S 1244 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUII.DINC-T LECI'RICAL PESIT NO. 1244
BUILDING DIVISION APPLICA'1'ION/PF,RMIT PLUUInNc MECHANICAL
RUILIIING PR(IJECI IDE\TIFICIttl ION
BUILDING ADDRESS,. SANITARY NO. AI'PLICA'I'1lnN SUIIMITi'AI.DATE
1021 °1 I�� I-G vISTF� Z- 23 -V
(lW 'S NAME: I'110NE: CONTRACTOR'SNAME; LIC NO C NIC CONfHOI,M
EV ' A � TEI 255- 54 I DA t1Ud11'JIN�L TIN D
El
SRCHITEC'UENGINEER: LIC NU: ADDRESSIT
�701 AL, Si P Q Tn
OCONEAC14
(� ren PHONE I.. BLDG
HU ILIJING PERMIT INTO
11"•�"L, 6RV-% (�-1-)j•�,Z,� � JS�O ❑ Consultant Fees Paid by Applicant H DDc IiU❑SCI' PLUMB NIECE
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby attrm that I am teemed under omni:inn..of chapter 9(con titeneins JOB DESCRIPTION
O�Z with Section 9fXX11 of Uivision3uf lM1u ilmioss and Pndcssioas Cade.andmy l Prean s RF ID NTI I'
W p PERMIT'ISSUANCIi
-12 is full A...cundminy SPEW], ❑KI'I'CIII?N RI?MODIiI.
9UI" License Inv >Ti -r Lic.« 7MO�IoiJ
Q U —� nl'1'L1n NCE5-RESIDIiN'linl. []ADDIT-UN ❑STRU 11IURAL PIPE
p.Z yl Ilse TSD1c \YYII
C]MULTI ❑STRUCTURAL
�y ARCIII"I'ECTS UECIARATION PANELS MODIFICATION
ZO Z_Z I undersm a my plan shall be uxal as public records UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FQ•0L-I,y LiccnuN Profir"knel 7SPECIALCIRCUITIMISC.
PS Ih1PROV1'.,MIiNP EJ SWIMMING POOLS
ayd � OWNER-BUB.DIeR DECLARATION AMPS ❑BATH REMODI?I/RFPAIR ❑DI?MOI,I'I']ON
C Q 1 hereby alliin,that 1 ant cactnpt Irum the Contmcmr,Licenec Law for the
X O L U rulluwing noon.(Scclion 9(191.5.Business and Professions Cada Any city m mmntY TRICAL OTHER
LL 3 LL y which requires a permit In constant,cher,improve,demolish,or repair any structure
F'4•p prior n its issuance,alw requires the applicant for such permit m file a signed sidement RCUIT/MISC.ithat he is licensed pursuant mmepmn.mmofthe Contractor's License Law(Chapter9 COMMERCIALa <C (c°mmencing wise Scclion"I(NX))nl Division J of the Business and Professions Cadr)or ER OR POLE 1NST.Lha he is cece,m0wrefrnmmulInc hasi,formealleged esetnpaen.Anys'inlalionnl ❑NEW BLDGIAIlD T10N ❑DIiMQ1.IJdQN
1, Sccfioa 91131.5 by any n,pliwm fin n rtnit,mj,chs the npplintnlla a civil Pcn:dty of VICES ❑TENANT ❑POOH SERVICE
mf more Joah Ine haadred dollars($5(X)), IMPROVEMIiN'I'QC)I,acownerof the propcny.or my cnhployecs with wages asthcinnlc mmpcnsatice. TOOL,17 AT HIC
p.. will do the work,and ihexausoure nmol intended or offered for sale(See.71yl Business ❑O'THIiR
C 3 m and Professions Coale:The Commca,/s Liceme law Jots not apply to an owner of OU'ThFTS—SWITCHES—FIXTURES
property who builds or improves thereon,and who does such work himself or though
his own empl(iyees,po s'idcd that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ 14.
sale.If,how a the building,,in q To,, rad issnld within oncyeur of cnmplclunt he SQ.FI'.FLOOR AREA $ISQ"FT.
