S 3051 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOB DING.-ELECI'RICAL PT: 1 p NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBfNG-MECHANICAL 3051
BOILDINC PROJRIII' DFN'I'LF1CA'TON
EUILDINGADDRESS: SANITARY NO. APPLTCAJ ONSUBMl'19AL DAP I:
6o S. 5 \A 5 7s of /0-Zai-�Z�
OWNEN'. NAME: PHONE: CONTRACTOR'S NAME. 1.1CN0:
�a� 1.6 032 CONrx(ILM
�CHI'I'r:C'UENGINEER: LIC NO'. ADDRESS'. ❑
CONTACT: �iPHONE. BUILDING PERMIT INFO
❑ CnnSultaut FttS Paid by Applicant(Initial) HLIIG iLEC' PLUMBh1ECH
LICENSED CON'TRACTOR'S DECLARATION QTY. ELL'C'I'RIC PERMIT FEB
1 hereby aftion mat 1 am licensed miner powim+n.+d Chapter 9 amm�ttneing JCFB DESCRIPTION
Od'7_ wim Section]0110)nf Division3of the Nosiness and Rnfessianh Cale.std mylicenw is RESIDENTIAL:
WO, PERMIT ISSUANCE
Fx W= in full have and effect ❑SFDW'I, ❑KITCHEN RFMODEL
aUU
License Clan Lica APPLIANCES-RESIDENTIAL. E:1 ADDITION ❑PLUMBING RE PIPE
L.Z W Date Conmminr
a,<a. ❑MULTbUNI'I' ]STRUCTURAL
ARCHI'I FCTS DECLARATION
'yZ Iundersundai...shall he mad aapablueneanda PANELS MODIIICATION
O Z N UP TO 2W AMPS
[I INTERIOR [I CHIMNEY REPAIR
Licenced Professional 201-1000AMES LhIPROVEMENT El SWIMMING POLLS
OWNER-BUILDER DECLARATION OVER 100MAMPS E-]BATHRFMODEUREP R [I DEMOLITION
y-CEE 6 I hereby pins..Oen n I wxumpt brut,Lha Cann c...t,bleep-Law fist the
WadU following.emon.Sect 9031.5,Nmium—nd Professions Calc AnY cilY or eownY SIGNSELF.C'IRICAL ❑O'I'lIP
LL N which,'quite..a perm,u.e,mtact,alcor,in+pnnx.demolish,nr repair any ntrvclarc
FLLvl�q ma,its is.uanae.mw,requimstheapplicsnlforsach perminn fileasigned.umnem SPECIAL CIRCUIT/hf ISG
�ylY� that he is licensed pursuant the provi.ionx of the Contractors Licence Law(Chapter 9
a,ap0 (n.mmmncingwith Sect ion]IXX)ofDmiamr3 critic Nuaines and Pod--mo Ctaulnr 'r EMP.MNTER OR POLE INST. COMMERCIAL:
Q,6 ea mat he Is exempt uheretnm+and the basis.for the alleged exemption.Any violalinn ❑NI:W BLDG/ADDITION ❑DEMOLITION
x�NSeen 911,115 by any applicant far u permit xuhppct%the applicator to a civil Pell I i POWER DEVICES
sol more rM1nn five hundred dollars(S500). t�/G!/R�t1W� ❑TIiNAN'I' ❑FOOD SIiItVICIi
G=Q ❑1, fthP pc^Y Y PIY h g: .Ih I I . SWIMMING ITIOL ELECII OTHERVIiM1iNT
P., %ill& thek and the t t tintendedofferedf S OTHER
IWiland I f . Cmb'The Conleachae.,License Law does net a,Qlysl .net of OUTLETS SWITCIIf3-FI
ptTety aho h 'ld or intiosevthereon, J who does: 5 set or through
h.. v+pl)yscs.PnvJul len rah q nv.m in oil nr dfusd ry NI:W R17 JOE I'In1.LLECI'K
. lr,however.me nadding or improve+nem i.rola whldnAVleyu�9fam+pled t.1he SQ.1T.1 Loon nREn s/So.Fr.
me
r-Nmlder will have he burden of proving that he did uohb�odtl a.improve Ice par-
It
po.e,f.om.).
❑ L::s owner of the See 70y am eadmsivcy contracting with
av Even ed cnmmamrs n.
