S 2267 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN0 BUILDING-RLECTRICAI, PtagD'NO. 2267
BUILDING DIVISION APPLICATIONIPERMIT ILUMBING-MECIIANICAL
1......LNG PR(UECI'IDEN'TIFICA'1'111N
Iil11LDINC r\DDkf:SS: n SANITARY NII, AI'I'LICAI'ISIN SDI{MI'PD11.UAI'I
21 y 7S / J-M VE f12-119
OW ERS NAME. I't){O(N�G CON'I'RACIORS NAME: LIC N(1:
oll
ARCHI PCT/ENGINEER: I,IC NO, ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant FCes Paid by Applicant(Initial) BLDG Ii1.ECl' PLUMB MLCII
54 n� ❑ ❑ ❑
LICENSED CONTRAC'TOR'S DECLARATION QTY. ELECTRIC PERMIT FEF
0 1 hereby drum that 1 am remnsed under provisions )I Chapter 9(immncndng J013 DESCRIPTION
with5ccunn]gXl)o(Oivisinn3 uftM1C ltusincse vnA l'ndnsionc Cndc,anA my license ix I'ERMfT ISSUANCE e` RESIDENTIAL:
0 in full fotcu and etceL -?S-,SV El Slim[. ❑KI'I Cl HEN REMODEL
QOU Liceme Class Lic.a 2 APPLIANCES-RPSIDENTI Al. CJ X e/V ❑ADD[TION [I PLUMBING RE-PIPE
FZW
mL,Q❑myDalc C'ontmctor
ARCHITECT'S DECLARATION
ARATION
❑MUI.T-UNII ❑S'I'RUCTURAI.
PANELS MODIFICATION
Z O N'Z 1 and crs.ad in,plane shall M1c used us Pnblic rucurds
�LmQ UPT021NIAMI'S ❑IN'1'likl(Ik ❑CHIMNEY klil'Alk
Licensed Prnfcvinnvl 201-1000ANIPS IMPROVEMENT CSWIMMING POLLS
y Cp OWNER-BUILDER DECLARATION OVER INXIAMPS ❑BATT{REMODEL/REPAIR ❑DEMOLIT[ON
W d 1 hereby affirm that 1 am exempt from the Contractors License Law for the
O y U following (Section 7031.5.t ones d P f ns Code A y ly or county SIGNS IA.I,CI'RICAL [-1911 IHR
WLLOy which y P d contract, II p I limb p' ysmcnrc
F•-ay pro I t at,,, yuires he oo,pli,vomI to teta]fit x,i,nad,moancn1 SPECIAL CIRCUIT/MISC r v4/IiGL.
that he is licensedpursuant the pro,isions ofn Contractor,Licenoc L (Chapters COMMERCIAL: -/�
�aqp (evmmcocng w'Ib Sectio 700Euftivso 3(fto R - ss dl !:.' mCcdd or TEMP MF'IPR ON IroI.IS IN ST.
C a o a that he is exempt thereBont and the basis for the alleged examptirn.Any vinlntinn of ❑NIiW 131.DGIADUI'CION ❑UI?MOLI'TI(IN
� Section 9131.5 by any appbcam for alwnnit subjects the upplieanl ,,a civil penally of POWER DEVICESTENANT
t more than live hundred dollars($5(X)4 ❑IMPROV POOO SIiRVICI?
las owner of the leers with wage, thei ,ole con tion. SWIMMING Pool ELECTRIC a[HER IiM1iN'C
pn'pny. re is employer, gds as Boo ❑OTHER
F. and JDthework,andthe suucmmtutorintended prim,dos timned naval. ply7044.an
Y"m and Pmfessinns Code:'Ila Contractors 1 iccme Lim,docs not apply m an nwoar ul' OUTLO'S-$WITCHIiS_Il%'PUBES
a.. prrprty who builds cr Impnrves Werttn,and who Jeers such work himself or Ihnegn
his own employees,provided that .on has rnvennms am not intended or offered Iter NEW RESIDENTIAL HLECIR SQ FT.
sale l LhuwevcrJhe building or improvement isaeid within one yearofoominctior,the SQ,17,FLOOR AREA TJSV PI'.
