S 2122 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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ITV OF CUPRRTINO UMLDMING-I:LF.C''RICAL MECHANICAL pu n'No.
BUILDING DIVISION APPLICATION/PERMIT BUIING.MECHANICAL' 2122
ainIBUILDING PROJECT'IDCN'I'{F•ICAI'ION
lilll GAllDktiSl: SANITARY NO. - APPLICATION SUdMITI'A I.DA'I'S
(sp =c — 3
OWNER'SNAME PHONE: CON'I'LOW I ORS NAME: LIC No
NIC CON'I'ROLII
ARCHI'I'F.CTIENGINEER. LIC NO ADDRESS ❑
c 2 Sig S
coN'IaCr: PHONIC: _ EIJ ING_PERMIT INFO'_
❑ Consultant Fees Paid by Applicant(Initial) BhD ELECT PLUMB MECH
LICI NSCD CONTRACTOR S DLCI ARATION .r
s
QTY',. FLECTRIG PI RN1I'I' FOE' i
nnereby ars nthatl I I drp rcnapmr9(c..orae s n t JOB DESCRIPTION
WOO with Seu'o.7000011)...' ,3..Dbr Boonesa II ntebx�nC�Ie and ny(ee be x - RESIDENTIAL:
W O p FERMI ISSIJANCIi
x-F- In fallforceClass
effect. ❑SPDWL ❑KI'1'CIIEN kIiMODEh
<U�' Ciccone Class Liep
<—U API'LIANCF.$-RESIDEM'IAh []ADDITION PLUMPING PIPIT
on tE Dom Cnnwcmr
'" L ARCHITEC'T'S DECLARATION ❑:Mllla'I-UNIT' ❑MODIFIVRN.
f-m Z I understand my plan%shall heated a,puhlic records PANT-IS hfODIFICA'170N
'2'O ^ 'IO 20f1 AMPS
pZm—� UP ❑INTIIRI El CHIMNEY REPAIR
F•'/_',EC,IaI Licensed Pn mWonal 201-1000AMPS MMPI SWIMMING POOLS
OWNER BU...... DECLARATION OVER INY)AMPS ❑B 1 I
'�¢ hereby alrr�n that I mit BUILDER
rant nm ROTI mrx Llaeme Lee r�rr he
3 iE F foMlnwins`redenn.(Section 90115,Businms enA 1'rofessinna Codm Any city or county SIGN$ELIeC'IRICAI.
which 4 ' R tI construct.all p demolish. P y_I enure
L^��-1 pit I 4 0 ppll II hI tt II 6 Lnteocm SPICIAL CI IICUIT/MISC.
ww} matt licensed p n t1 hoIp 1. a fm C t t I c Lim(Chapter) COMMERCIAL:
W OQ
(commencing its Sect n70X0of Divx i fth B .' s dl f n'Code)or TEMP MFER OR POLE INST.
W p, Thal he Is exmnpl dmrebnm a I the Keie lir the alleged t,mrnfi i.Any violation t f ❑NEW BLDG/ADDITION ❑DEMOLITION
DC SecdsoIII LS by any applicant for a permit whjec,,ftepplicannn a civi l pcumlyul POWER DEVICES ❑'TENANT ❑FOOD SERVICE
Fmannnrc than Five hundred dollars($500). IMPROVEMENT
C
0' O ❑ I,rwownvm ufthe pnrpeny.onnyenrpinyeeswish wages nsthcir-snlewmrpmnsminn, SWIMMING POOL.1E.P.C`RIC
1,
c, willdwm
athc alEvindthcnWcre is not mended-onemd forsale Sec.TOT Bieiac,, ❑Ol'1II?R
NW and ProficWtnb Code:The Contractor's License Law does not apply man owner of 00"r LETS-SWITCHES-FIXTURES i.Z11
cy—
prolieny who builds or unproves thereon,wad who docs such work himself or through
his own employees,IF... Ihm such in.......ncnn arc not intended or oflcred for NEW RESIDENTIAL ELEC'llt
sale.If,hoxrvcr.thc building or improvement is sold wuhinorre,arief cAulpletionJhc SQ.Pf.FLOOR AREA SISQ.FT.
owner4sidder will have the burden or proving III,.,he ala ran build or improve for ran-
p wo of bale,).
❑1.as owner of the pmpeny,am exclusively emamming with licensed contractor to T
m1- td project(S 7014P ss dl f ae Cmin)The Contractor s l i 'fry .
