S 2568 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY —i
4JW, :R
F CUPERTINO BUILDING-IoLFC'rRICA], IRMII'No,
ING DIVISION APPLICATIONIPERNIFF PLU.MBING-MpCWwICAL S 2568
BUILDING PROTOCI'IDEN'1'IFICA'I'IOIN
G AODRISS: SANI'IANY NO. AI`I'hICAI'IONS1IRMI'MALDAI'E to
4NAh!Y p li: WR .V 'SNAM' LIC NU:
(Vl NIC CONI HOLN
A. ❑
'GIN:ER: LIC NU: I I '. ST
CONTACT` 1 HONK: J BUILDING PHRMI'I INFO
Consultant Fees Paid by Applicant(Initial) RLUO '.I:Cr PLUMB VpCI
ID
LICENSHDCOME RACI OR'S UI!CLAItA'I ION Q'rY. ELECTRIC PERM IT FFF
1 III affirm ma 1 am licensed under provision.of Chapter v(commencing J013 DESCRIM I0
Z with Section 7000)et DI �ACH
Ohc Business and l•rnfcsxinnc Gavle.send mylianse is RESIDENTIAL:
C=Z a0 � _ PERMIT'ISSUANCECSF- Ire lull force mtM' — O ❑6PUWL ❑KI'I CI HiN RI!MOUF.I.UU Liccnxc Cla>x�,, /. Lich APPLIANCES-RESIDENTIAI. ❑ADIOITION ❑PLUMBING RIiPII'G7. mu ❑MUI'TITNIT ❑SrRUCIURAI.T'ECT'S OIiC1.AR 11 I'ANEIS
I ,oz I undcmm�dmy plans shall he used ax public o/oils MODIPICA'CION
v� UPrO 200 AMPS ❑HTpRI(OR ❑CHIMNI'Y RF!PAIR
F'�I_'aw E7cnwd Pmfe.vsional 201-IIMMIAMPS IMI'ROVIiMEN'1' SWIMMING POOLS
st 77 OWNER-RUILDER DECLARATION OVER IIXMIAMPS ❑BsVH RISyW]I?IIREPAIR ❑DIiM(LITI N
C Q I hemb,nlnnn thin I am exennp,Irnm The Crnlrarru"Licenm Law for the
x6�i U following morour.(Section 7031.5.Ilu.incsx and Notession,Crxle:Any city or Omm, SIGNS IiLFCI'RICA]. ❑(fl'111iN
LLl LL v which mquircs a permit To construct,alter,improve,demolish,or repair uby suudurc t
pot" t 'I: :th 'PPI ,it,,ord,P 'u.)file I,signed oband zSI1pCIA L CIRCU IR
Did C. !
E } )but he is licensed pn the isonvi,ime.sitilt Contractor,L for.Ch EA CQMM`R IAI'
W�00 (cin cngwishSsctirn 70O(TofUvxo 3ddn Bus ncxs JI fico to CM1c)ur TEMP.M ITER OR POLE INS INS I'.
a a e C than he is exempt IhomI n o and the basis Imo the alleged exentpmo..Ary....lair m ,I' C]NI?W 61,DOIAIOUITION El UIiM01.1'rION
Section 1031.5 by any applicant for a permit subjects the applicant a civil Penalty of MOWER DIiVICF_S ❑TI!NAN'I' ❑POOH SIiRVICIi
nuI,norc thou E.0 hnmdmd dollnrs(850X1) r
OVEMENT
SSC �I,axowncrofthe ImpnY•ormy employees with wages as nheiranle compcnscout SWIMMINGMR)Lpl,,TRICce F.. will dr The work.andtheswcmrcn not intended or offered for sale(Sea.90,14.Bmxinos l I TI .0 t T : I t toryI ncr of (OUTLEI;S SWITCHES FI%'IUkES P opmry I b lot. p .d d h J h k h II ThnmgM1
h v o pl ) P J d Th t h' p t T t d J r 0, ed for NEW RCSIUENTIALI:LICIH SQ Pr..Ic.II 'moor.thi buI Ig Pnrv.nm t swldwthnn Y I PI(u the enbaimer will have the burden orprov,ng That he did not build or improve for put- f'�pw.c f al 1 TO (.lI n I J P I Iy 'I : ly i b tM1 I' 1 t T Ima TTh P J t(Sc 704P.H. dPrf:- 'Cox )IT G I CI :L-
QTY. PLUMBING PFRNIIT FGFwlutaulacofrrxcch pmRctswdn umnwc¢n(M lrc ,vd parsu.ut t II C alitio ,ILicenm Law. PERMIT ISSUANCE
um exemt underSec. .B&PCfor Ihix maaonALTER-OHAIN&VNI' 'AIER(IiA)Owner Date
WORKER'S:GNSNSAim UE CLARATION HACK PLOW I'R rl: ).