owner builder will hive the burden of proving that he did not build or improve for pur-
pose of sale.). /
1,as owner of Ice d ern %wed 'TOTAL:
❑ propcoy,am exclusively amain )h licensed contractors in NJV
nae aInces nol (Secoan wnerof andimwhobus Calc:)Thr ienhreonLi-
whoconwctsfrmrpplYman it],ampropnswoosedpurds rimpro the
Commenceands QTY- PLUMBING PERMIT FCC
who mmncL rnoueM1 projects wit],v cnmmemr(s)licensed pursuant m the Conwemrc
License Law, PERM]I'ISSUANCE
❑ [vm exan t under See ,B&P C for this attracn
ALTER-BRAIN&VENT-WA'I'li P VALUATION
Owner Uate
C2 U
WORKER'S COMPENSATION DECLARATION RACK PLOW PROTECF'.DF 1
herebyaRrm under mallyof porjoryon,of Ne following Jeclamti...: ''^^
E] n Iha-mil will maintain a Certificate of Consent aself insure for WorkeLa Compo- DRAINS-FLOOR.R( E/0. D. S'1'OR IIS 1 PE CONST RUM ION
,orlon,m Provided for by Section 370b of the laid, Cale,for u-performance-the
work for which this pram is issued. FIXTURES-PER I RAP
❑1 have and will maintain Worker's Compnsvtlon Insurance as required by Section
Tloll of the Labor Coda bar the performance of the work for which this permit is issued. GAS-EA.SYS TEM-I INC.J OUTLETS OCC.GROUT' MoN
My Worker's Comwasit m Insurance anter and Policy number am:
Carrico Policy NO,: CAS-FA.SYSTISMOVER i(FSA)Career:
CERTIFICATE OFE%EMJIIION FROM WORKERS' GRIiASFANOUSI'RI.W'AS'181MfF.RCE1'lUk
COMPENSATION INSURANC12 BUILDING DIVISION(ELS
(Do,seGam maxim faccompleml ifthe prmit&fornnehundneddollas19100) GREASETRAP
1'LANCHLCK h12i
or leu.)
J certifythas io in prhsnnance of the work for which this permitisirs cal,I hall SEWER-SANITARY-STORM EA.2(X1 FT.
p1o,any�{ rte becrt s u the Workers Compo- ENERGY FEE
O z caton ion laws of(:d/f in an y YrhJt- o WATER HEATER W'/VENT/ELFCIR GRADING FEE
Applicata �(�y /VY
= NOTICE. -0 PPI IC If,after making tins CmiGcam of Exemption, no should WAI R SYSTGWI'kFATING I;
F' become subject In the Woekxr's Compensation provisions of the Labor Codeyou must
a fonhwidacompbarith suchpmvisiunsorthis .it shall beJecmedrevoked. WATIik SERVICE
Z Q
a
CONSTRUCTION LENDINGAGENCY NEWRESIDENTIALPLMN. SQ.IT. PAI
z kecnptM
I hereby ammoo
that is a construction lending agency for the performance of Date
[UL 0 be work tar which this pumit is issued(Sec.3(199.Civ.CJ
O ..Lenders Name TOTAL:
TOTAL:
LendeAddress
rs
W I fcnify that 1 have mid this application and state that the above information is D 131-01 G FIiE
comet.l agree w comply with all city and county oninances and u,am law.srelming as QTY. MECHANICALP RR EEE SEISM( .LEL
U z builJingemamceon,andherehy autbmlm reUreunntives ofthi.v city numeration the ''^1
move-meminnal pmpny for impeairn purposes. PERMIT ISSUANCE 1-1 5y IC ECB •
We)agree ut save,indemnify and keep harmless the City of Cupertino against
Iiabilitieyudgmetns.costs and expenses which may in any way aceme against aid City ALTER OR ADD TO M ECH. PLUMBING PEE
in consequence of the counting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT LTO 10,000 CFM) MECHANICAL ITH
SOUr' E REGOI ATIONS
/
1 / AIR Us10,000 CPS) OST
mre mfAaDate EXHAUST HOOD DGDUCT) HOUSING MllEGATIO
N EE
HAZARDOUSMATERIALS DISCLOS
Wit]theapPlicam.lboom Wild,.,necufumsmutohand)e
haeallom material HEATING UNIT(TO IfI(I,IXM)IfI'D
as defined by the Cupertino Municipal Cale.Chapter 9.12.and the Health and Safety
Code Section 25SI260? HEATING UNIT(OVER 100.001 BTU) �'7 9
❑Ycz ❑Nn VENTILATION RW(SINGLE R[SFU) PAID
)a¢ Receipt a
N'i11 the applicant or future building mu equipment or devices which I101LER-COMP PUP UR 10(l qkl BTU)
emit haeardmus air conmmmanu as defined by by the the B Buy'Area Air Qualify Management TOTAL:
District? BOIL12k-COME(OVER 100,000 ETU)
Cl Vic, No
AIR CONDITIONER
I have read the hmrequirements requirements under Chaptcrfi 95 of the Cali
materials ISSUANCE DAT14
fumin Health&Safely CWC Sections 25505.255]3 and 255311 understand that if the NEW RESIDESUHAL MECIL SQ.14,
buildi tly have.tenant,the it is my respomm
ibility uunify the occupant
of I ,requi wnms p'�te{t muutyryy�Rnno issuance of a CyQIL yRa a -J/
rnamthonzed amid D.11c, TOTAL ISSUED RYZ � �����{"�Gl
OFFICE