S 0444 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD ING-ELECI'Rl AL It[' IT No. O
444
HUII,DING 1361,SION - APPLICATION/IaERMIT PLUMBING.-MECHANICAL
(' •:(ifs '!tint111.DING•PROJ1'ICTIDEN'1,iFICAI'I0N, i;+ " j'
BUILDING ADDRESS: SANITARY NO. APPLICA'I ION SUBB7MI'PI^'AL DA'I'S
f
OW iR'S NAME; QL , _�� NAC'IT)R' NAMIi: N hIC NO:� SIC - CONTROL#
ARCHITECI'IHNGINEHIL LIC NO: ADDN'Sg: ElI / 9th
CONTACT: PHONE: - DUILllINC PERMITINFO
/ n � ❑ Consultant Fees Paid by Applicant(Initial) t BElLDC. [LO PLUMB � MOH
LICENSED CONTRACTOR S DECLARATION QTY 1 - s. I I FCTRIC PERA1IT' I. I' f FhF. }'o;,
I herchy uRrm thtlunl d d p '' n. fChupter9(cnmme g I - 1 ,•.R I JOU DESCRIPTION
Cd'Z 'tit Secfon'lnsoid'D v nJofthe Bu and Professions Code,unJ arty lie .e.s RESIDENTIAL'
�JOQ wi PERMIT ISSUANCE
I,, allface a-J ef�� fectC . '�O ❑A D ITI ❑KITCHEN REMODEL UPIPH
aUZU License Lica APPLIANCES-RESIDENTIAL []ADDITION [I PLUMPING RIiPIPIi
In 6� Dina x TS DECLARATION
ARCHITECTS DECLARATION ❑MULThUNI'f ❑MOINFI UHAO
N❑N PANELS _ -
ZpmZ lundentand my plans shall he nsal as Public rentrJs M(IDINEYRION
OZ.`O-0 UPTO?(MIAMI'S ❑INTERIOR ❑CHIMNIiY It IiPA1R
I-s, Fp' ! Element Pmfesmined - - 201-10RIAMI'S IMPROVEMENT .`0SWIMMINGPOOIS
g q•]] OWNER-BUILDER DECLARATION
CC�' OVER IIMNI AMPS 0 RATE RIiMODIi1JNIiPA1R Q DIiM01,1'I'ION
1 harehy affirm o nt 11S exempt from Iho Contntdm'x i,icaree Lawor for me
�d U follnwin Section 911115,Itusines and 1'ndesians Ede An I I ❑0 HEI2
g reamn.( li ci y or county SIGNS[L[CI'RICAL �'/T a
LL C N which trellis o fermi.ut camera,,alter.impose,dammi,I or repair a d slrumme /Y i)'p�(X )NC
prt(he isscense pausturegnithe lheapplicary Rtr such permit Live
esigveo(mhaplin t SI'ECInI.CIRCUIT/MISC.
yy� IIIUI he is llecnxcd pursumtl mile provisions ofthe Commeta'.e License Law(Chuplsx9 r -
Iy 2a Em he is ons.o,d Section 2101(IAdDiv far of thee,ed exemption A.,violation
of TIiMI'.ME'I'C:R OR POLO INST. COMMERCIAL:
Ii a o,' Sec he is exempt therefrom and the basis for the alleged exemption.Any l ver Pty of ❑NEW BLDG/ADDITION El DEMOLITION
Section 7031.5 03LSby any applicant dropennit subjects the applicant tuacivil pcnahy of POWER DEVICES�r� mart more then live hundred AnlWm 18500Y ❑TENANT E]FOOD SERVICE
�ZY 0THER
IMPROVEMENT
Dwer
Q has onof theproperty,or my employees with wages uxtheir sole ennnpcnselinn, SWIMMING POOL ELHC'I'RIC '
a 0 will do the work.and the stmctum is not intended or offered for sale(Sm.'1014,Business - ❑0'I'HEN
L3^ and Professions Code:The Cannanore,License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds at improves thercnn,and who tines such work himself or through
his own mnployee,provided that such imp in nnenls are not immtded or offered on NEW RESI Oft NAL LI.1!C'I'R SQ IT - -
sale.IL however.the building or lmpmsmem is said within one year of completion,the
- SQ.PI'.FLOOR AREA 4ISQ.HT.
owner-builder will have the burden of proving that he did not build or improve for or.
