05060140 CITY OF CUPERTINO _ yT ^'�'"�'� � � %' �"�`" ' k
BUILDING DIVISION PERMITzCONTRACTOR INFO R.MATION n
1,. ')'N'
BUILDING ADDRESS: ICOM MECHANICAL INC """05060140
47c; RAhMT,17,V DR
NER'S NAME: PERMIT ISSUE DATE
APPLE
ONE:
SANIARY 0. CONTROL NO.
ARCHI=fENCINEER, BUILDING PERMrr INFO
ee ZZ BLDG ELWT PLUMB MECH
_Op LICENSED CONTRACTOR'S DECLARATION O O O
F lob Description
1 hacby af0rm Jur I w Iiavm.mer go.ieom of Chapter 9(--in&
�4 with Scci 7OIIU)d DhWno 3 of de B%wi.and Prorauim Cock.am my liccnca
EEE
ifall forand dfat
yOQ67 7 REPLACE A LARGER DIAMETER LN2 SYSTEM
q i hernn�r�a
Comrr��. I C 'M G t poo A,,)[ L
7W ARCHfIECI'S D LARATION
I.not od mY I hcutm ublic m N
(n Lxvaed Fufcub
WNEA-BUILD E ft C.TI�
a�n C 1 mato .Rum War I am cacmpr(coon No cmuacm of c:An a city
o for We
DO f cb ,,ui.. (Smlm](1313,BUWess.nd vo.donum Co de:Mycity armoury
$� wMN mquirta•panit n tmuruo,alter,vnprrne,dcmd"uh,a rtpdr any urnnurtnll
_z> ptiorbiu inuama,.4o mquima We appliant far>vch permits Okad{red ddcnem
< War be is lie d Pmmant b ftcrorktku athe conuxw'o LJanm Ur(chap=9 Sq.Ft.Floor Area ValUatlOn
F�G (eommeming with Sauon]000)N Div 3 of Wo Budrcst am Pmfauooa(Cd)a .
$ thd be h ennnpt lbocfmm am We lad.for Ja allgM—Prion My Hddion a
soon7031.5byanyapyw.<fQ.amrilsobj tho applicant na�latonally of 32�ff�rfl0 Occupancy Type
no mmc Wan fi.e bumrcd da1Ln(15(101
C)1,as owner a de Papenl,or my mop".rhh wag.u YeL aok cwnpoumlm•
Mill 10 Wt wort am de twcoee It eat Imodcd ar oEcmd f..ak(S..' .Bob.
am Pmfodw code The cacva Ines Lic,,nac V.a .at apply n an o w of Required Inspections
Pm WRY who bWRl io no ca Jerron,am who docs tuchwarthit
own cnvbycu.proriOrdwranoontla old Oit in am of Ctnnpk mforuk.u. �� LES
hornet,Webdldlna orrmpta mviokhob MWmot )ear dcompledoo,the POac a ®®
Witter MO ba.e Je burden or prtNng that he dk not bWld a Improve fa PnPomc a(
talo_).
❑ ouowrcrof ct property..Ronmlvely eovuctint with Iimum amuacrara -
cmRtantbepro.applyotan.Bt aWop Pnfehdaru Ca dc,Tie Caaucn(h la. JAN Iz 7nnfi
U-
.Irx doo nor apply b w Doone nou-mrty rho W IWh a impm.n theman,and
who mnuan. for hath pojttu Mth a eonusror(t)liarued Wha'nr m We Cmuanar.
l' "� ave.
❑lam avopt mi@n See .Bd PCfu thin rano O e�� �( �
-er Dam Ip]�/flt ff�{IS
WORKERS COMPENSATION DECLARATION
1 hoeby allbm onder peoaliy of perjury one of the follwing 1cclan,do.
I have am MJ MainWn acauf mofeoo—,n,alf-mon,rvwctr .Conpco-
hulm,o prowc1u fa by Semen 3]00 of dm'- Code.for the peA«mure of Je
work fa which Nim p ft is ivued.
❑I lout and M0 mainwn Wa ,ComprmuJon Inaoraraa,u rqwN by Sat]-
3M ofthe LAbor Code,war the pedonn.of the wart for w ich Wit Pmmd ia ihwm.
My wow .yC fvwdOn Inwnrce amly am Policy norther art:
Camel-. N Poi 03LI S Oje
.
CERTFlCATEOFEKEMPTONFRO WORKERS
COMPENSATION INSURANCE
(Thtthmlm Decd oat hampked it We pamH V far areburdrtN do0u.($100)
ar Toa)
IoeNyanyptn We Wfumarce of t"lo, rbicE Wh the uitdN,ILWI om '
cmP dcalicrnta. Ny aetlf;pSoobbd'ehn ryE We Wortcn Cmnpcoharko
Ipwaaf CdiforNa.Da
Applicant d
NQTCETO APPLICANT:tiOc If,afro mating Wu CeNfka�at,ca co,You uabOOW
nom
become t scan t n We Worker.ndons wJm praykatcna it"of Je Dhow Code,. mud
.JO fonbMWcwnply Wirt Arch povWooaNit permlthWll he decmm rtvatal
Z" CONSIRUCrION LENDING AGENCY
Ihcrtby alarm Nat t ua..fim kminj;.gncy ror tM Poforat.a
p.' > the wart cur which Wit pewit u'«..d(Sm.309'(,Civ.C.)
Q I<meNairn
=z UmetAmw
UO I anlfy War I ha.c mad thk applicdion am wm Jul rh aho.e infamatbn u
Iy const l agm W comply Mth dl City awavy onit an,1 toot la mr.�:.'n
C) ,^ btdlding ewrlankn,am kroby ambodre rtprtxmdi.et or thu city to talo upon the
ftl aM.e-menJomA prupeny for lmpcciuv puryoz..
(WC) V=b ave,imemaify and keep humkv the GIY of Cupertino 3POOR
rjj IIaMIIJo,jWimcnu,cmu oma pct which may In any Y acauc.0call hod CRy .
fJ7 in cuucquuec of the panJv� i.permil
ram APPLICA ERSTA ND W COMPLY WITH ALL NON-POINT Issued by: Date
SWRC AT10 is. - - - ._- _
Re-roofs
SirobraffofAppbanv n or Dw
HAZARDOUS MATIALS DISCLOSURE Type of Roof
Will the vNiam or I.ltulotot o¢upmt ante or hulk bautdmh maleai.l
as dcRrc.A by We C"mm Mumripal Codc.ChLpw 9.I2,am We IINth am Way
P"e•setJonn53a(')' All roofs shall be inspected prior to any roofing material being installed.
❑ya °
- If a roof is installed without first obtaining an inspection,I agree to remove
WIII the applk.m or f
emu u conflbul occupant ire cyulpmmt m Mkh
u havaNnaa aircmumimna ned by Je Bay Am Air Qadar Mwyanzd all new materials for inspection.
adnen
❑yo _ .t�Nai
1ha.crodthe Myr whm••rot.r immmuu rClopar695orthcCdibr-
wHolNhSdayCo1c,sccdw ,25533am"'Iuvkm.m Jur irthc buiwina
Jou mll�wrent Y hovo a rrn.nL.L Ir u my mmpuvibilnY n unify o¢upant of Ne .
ma /pl{a m"dx am ar'c`"I"t„t°r : Signature of Applicant Date
' All roof coven ngs to be Class"13 or better
mtlnnrtd t VDare