c,maldcr will htrvc the nurdcn of proving that he did nut hould ur Impose lur Ian
Psn••of sale). 'L'(1'I'AL:
0 1,as owner nr the Wopery,sun court suavely contracting witla licensed cantracon,;In
construct the pojmt(Sec.YON,itusmes and Professions Call The Contractor's Li-
cense law docs not apply to an owner of prof a ty won builds or improves(resume and QT). P, A NG PERM 1'T FEE
who contracts for such pojeco,with a rommetortof licensed lmtzuantto the Comm lot's
License Law. E'ER IS, NCE
lamcsmnpnmdm Sce. ,Bk PCfa FI,isrcuon
ALILR-LIRA F?N'I'-WATER(EA) VAhUAI'I(hN
Owner Dale
WORKER'S CONIPENSA'f[ON DECLARATION BACK Il.OW PROTECT.DEVICE I �O vU
I hereby alfirn under penalty of perjury one of the following declamtiom: 1
❑I have and will nminuin a Cciificatmd ConsenOo soelf-mvaoc far Wool Camper- DRAINS-FLOOR.EDGE AREA.COND. -,TORIES FYI 1:CONSTRUCTION
salion,mm provided h+r by Section 3701 of the Labor code.for the Performance of the
work far which this penial is i,Im d. FUTURES-PER TRAP
I�'1 have and will mainmin Workefs"Cmnpnnutinn Insuruncu,as rcyuiled by Seatinn
1 Nlofthc Lm,C+dc.to,the prrhorne .,,I(Joe work fur which t his pemhil is'datnL GAS-lin,SYSTEM-I INC.J OU'1'LETS OCC.GItUUp APN
My War t C'omppmaamn lnwr�n. e d Policy nutnlwr am:
Came'. LA iµII o Policy No:WCnI\71b�'"G GAS-IA.SYSTESf-OV1iR J(EA)
CI[H
,ATE OF 1: FROM WORKERS' GRFASI%INIIU$TRL WASTE INI'F:HCEPIC)R
COMPENSADON INSURANCE BUILDING DIVISION IgiLS
(This.seclion need notbe ssnnplcted i fmc permit is for one hundred dollars($111) GREASFTRAP
I'LANCHF.CK Flili
+)
I certify t er In ted peafurjurer of the work for which this permit is ass Cod.l shall 511W lilt-SANITARY-SI'UItM GA 200 IN.
mol employ any person in any nwnne colo become nuhjeunothe Wnrkcrs'Cnntpmh" ENERGY 1:171:
Z sution Laws M California.Date /' WATER HEATER WNENT/E ECTR GRADING FEF.
0 0 AP hem
z y NOTICE TO APPLICANT.If,cher making this Certificate of Exemption.you should WATER SYSTEM/TREATWO SOILS PEF:
F" become subject to the Workees Cnnhpensmimn povisiam of the Labor Cole,you roust
ai Ionhwitheomply with such provision,orchis permit shall be deemed invoked. WATER SERVICE
Q Q
CONS"I'kUC'I'ION LENDING AGENCY NEW RHSIld7NTIAh III M13 SQ.hII PAID
U Z l hereby aftirm that mere is a emtslmniun lendingageacy lit the Fwifnrnmuccof Data Rccci Ptp
LL 0 the work for which this permit is omeJ(Sca 3097.C'w.C.)
'CO'I'N.:
O 1<nul Name TOTAL: -
{U Lcadc/s AJJrccs BUILDING ITE
CIL. I crony ohm I base read this applicmWn and shute Nm the aMvc infammlion is
U,1 cored.logres tonnnply with Ill city coil coalync iam"cl:hodsmtc lewsrdutng to QTY. MECHANICAL PERMIT FFFrI SEISMIC PER
U huildmgc iicdtiEmpen forcn,cloanplacprucnmtivcx"I this lounfm noon him .52
uhovo(We)"ncd popery for inspection purpnscs. i'IiRNI'I'ISSUANCI3 J L ELECT RIC FEIi
(We)agreeit)save,and expenses
keep hayin any
uCity ofyarct Culmnan st said City
liuhilitics.)udgmcnu.costs and cxpcns>whicM1 may in any way nccmc against said City ALTIiR OR AILD TO h11iCH. h181NG FZli
aironsequence of the g.nting of suis parmiL
APPLICANT IFNDERSTA NILS AND WILL COMPLY WITH ALL NON-POINT AIH I IANDLI NO UNIT TO U1.0NI CFAO MECHANICAL PEE
SOURCE REGULATIONS,
AIH HANDLING UNI'1'(OVER 10,000 CFMJs CONSTHUCI'IIhN'I'A%
V
Slgmwrc of ApplicanVCummnor Uare I?%IIAuS'I'IIUOD(WIUIIGq IlfluSiNG MI'I'IGAI'IUN ITE
HA9ARDOUS MATF?RIALS DISCLOSURE
Will the applicant or future building occupant stare or handle hazardous material HEAPING UNIT(TO 100.000 BTU)
us defined by the CoNi im Municipal Code,Chapter 9.12.and the Health and Safely A
Code,Scmim 25532(x)^ -�! HEAPING UNIT(OVER 111.(1()BTU) 14.4
0 Vic, LGN'(' VI:IN I'LLA'TION TANS I NGLE RESID) PALE
Da,, Receipt#
Will the n,dicant or fal a huddlin6"oupant use v,,III u I or devices which BGILIiR-COMP(LHP OR 100.000 PTU)
mit b cardous air contaminants as defined by the Boy Arca Air Quality M:mugmaran TOTAL:
Diarul? �� HOU_ER-COME(OVER IU(I.IXI BTU)
❑Yes [oj<Na
AIR CONDE'IONER ISSUANCED TH,
1lhavo real the hamNnus nmmrials rryuiremcnhs umlvr Chuptcrb95 of the Cali ^ r1 ,p
fomiu Health k Safety Cotte,Sl"ns 25505,25533 and 25534.1 undersand that cote NEW RESIDENTIAL MECH. SQ.IT J /3 71"
huJd g laesnn, anlyhas a al that 11 is my rsIx,nibilhy In notify the taagnan f� I� Q�
rt
1 nnlptnielrjaimmunis.vhicn more(nrinr m'nsnaneo nen Ceni scarf ar(katpamy.
K A
Owns raumoriz gem
Date TOTAL: ISSUED BY: N
OFFICE