S2042 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI RICA PEtITN O
BUILDING DIVISION APPLICATION/PERMIT PLUMING-MECHANICAL J
42
BW LUING PROJEI'1'IUEN'I'IFICATION
BUILDING ADDRESS,. SANITARY NO. Tk;PLICXf ION SUBMITTAL DATE
DI la L41 t-� l7fP� -ZY-SY
Ow 17RS NAME: , PIIONR: CONTRAC'fOlt:S NM I I m hIC NO: NIC CON'I'kOLA
a Q M1AN 2 U -Tb L� . ell
4WARCIiITECI/ENGINEER. LICNO:CA-DRESS: A 13�. a X S At7s 7
CONTACT: PINDI—, BUILDING PERMIT INFO
913 PC- 667-6010 ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECTPLUMB MF.CH
❑ ❑ ® ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby rfir;n that 1 n.t licensed under pravinan,of Chtlln,r)(enmmcneing JOB DESCRIPTION
Oaz, with SOP 7WI)ofD.,i,iml 3oOheBasinessed Profession,Cade,and my license I, RESIDENTIAL:
z,= iamillnreeawelle & 815 rlaRnUT lsswwcE
a+I OSPDWL ❑KITCHEN REMODEL.
Q,UU ;,scenes(:;acv �Lic.K APPLIANCES-RES I DEN I'I A I. ❑AUDITION ❑PLUMBING RE-PIPE
F Z y] Dam Canounm
ti. HCHITEC7S DEC;. ATIO r OMUL'D-UNIT OLS FRUCTURAL
PANELS MODIFICATION
Z C m Z I underswed my plmt„hall horsed as pub lc rerrud,
Oz4Q UP10200 AMPS OIN"TERIOR El CHIMNEY REPAIR
W Liccmiad Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION h
C Y J OVER IfNXI AMPS ❑HATfI REMOUEIJRhyy'P��AIR O DEMO;.TION
C W Q I hereby dl'mn that I an cxcuyn from the Conoocmtts Limnsc Lnw Ibr We 1Y%SIf tj 4�S /M e
3 C U following reamn.(Section 70315,Business and Professions Carla:Any city or mum, UGNS ELIiCI'RICAL OOI IILR
F� CA
C� wh-h.,.air, Pe jusur III its issirue, ltloc tso Pennines hl pPlArtman—Pe,a< I,h file p'g Iasair guy ttcmem yl'IiCIALCIRCUITIMISCure0~ �e�
that he licensed ptnu n thep 'Pion fth C t t L Law(Chpterin dfR.li$R
W
C) