemed revoked WATER SERVICE
P.. GA(11?NCY NEW REST DI3N'1'IAI.I'hMH. SQ.isl'. PA
] ,Z _ Date Receipt
U O 1 hereby afrnnmal mem is a wnasrutmn leading-Scour fill the Prrfermeme of
— the won,for which this peril is issued(See3W7.Civ.C.) 'POI'AI,:
Q Iendera Name D
T lenders Address BUILDING FEE
1 certify that 1 have mad this applicatinn and state that the above information is
O.
Fs V) cmmet.Iagreeto cnntply with.11 city.adr...yomuessirs and stem laws relating Rs QTY. MECHANICAL PERMIT FEE SEISMIC PIiIi
V Z hulliing enmtmetion,and hereby andumre mpreatnatives of this city to enter upon the
nbovo-munimmad pnmrny for inol"ion purpose'. PERMIT ISSUANCE 1:1"i I'RIGFEE
(We)agree to marc,ndeninny;md keep bun ale,The Ci(y of Cupeninu aguina ^
Indshtics,juJgnams,cmoand caps which may in any way accmc against said City ALTER OR ADDTO MFC I L PUIMBING FEE `� a
in nrsequence of the mase fg of this permit.
APPLICANT ON DERSTA N US ANI)WILL COMPLY WITH AL1.NON-POINTAIR HANDLING UNIT,(TO 10,000CFM) MECHANICALIIiB 0
SOURCE REGULATIONS, //
AIR HANDLING UNIT(OVER IO.000CFM) CONSTRUCTION TAX V
Signammof Appluscro(Contmtor Dau EXHAUST HOOD GODUCI) HOUSING MITIGATION FEE 190,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or Ennm building occupant store or handle h...do.,material HEATING UNI'('(1'0 100.000 HTU)
nx AutlneJ by The Culwnlnu Municipal Calc,CM1'vpmr 9.12,and she Health and Safety HEATING UNIT(OVER IIXLI1fX1 H'rlll
u1c,Srcninn 25532fu1'!
_ ❑Yes CNa VENTILATION FAST(SINGLE REST])) PAID
Dom Reueipl a
Will IM1e vpplicam or future building oecupu-t use equipmam m devices which BOILER-COMP GHP OR I(0,IX0 BTU)
mit lueardnus eir asnmmimmts as defined by the Ray Arca Air Quality Manvgensanl 'I OI'AI.:
,)isrdm? HOILER-COMP(OVER RERRMBTU)
e ❑Yes ON.
I have acral me herondons materials requirements under Chapter 6,95 of the Cul-
AIR CONDI'T'IONER ISSUANCE DATE,
l .:anise Health As Salty Code,Sections 25505,25533 and 25574.I mtdcrsmnd That If the NEW RESIDENTIAL MIiCH. SQ,IMI'.
huilJing docs nm omcnty Intoe assailant,that it is lily m'pnmihlllly na notify themcupwn
of the reqununtcnls which Inst.ba stet prior m Ixsuaneo oi'a Cenifentr of Occupancy.
Owner or auThoriuJ agent Date ) _ ISSUED BY:
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