S 2871 (2) --APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUt,DING-ELECI RIGH, PERMrr NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMIUNG-MECHANICAL
BUILDING PROIECP IDESN'IBICATION '
S 2871
BUIIAINT ADDRESS: ' � 1 a SANITARY NI APPLICATION SUBMI'I'IAl.DNIT
OWNER'S NAME ONE:111-r 340 OM'kACTOk'SNAN LIC NO:
//,JTel`L Fv arLo�.,�:, (r16 T j- y NIC cGN'1ROLx
• ARCHII'Id'IOENGINP"ER, LIC NO i. ADDRESS', ❑ 92 '71
11 ll ZCU VZ,uue /
CON'T'ACT': /1 PHONE: -BUILDING PERMIT INFO
-3(^ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECll
7 ❑ R-� ❑ ❑
LICENSED Ill CLARAITON QTY. ELIECPRIC PERMIT I'EE
Ihereby alum 11.1[ano licensed d nnovillon,of Crucial 9(enmtoa, htg JOB DESCRIPTION
Zp wan Sdenot 700B.I'Divi,ent3offthe Brosinte,andi fesslon:Cd and mylca se is FBIONin ISSUANCE - RESIDENTIALW O
CSF in full force and effect. /(9 (13 ❑SFDWL ❑KITCHEN REMODEL
QUV Live
me Cl. _ Lic.N G ] APPLIANCES-RIESIDENTIAL ❑ADDITION ❑PLUMBING Ri!"T'il'l:
N Zj a Date Conlruclor
v
AT I'I'ECT'S DECLARATION ❑MULTDUNI'I' ❑S'ORUCTURAL
1..Dm • I'ANtitS
z InnJerstand mYplansahall be us:vlux Public rtcnrds HE If)200 AMPS MOUIFICAT'ION
OZ�Ls ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Pn fessiouai 201.140AMPS IMPROVEMENT C]SWIbIMINGIIOOIS
; OWNER-BUILDER DECLARATION OVER I(NNIAMIS ❑BATH REMODEIIREPAIR ❑DEMOLITION.
M'G y' I hereby alTtrm Thal I am exempt Turn the Contractors Deese Law,tor Tho
3dO 1a1flmvhlgm:sson.(Section)I3I5,Betimes and Prolosslons Code Any city or nnlnty SIGNS ELCC'IRACAL ❑OTHER
LLT 41" which requites a Permit an cod,mm,elmr,improve,dcmfilhb,fir rcpulr any xmnml'e
~°05 prions its issuance.aho requites the applicant lin such Permit to Blc a signed ueelnem SPECIAL CIRCUI'L'IMISC. um
Ibar he is licensed Ponmmm the pmvrsama of the Charter Liceme Law(Chapmr9
WyQQ (commencing with Section 7000)of Division 3 of the Business and Professions Code)it I FM R METER OR 1101.1E I NSI COMMERCIAL,
d y o C Ibat he Ix da, al therefrom nail the bans far die alleged esenimaon.Any violatlnn of ❑NEW BIDNADDI'I'[ON ❑DEMOLITION
tirtl,ti 4y Sedinn 70315 by any appEleaal fn ii pennll xnhiller,the epplicanl la a civil petrify It POWER DEVICES ❑'fHNAN'f 3I'OOD SBRVICI?
not marc Tittle live hundred dollar.(550).
ESQ ❑I,aurwnct find progeny.ormyemployees will,unga nstheirsule compensation, SWIMMING POOE.ELECTRIC IMPROVEMENT
F will Jo the work,and theshrocmre is not intended fir offered for%air(Sea 7W4,Boling, C1 OTHER
W he and Professions Code:The Committees License Law does not apply to an owner of OOTLEIS-SWJrI'CJ ll -FIXTURP_S 5 I rC L I C in,T//11 C
Ptopsai whit huildx or innpmvcs Iheman,and whit dims such work himself or through
his awn enlployccs,pmvldwl lim such impmvenmals me on lnaa t'l m uttered Bl. NIEW RECIDEN'FIA 1,11LECTR SQI"r.
sale,If,however,Wn Naldingol'Improvenlunt is solid within one ye,,ol cnmpinlnn,IIIc - SQ.FI'.FI,OORAREA $ISQ.FI'.
ervhm
uildcr will have the burden ofpvia,that he did non buddor improve for per- Z CInTC F,'x TU2L5 Y
pore of svle.). I -
1,as owner of the progeny,am exclusividay contracting with licensed contractors to i T 5`s
construct tit project(SeV(HJ Hustricis failI f, Cxlu)He Comraeo r:l'
Lawdoe,notopllyl f, E Y.1homild,atioulaile,da I QTY, PIIIIMBING PERMIT , "'a FEE'
whnennlrnrx forsueh Engem w'th tamura 1rts)Icessed lonva no the Codrau:'a r '
License Law. 111 RMI'I-ISSUANCE
❑lam«emptunder Sec. ,II&PCfonhismaom .