0xw ofsele.). -
❑ I,as owneP nl'the progeny,am exclusively contracting will licensed continues I) - TOTAL
intranet thprocent(Sec 704,L Builinso.and lkf.. C son.Conuadt L p. I
c La I t apply to (p pent h bids he
or tino d Q'ly7 PLUMBING PERMIT 1 'f' r 2 rT
who lmUx for suehP projects with a communist)licensed pursuant to the Containers ' t I`/ ry-.D
License Law r ...PHRM1,�T ISSUANCE, Y J../
❑ I am exempt under Sec. .B&P C for Iola mo...a
Owner Date ACfER-DRAIN&VENT-WATER WA) N VA UATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE
I herchyaffirm under permfic of perjuryoneofthe1'nsure ingdorker'Co
❑!have and will maintainalion 1cmtnnf me Labor Cods,
for Wolds Comitcm DRAINS.-FLOOR.RWF,AREA,COND. 'I'YI'E CONSTRUCTION
ounce,f r provided for by S,o nsu l)Igl of tM1c WAn Cade:for the perfnmmnce of the -
wnrk have
and
hlsparnhtls orer PIXTUR&S-1'ER TRAP
❑1 have ant will ode.fan he performance
I ds,w Imumnac,arc reyuainocd t i Section
3700of the 186or Cale.for the performance of the work for which this pennil in iesmeJ. GAS-EA.SYSTEM-1 INC.40U'ILIRl OCC.GROUP ni'N -
My Worker's Compensation Insurance carrier and Policy handier are:
Carrier: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERA IVICATE OF EXEMPTION FROM WORKERS' OI21iASP/INOl15TRL WASTE INTERCEPTORCOMPENSATION INSURANCE BUILDING DIVISION FELeS
(This section neW not be completedifthe permitis RhoushuadwildollaOSIBB GNEASETRAI'
cr Iv,0 ' PLANCI IHCK FEE
Ieanlfythminthe performunceol'Ihewmk ka whir'h l hieproat is issued,lahhll SHWER-SANITARY-SIORMIIA,200FP.
m
not employ any person in any anner yo as m becnnn 'aim the Workers Camper ENERGY PER
sation Lips"f Califn Date
) WATER IiIiA'fER WNF.NI'/ELECTit
O GRADING PEE '
7O npNicam arra ,G�
Fw ti N come subject 1O to th NI:If,n ser n n king n pr CumOcme of Lxempno d yarn should WATER SVg'fGMITRIiATING
a , become sna,m the Workers visions or his provisions of the Labor Calc,you!must SOILS FI!li
L[7 frmhwith comply with each provisinmmthis permit hall be JCCmM invoked. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RIigIDIiNT1A1.ZI'LMIi. SQ.I'I'. PAID 1 hereby affirm(lint them is u mnxWdmnm Date Sort p
inn lending agency for the perlbraarts
gL. the work far which which this permit is issued(Son.31191.Civ.CJ
Re IOTA].:
Lend es Name Ur
L) Lender.AdJ OIAI -
ISI BUILDING FUE
fy 1 agree to
l have comply
llcityais application and suite ilia,ll stat information e , t t p - "}Pr r - "�> }.
Z building gnat and here dlcryarmr my tat d rt I upon the
QTY ' MECHANICAL Pf,RMIT r
C.) Z building connmction,and hereby emhnme representatives !this city it)sn¢rupm the � l.. • SEISMIC FBI:
thave.-mentioned property for inspection purposes PERMIT ISSUANCE
(Win)agree m once,indennnif y,mtd keep boundless the City of Caparlino agnitwl ELF.CIRIC FEE
liabilities,judgments,eons and expenses which may in any wnyacereargmnel said City ALTER OR ADDTO MLCH.
PLUMBING IEE
in consonance of the grunting of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITO'O W,00ICPM)
MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING ONIT(OVER 1LxX)CPM) CONSTRUCTION'FAX
Signamin of ApplicanVComramnr Date EKHAUSTHOOD(W/DUCU HOUSING MITIGATION FEE
HAZARDOUS NUH RIVALS DISCLOSURE
Will the applicant or fumrc hullJing occupant store or handle hautNnus material I(EATING UNi'T(10 1011,0110 RTU) _
as defined by the Cupen ino Munic I Code Chapter 9.12,and the Health and Safety
Code,Section 25532m), HEATING HEATING UNIT(OVER i0of"1t,'1'Of
E]yes CJ tett DVD - -_
VGNTILAI'ION PAN(SINGLE RHSIU)
Will the applicant or future building bhe B Date Receipt A
use equipment or devices which
mit factualair nmtaminants as JcRned byy the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,(0()BTU) 'TOTAL:
.�D....let'I BOILER-COMP(OVER II%dy)BTU)
Ihave mad the hisafdous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomia Hcalth&Sabsy C de,Secduns25505,2.5539 and 255W.I understand that tithe NEW RESIDENTIAL MFCH. SQ.HI'. �J/J
l!ding tines no cunmaly hnvenuntam.tnat it is mY repand they m ami l y the occupant - �p�Zz
of the m,irey9 hichn ttpr to imuance afar C,ofcme of Occu ncy.
- Owner arra ntTin zed agent Date Tcrrnl; ISSUED Hy:
OFFICE