S 0530 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LRCgRICAL P� IT1'NO.
BUILDING DIVISION APPLICATION/PF.RNI T PLUMBING-MECHANICAL � 0 5 330
BUILDING PROJECT IDENTIFICATION
-✓ OT SANITARY No APPLICATION SUBM(MAL I]AI'l:
n/CUING ADDRGSti; IY�r , �:,-, 1 ' • ,, 1 Lh/ r7
Ek;S NAME: II// jT1 yY(_IK—iv P CONTRACT OR'S NAME: / LIC NO:
,/ 4LG NIC CONIROLM
• ARCHI'TECI'VENGINVER: LIC NO: ADDRESS
CONTACT: PHONE: BUILDING PCRMIT'INFO
J P ' �✓ 5372 ❑ Con,011RD1 Fees Paid by Applicant(Initial) BLDG n"rt;[ PLUMBM
ECH
W✓✓110 Ida >;[ la��/
LICENSED CONTRACTORS UECLARA'I'ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm in.,I am licensed under provisions of Chapter 9(commencing
OZZ with Section 100([uf Avislon3ofthe Businessand Pmfessiom Cade.andmy license is IDE
W p PERMIT ISSUANCE NIJAL
� infull forceendeRecl. T)WL [IL.
KITCHEN REMODE
aUU License Clan Lie.is APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RI's-PIPE
N Q L r ❑MULT
DoleCommen
art
ARCHITECTS DECLARATION PANELS I-UNI I' OTUkAI
~. MODIF
Z 1 hndersratd my plans,hall be used., .hire records MOUIFICA'f1ON
OZviQ UP 10200 AMPS [I INTERIOR ❑CHIMNEY REPAIR
F�FW Licensed PmfeW...I 201-I000AMPS IMPROVEMENT C]SWIMMING POOLS
�WOWNER-BUILDER DECLARATION OVER!(")AMPSy ❑BATH REMODEL/REPAIR ❑DEMOLITION
lY tY 6 1 hercby vffrtm ohm 1 tun exempt front OM1e Contra.....'.Lieco,c Law far the
X 3 4 k) following reason.(Section]031.5,Hadmic,,and P hellion,Gale Any city ar ar unly SIGNS ELECTRICAL. C1 OTHER
y which reuire
q ,a p,rmit ill convect ohne,i npn ec.demolish,ar repair any'tmmarc
F-LL0¢ prior m its issuance.also requires the applicant fresher permiuo fileasigned,lmanrnt SPECIAL CIRCUITIMISC,
flythat he i,Bestowal pursuant to the provision,or the Contractor's License Law(Chapmr 9 COMMERCIAL'
�y'QDLITION
(cammen<ingwith Seainn]gppd pini,ianJnOhe[usinexx enA Pmfesions Cadc)+t TFMY METER OR POLE INST.
L X e y
that he is exempt therefrom and of hast,for the allege)cxcmmtinn.Any violation of ❑TEN BLDG/ADDITION ❑FOOD SERVICE
�, m
Sea mn]1131.5 bymy.pplleunt I'marysmk,uh,i,el,the applicant mn11,11 penally hf I'OWIiN UEVICBS QTF.NAN'I' [_1 FOOD SF:kVICIi
not more than live hundred dollar,($500), IMPROVEMENT
=O ❑Las.nater of the pmpenY,or my employee,with wager vs their solve compensation. SWIMMING POOL EL T El OTHER
F. rill dr the work.and thesameum is not intended or offered for sell(See 70&1.Braine,
Wm and Profession,Cade:The Cammctor,License law ams not apply to an Owner of OUTLETS-SWITCI HIS-FI
a 3 property who builds ar improve,thereon,and whit alms.such walk himself Or almost
as own cntpdoyce,,provided don Inch intpmvemcmk The not intended m offvarl for NEW RESIDENTIAL.ELEC R FT
side.IL hhwcver.the huilJingOrimprnvemenl i.v sold Mahan eyeshot emopleaod"he SQ.PI'.1'LOORARBA SISQ I'I'.
ter-builder will have the burden of proving that he did not build or improve lit put. "10
pa afsalen6 AL: 3
as w er of property,am escla,ively contracting wan licensed comma..to
eamamm m,p i«used.vua,Business and Pndeaim,Code:)The Cmlmcrors Li.
c se1,uwJavesnotvppdy m an owner of property who holds or hnprove.s thereon.and QTY. PLUMBING IT FEE PAID who mnuucrx fur sucM1 poi eels with.enthrall(,)licensed pmvunm Rx the Cnnoano', M
License PERMIT ISSUANCE
❑1 aml� for this rca,am
ALTER-DRAIN&V6YI'-WAT13R(13A1
Owner Dale Ty
O ERS COMPENSATION UECefollo ing BACK PLOW PROI[GT.DEVICE C11I u -
veandwillimttainaCunder cnahcancolConseny ncolelf-sen ire for Workemionr. V 1'
IM1uvc and will maintain uCcnifcvtc of Consent msd4inxure fnr Worker Cnntpcn- DRAINS-FLOOR,ROOF.AREA.COND. $TOg[;G PH GONS'1'RGCI'ION
whom,as provided for by Section 37M of the labor Cade,for the pedom encs Of the
work for which an,pcmtiO is i...ed.