AI:1'IiR-GRAIN k VIE - .TER ICA) VAWAfI(IN
Owner [).,,a
WOR K1iR'SCO"at n i.,on DECLARATION ', RACK 1'I,OW'PIt(YI'I?:I'.I - ;li
1 hurhy affinal mai under penally teol Con one t the following do rker'sami ns:
❑Ihavera,,and ideforhiSeliour 3cateof,hcLabrsell'-.Bertha Workrs Comlsem - IIItAINS-FLOOR,Ii(101',AR OND STORIES 'TYPE CONS"1RUCTION
smion, r Provided far M1y is i... 3TW of the Labor Cola Bathe PeHnmence of tha
xork by whid his Permit is issued. PI%'1'URES-PER TItAI' j
❑Ihave and will maintain Worker's Compensation Insurance,as required by Section I- pP
39!X1 nfdlc Luton Cade,far rho performuna of the work for which lM1ls permit is lxsreol. GAS-EAAYSI'IiM-I 1 O OCC.GR(IIJF' APN
My Plulkel'n p � --�
Currier: •j°t 1 ylrljl Pnii,,No.� n' GAS-IEA.SYS'1'17 -1
�3�FFIICAAr�EXFMF11'ION FROM WORKf:RS'
COMPENSATION INSURANCE GRIEASFIINDUSI'W EINE"H H
11 BUILDING Di VISION
(This scniofroal not lecompleted Hun,Tarrant is foronehnndteddollet-,0100) ,GRIEASETRAP
of less) 1'LANCHECK FEE ,
I Oen i fy l hat in the perfnnnancc afilm work far Is l hi s per air is issued,IthvdSI?WI'I(-SANI'IA -STORM I?A.-I I'
dn
not cngsdoy any person in any manner so as to twconlc subject Io the Worker,Cnnlpa n- ENERGY FEE
OZ salion Laws of Cubfomia.Dare K'AI CR HEATERillyl�fDELECI'R 1FIEE
Z Q Applicata
(�)
NOTICE 10 APPLICANT':If,after making this Cenifca a of Exemption,you should %VATFIT SYSTEM/REATINC Kfl
(•'I become subject m the Worker's Cnnspensation provisions of the Iaihur Code,you must 501E FE"
W F.I
fort colf,ly whit such previsions or this pennll shall he dcemel revoked. WAI FIR SERVICE
� Qqqq
z CONS I RUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ IT. I I'A 121.11_
L)C) I hereby sffnn that ixaconalmelion lending agency forthe Pcrbarmmice of 1"II Ix Dale eceirt
the work for which This .,it is issued(Sec.3097,Civ.C.)
I<nder's Name TGIA
WLenders Address TOTAL:
E canily that I have road this upplicvliull and state That theabove Infonnminn is - - - I Ij11ILE_) _TNG Eli t
tiVa] aonee,l agree to utmply..,If all any sort county oNinan",mul state lows miming To QTY. MECHANICAL PERMIT TPEE
U ,z building conswmion.and hereby avlhonze representatives of this city m enter Olson life I - SEISMIC FE'
alcove-mentioned pmpcny for inspcninn purPfims.
(We)agree In save,indemnify and keep harmless the Ciry of Cupenino ugai est PERMIT ISSUANCE IiLECTRI FEE O Q
livbilitieu.InJgmenw,emts unJ expenses which nnay in vny way ncerue ugnlnm mTA City AM Ilk OR ADDTO MECH.
in"as ual
"'o"'
f the granting nl'Ihix PLUMB '1, 1i
APPI.ICA UN F S'I'ANUS D LL COMPLY WI'I'If ALL NON-POINT AIR I JANGLING DNI'I'IPO 10,0110 CEM)
SOURCIE t Ol'., N5.
2- A11iC1 IC .hili
2 A IR HANDLING UNIT(OVER 10,11i CENT) CON:TR C ION'TAX
Signmur n phcandCnnmlemr Dee EXHAUST HOOD(WIDUCT) DOUG G I'HGAHONFEE
HA9.Nl A'I'HRIA S DISCLOSURE
ill lhonpplleamin fulurc adding naupnnl score or hunJlchazmdom lnlllcrial I IHNGNGUNI'1(TOIIXL000BTIG
vs defnad by the Foramina,Municipal Cute,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? BEATING UNIT'(OVER 100.00)IT I'UI
❑Yes tT�N
VENIELATION FAN(SINGLE RF,SID) PAID
s D:n Receipt p
Will life applicant tanned onxmpanl ,e oquiI pinenor menet,which
sell humulnos alrnonwminnnu us datincd Ly tha Buy Area Air Quulhy Mnnugclnnn BOILER-COMP(31lP(1R 100,0001111T)
Diatrin4 BOILER-COME'(OVER 100,000 BTI))
❑Yes Uila�
I ave
mPllrenen p AIRCONDITWNER
read thele r 1 tit is utile Ch- t (95 of the C;TI'- ISSUANCE DA'f8
Tom Il hl .$+SafcryC 1 Son: s 51t 25noy d155
s"AI.E dt rod lhtt not NEW RESIDENTIAL METH. SQ Tar
bud J qT1 OyE Ihatl y pnnvibllyl ifythcxwp:n 7 z2"
fifth a nue, n c I pdono issaance fifa re ill of
Owner omedsgcat _ •�Date
TOTAL: ISSU17D BY:
OFFICE
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