1 hereby uffirm under pewlty of perjury one I]the fnllosim,declaration
I have and will nuintri n a Coni licaanf Consent n wlGinsure for Workers Cortaro- DRAINS-FL TO GO ARBA. YrORINS TYPE:CONSI'R TIM[ON
cation,as provided for by Section 3100 of the Labor Code,rot the Pcrosnnunce of The
fa which This permit is issued. III%TURIS-PTR TRAP
I have.,Old will maintain Worker's Co,mpena:nion Insurance,as required by Section
Mlnflhclshorcod for Thcperfornmnce, thew;sd,b.rv1udOhispcnuilixi.stud. GAS-IiA.SYS fIiM-I INC.JO .?'L UCC.GROUT' ANN
M `� is Cpm mon n'�,r Re come nJ I'alic) GAS-IiA.SYS'I'IiM-(OVRk J(EA)
Cn,ricr� ��g. I: ,.icy Nr:
C'uRTIPIG EOPli%'.hlPl i PROM ORKIiHS' GREASI9INDUSTRLWASTI3 INTF,RCEPTOR
COMM?NSAUON INSURANCE BUILDING DIVISION FEliti
rlllixwrtimt recdnm be.u,nplc,ul it The, if is lia..nu to died drllam(SIUU) GRI?ASI!'rRAP
PLANCHYCK hili
less..
Troy inythnt trithe icurncenf oit,ishe kfor which Th in tine Woikors'C.lshallpen- SIiWIiR-SANITARY-STURAt En.NMI hT'.
� not employ any Mrsnn unity ren'^reef Ma use mheeon¢subject u,the WrrAad Cunryen_ IiN1iHGYFBE
Z mtism Lars.(California.])ate WATIiR HEATER WJOHMPEI.CCIR
Oji Applilan GRADING FEE
.N.. NOTICII TO AI`EACAN'1:Il;ml{crmuking this Ccuil{cutc rr Exc,npnrn,you.should WAELR SYS]ICM/T'THESE'ING SOILS FTI?
a become whject to the WoAcr's Compcccuion provisions of the labor Gxil:.you must
ford,widl comply With such provi siomsonbis per mit shun he deunmd revoked. WATER SERVICE
❑ XAID
CONSTRUCT ION LENDING AGENCY NEW RESIDENOAL I'Lh1H, SQ.1'C
u C) Iherch lBr,n TWn,h1re lx a cnoxvnolnn lending agency fur the lxrfmm�mee ml Date ceiPTN
U O hi
W F' the work for which this I%YmiT is iszucJ ISc<.31MD,Civ.Cd 'HYI'Ah:
O bender's Name TOTAL' _p I.cnersAddrean "I certify that I have read This application and slam that the above imbrication is rrm I name u,comply with all city and county ordinances and state laws Tc6ting to QTY MECHANICALPFRIOII' FEhEU Z huildingmnswetion.and herchy authorie representativanfmis city Tocnter u)we The -
aMwe-oantiotedPropmny for inspection purposes. PERMITTISSUANCI: D IT s O0(We)agree to save,indanmly and keep harmless the City rrCupertino againstIiubilinies.luJgnmms,costo unJ aponxcs which,nay in uny waY uttre agninu(card City AI TI3R ON AU oTO MSCI{, lilinwgrimncud granting or This per,nil.AIRLICAN ry1 D {SIANDS ANI)WILL COMPLY WIIl[ALI.NON I'UINT AIR HANDLING UNITfTO 10.000 CFM) AL LLSIOUgCFp(GUI. 'IONS.U/ AIR HANDLING UNIT(UVIIH 111000 CFM) TION'
Signature x,muCrntmar rut. IIXHAIJS'r HOOD(W/DUCII I IOIISI NO M I'1'IGAI'ION PEE
HA%SRO( , SI ATFRIALS DISCLOSURE;
/J
V ,Il the aPPliemm or furore huildin6"evupwm stem orhunJle Ionic n.nus mmcdal I IFNI'INO UNIT(To 100.00f)BTU)
on,defined by The Cupertino Municipal Gale.Chapter 9.L2.and the HvIdth and Safe', HEALING UNIT(OVIR I(XI000 BTU)
Ctslc,Suction 25532p,1! /
❑Yes ![]Mo YEN')ILAI'ION FAN(SINGI.h RESIU) PAID Dam Xeccitaa
Wit tbe nPPlicam or lulus,M1uiIJing)sago,use equipment or dovico,which
nit harwrdous air contaminants as defined by the Bay Arca Air Quality Management B011.lilt-C(IMP(.511P OR IIMLUPAI l{'N) )l,
District) BOB.1?R-C(OMP((OVIR I00,0001HU)
❑Yes 7
Iba-rend The h:vallommaterialsre,irememu under Chapter 6.95 of The Cali- AIH U)NOI'I'IONr:R ` 6/► O ISSUANCE DATE
fomlu health A Safely Carle,SectiTnu 255115,255331 125534.I undasnmd Thin Ir the NTW Il p_SI DIiN'IIAL MCCIL SQ.PI'.
building Jses not currently have n tenant.Iha it is my resionsihility to notify the vocup",
of/�typirmmm�s which sM1e ma prior amu nfa Cenifcu¢'If Occup:mcY.
Uw m a'Za'mJ ngcm Umc ISSUED BY. `
OFFICE