,e 1st doo,mlapplymtot woe I'p peny h hailu,a, nproc,mere..., .d Q'TYI-; PLUMRINGIERMI'It ai -
who contacts for such projects with a cn anscomP)licensed pur vi anon Ilia Common s
Lice Law. PERMIT ISSUANCE
❑ I am uxennpl under Sec. ,11&P C ba'his re ,on
ALTER-DRAIN&VI?NT-WATER IEA) VALUATION
Owm.T Dane
WORKE'R'S COMPENSAHON DECLARATION BACK PLOW PROI'ECI'.DEVICE
.1 ❑ fCnnxn
I herchy affirm under Iw.all,of P'jury line of the follies in,declabousAt:
V\�/
! Ihnve anAwill muinwinnCrnifia�montonelf-item"Inr Wcaker'a Cou"o- DRAINS-FLOOR,ROOF,AREA,COND. STOk FS TYPE CONSTRUCTION
W sml.n,a,provided her by Section 3701 of the lahur Cottle.for the perlornn'nce of the
xork for which this permit is issued. FIX]ORES-PERT RAP
❑ I have mal will maintain Worker's Cumpematlnn Insemnce,as re,mmd by Section
3710 of the Labor Code,for the performance Of the work for which this permit is kond. GAF-EA.SYSTIiM I INC.40U'I'LI?'I'S OCC.—GROUP AI'N
Aly Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy Na: GAS-EA.SYSTFM-OVER 4(EA)
CE"of[IICATH OF Fx EMPTION FROM WOR K Ii RS'
COMPENSNI-ION INSURANCE CHI?nSPlINI105TN1.WAS'r131N'TENCP.PTOIt
BUILDING DIVISION IIiFS
('this section wed not ho mmpmleled imhe pr ,is fortune hnndmd dollars($Fall
i mlund CI113ASFTRAF I'LANCHI!CK FIT
I cenily rant inure perfnrmanceofine mark far w'hlchthi,permit is issued.l elmn SEWER-SANITARY-ST(IRMA.2W EFI'.
nm ennploy any person in any nmnner ba its to became whjeet to the WDrkers'Compon- ENERGY FEE
O Z sedan Lowx Dl'Califeraia.Dare WR'I'ER III7 ER WIVEN'I'113LLC'1'It GRADING PEE
z 12 Applicant - -
H rq
NOTICE'10 APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSIEM/IRFATI NG SOILS FEE
abc<mue,object to the Work.r'b Conn)renmlinn prnnl visinnb the Lnhnr Cull,you roust
W fnnhwilh comply with such prounion,ormis pmmil,ledl be decnmd invoked. WATER SERVICE
Q p
CONS
tthercisaconN LENDING A(1ENCY NI1W RliSIUIiNTIAI,PLMII. 6 Dae RecclplM
U0 k for
rwhichmotion ubauhercissconsauc.301D.Cm agencylirtthe penbrmaneeof - .rs
p. F me war,far which nein permit is issued(Sec.turn.civ.c.)
O U Lender',Name 199 TOTAL
Lenders AJArcsb 11[ L'
�•' a Iverify that ll ad this p, I d.rt th uh b f t s OU INC,
cornu I goat- aply 'll II 'ly I 'y fi l I: 1 l Tf 61st Q'TY. MECIIANICAI. .ERMIT, �'.: - , EEE, s : ncf 3
U Z building Ctmarvel nn.and bcrcby aahnme rcprcsn nal x:of b,ity toe ncrup�nthc
ahave-memloned p,,,,ny for inspection patrane.v. PERbfll'ISSUANCE:
- (We)ugrec w mvc,indcmnily.nd keep hamdcsx the Cay of Crdmn'm0 eguln't - LLE TRIC
Iiehilities,judgmente consand expeme,whiuhnmy in tiny wayaccmeagainst still City ALTER OR ADD TO MECI{, PLUMIi1N F,
ins.....c ase of the gronfn,ofthis permit.
APPLICANT UNDE'RST'ANDS AND WILI,COMPLY WITH ALL NON-POINT AIR HANDLING GNIT('rO IF ,F CPM)
SOURCE REGULA'I IONS. MECIIA ICI:
AIR HANDLING UNIT(OVER 10,1X10 CLOD CONSTRUCPI IN TAX
Signature of Applican✓COmmnOr Uac (?%HAUS'PHOOD(WIDUC'I) HOUSINGMLI A'UON FEE
HAZARDOUS MATERIALS DISCLOSURE is
Will 1Ite applkum lir fnmm hulloing occupant c'a'n or handl,h te,oln i,mnm,lal 11HATING UNIT('1(11(X),11(X)yfU)
Ob defined by the Cupertino Municipal Code.Chapter 9.12,and the Ecullb and Safety
Code,Secd..n 25572(a)? UF.ATING UNIT(OVER 100,000 BTU) IN /r3
Yes ❑Not/9
VENTILATION FAN(SINGLE RESID) LAID Date Rce ,
ecmWill Its,applicant or future building occupant use equipment or devices which
n'i,naHOIhFR-COMP(31IP OR 100,000NMl I{TU)
an..In—air mmin:un,as defined by dry Arca Au,Quality Man llon vat T
District? BOILER-COMP(OVER)10.00(1 ROD
Yen E3 N.
I have mad the ha,ablous mumrian mquiresentb under Chapter 6,95 of the Cali- AIIt CONIII❑ONlill ISSUANCCE'Dp/77E
ham.Health&Sm21y COde.Sections 25505,25533..,125534 1 understand that if the NEW RESIOENTIAt.MECIL SQ.LF l Y V
b.Mldhoo d..ebnot IonCindy haacalenarr1.Lhaitkoyrcy,mnihidty la n..e fythcomupant L L C
of the rcqulrumenn which must he oral prior to rbsvance of a Cenificme of Occupancy. `-_��/�q_Q
Owner oruulhnnzcd egant Date TOTAL: ISSUED 9Y:
OFFICE