FIXTURES-PER TRAP i
I have and will maintain Workers Compensation Insurance,as required by Section GAS-EA.SYSl13M-I INC.q OUTLEIs 1
3701 at the Luber Cade,for the performance of[lie work for which this permit is issued (KC.GROUP AVN
My Worker's Compensation lnr.urancecomerund Policy amulacrare: GAS_I3A.SYS1'P.M.OVE?R a USA)
m
Cae, Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS' GRHASEBNDUSTRL WASTE ING ERC FOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Ihis'utinn ncalnm be completed if the permit ix fonmc hunJmd Jallarx(SIO)d GREASETRAP PLANCHECK FIJI
or desx.l
Loy any Persian
the anyperharouracc
soflhewmkhhwhichlhl,,phe W i,iswctl.IxhW1 SI3WIik-SANITARY-STORM HA.200 PC I?NRkCY IJIIi
not employ any person in any manna nn m"m Ixcaxxm,suhjmun me Wnikcrs'Contpcn-
Oz satioulaws of Califrmih.11me WATER HEATER WNEiNT/ELECI'R GRADING FEE
z O Applicant `
NOTICE.TO APPLICANT:If,after making this Ccnificalc Of E3xwmption.}ru xboutd WAf13R SYSTEM/1REATING SOILS IEE
F became shhjecl m the Worker,Compensation provision'of the lanae code.year mm"
C4 ? forthwith comply with such provisions or this permit shall be decnted resaked. WATER SERVICE
m G
d
CONSTRUCTION LENDING AGENCY NEW kISIOEN TIAL.I'LMB. SQ.FT. I`AIU
O z Dam keccipr p
V O 1 hereby affirm that there i,a<otm(See
30slending agency for the pcAormancc rf
� the weak for which this pemtit is issued(Sm.3119].Civ.C.) TpTgL,:
O ULenders Name TOTAL:
Leaders Address BUILDING IJJ3
C I anify Thal I have scan this application am] ,are that ate above immrnurnt i,
y
correct.)agree to comply with all city and county animators and nate law,rebuingm QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U z building vonswction.and hereby hatband,representatives of this city to enter apamthe
abavcnothroned pmpe0y for inspection foepnses. PERMIT ISSUANCE ELECTRIC ITEE
(We)egrcc to,ave.indemnify and keep hmmles the City of Coolant'achrid
Ii,daIiae,,jadgmeh...its..and expense, mchary in any way aceme agmmr slid Cal ALI ER OR ADD TO SUCH PLUMBING FEE
sin ou xlgam,hcrr me •r:aning rnni7 fo�7� `
AP A T N F S'CANUSA WII, 111 '/ P) Alk HANDLING UNI'1'(TO I(d.wlld CPM) MIiCHANICN,DI?
�iar,� /�/^/�� AIR HANDLING UNIT(OVER IB.(XX)CPM1) CONSTRUCTIONTAX
Sig//C1J0 pplsanl/Cunrreclor (///�✓PF;7 HAHAUST FOOD OVIDUCT) HOUSING MI'I'IGATION 113E
HAZARDOUS MATEiRIAIN DISCLOSURE
Will the applicant or future building(weapon[wore ar battle haardru,asurnal I117AI ING UNIT(TO IfX1.IXX1['I'll)
as)stinal by the Cupertino Municipal Cads.Chapter 9.12,and the Health and Sudety HEATING UNI"1'(OVER I WAgd[TU)
Code Section n532W)T
p Yes ❑No VENTILATION PAN(SINGLE R[.SID) PACU
Date ReceiptM
Will the applicant or future building Occupant use equipment or device,%hien 1{011 LR-COMI'13UV UK I(N1.INN1I1T11)
emit lemaulau.,air umlmoinnn0 a,defined by the Bay Arca Air Quality Manugnnenl 1UI'AU
Lr,,quirements
BOILER-COMI'(OVER 100,X01 HTU)
es [I No
e read el hmmdms oras 255 5,11.533 an under
4.1Chapter rsta al the Cali- AIR CONDITIONER ISSUANCE DATE
s mSufcty Code, 2551).1 an Tinily
eche NEW kl?SIDI3NTIA1.MECH. SQ.Pl'.
x ern euncmly hove u mount,Ihm It is niy re'lnmibiany m tartly tea mcup.nt
ements which must he mol prior to issuance of a Ce"themc Of Oecnmuncy.hrmed agent
Uaa TOTAL ISSUED BY:
OFFICE