+,sutra the pn+jact(Seat.'111&4,Business m+A n,+f he mi CoJe',)Tl+a comma...'.I d 8
c mLuw does nm apply lu can owner nfprnleny won mild-a,in+pawca therwnt,unJ QTY. PLUMBING PE � FP.P.
who contract.for such pmjeers with a umracluds)licemcd pursuant to the Contractor's 8661 L as
License Law. PERMIT ISSI/ANCE {1j• 1V• a10
1 am exempt under Sec. .H k P C for IN,.,,an 3
ALrER-DRAIN&VENT-WA'1'IiR H:A) VAI.UNH N a
Owner Dom �
W 1?11•'CO , SANG DEChAHA'I'ION BACK PUIW I'IIIYfI:C'f.DEVICE \✓—
I hereby affirm under yob penury one of the billowing decimations:
,-J l have and will maintain a Cenificate of Consent to self-imum fnr Workers Comp-n- DRAINS-FLOOR,RODE.AREA,COND. STORIES PE (INSTRUCTION
satiun,us provided fur by Section J]W of the Labor Code,for the perfommnce of the
work fnr which Ibis)emit is issued. FIXTURES-PER T
I hate a,J will mainwin Worker's Qmtpenxatlnn Lnxunn-a a.required by Section �s�
J911d id the,a',
Crvlc.fnrtbcperl'unnnncc nfthc work larwhich thapcnnit lx i.mcJ. CAS-I',A,SYSIV C.4 fl Iqp. (ICC.CROUP MIN
My Worker's Compensation Insurance Carrier and Policy nrnothi am:
Caner: Pubey N,.: GAS-EA.SYS'I1:R4(HAI
CER-fivicAn:OF EXEMPI'1(IN FROM WORKERS' GKEASF/INDf1 L WA 13H E )R
COMPENSATION INSURANCE BUILDING DIVISION FEES
1'rhixnccri,nnced nor be tdc'.I if In.permit'is barium hundred dol lnrx(S l for GRUASETRA 'iii
8 -• - --
or less) 1'.
Iect-dym:n in me perlinmanee,f the work for which this vaid is issued,I shall S1:WER-SA -STORM 17A.21X1 FT.
not.mploy tiny person in any manner In as m become 1-diea u+the Woderi Ciampi
IEAe
z inion l:Wxa of Califamia.Ilac WATER HEAAER WIVENI'1:,.' GRADING IZI:
O O Applicant z y NOTICE 10 APPLICANT:It,after making this CCC.icae of Emmption,yon should WAT'IiR SVS'1'IP41FREAI'INC S IL 9i
httvll+U nuhi,el IV the W..wr'.Cm11'al:num po+vt.tovt of IIm Lal r Code.y,ll annxl
IY: �. fonhwirh comply wim It +n+ n .r Ihlx permit shall INC de,n ed revoked. WAITR SERVICE:
B
Z) CONSTRUCTION LENDING AGENCY NI w RIS11l1:NTIAL PLMB. SQ.PI'. PAID
U Z' thereby affirm that mere is a Conswaion lending agency for the peafomm�ecor Dam ipta
u. the work for which this permit i.issued(See.30X97.Civ.C.) TOTAL:
O U aanLento',Nemc T(l'L'AI,:
r J Lders.'.AJdre _
1 I cenify that 1 have read this application and slam the e aMrve inha narmn
n BUILDING FEE
co c neer.l agree to comply with all city and county orditmnces and.state laws relating. QTY. MECHANICAL PERMIT FEE SCISMIC PIA:
U building construction,and herebya.horue representatives of this city to eamruptnr the
aMrvmn.ntioned pnpeny for inspection parpmes. PERMIT ISSUANCE: ELECTRIC FEE
(We)"t',In., ,Jen nify atod keep Em nde"Ibc City of Cope^Inu against
liabilities,judgments.costs and expenses which may in any way accme against said City A[TER OR ADD To M ECR. PLUMBING 1:171:
in consequence of the graming of this pemtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'1'II ALL NON-POINT AIR HANDLING UNIT(TO 111.1100 CFM) MECHANICAL FEE
SOURCE REGULATIONS. AIR HANDLING UNIT(OVER 10,000 CFM) CONST R=ION TAX
Sigo'g7ure(47Tplics hCouaaou Da. FXHAUST 11001)IW/DUCT') HOUSING MI'I'MAHON FEB.
HA%ARD . MA'I'17R AIS DISCLOSURE
5V&Uheappluend core M1uildin6 tecupam atom nr nanJle hvuNntu mnmdal HEATINGUNI'I'('11)100,00BTU)
as defined by the Cu nn Municipal Calc Chapter Q.12,and the Health and Safety HEATING UNIT'(OVER 100,000 It'I'In
Code,Section 25532()]
�Ycs 0 N VEN'T'ILATION PAN(SINCLE RESID) PAID
Dam Receipt a
Will the applicam or Imurc budding Iecapant use equipment,r Jevicen which NOILF:R-C(lM1yJHP OR RXI.IXXI ETU)
vm
nit hdous air contaminants as&-lined by the Nay Arca Air Quality Management 'TOTAL:
DladcIT MOILER-COME'(OVER 000.0011 NTUI
p Yc. ❑N,
I have mad the hxranlousmalerialx wpbpcacmx under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCES DA'IF
fond.U.Bb h Safety Cole,Sections 25505,25533 and 25594.1 undcrsmnd held the NEW RESIDERI IAL MECH, SQ,FI�
building does not currently have a tenant,that it is my msp,n.a+airy to notify the Neupant
of he mquimmentx xmi-h mac be,net prior m i...anee,f a Cenireme of Occupancy.
owner ur Inuhrni¢ed ugenl tram RUAL ISSUED I1 Y:
0FFICE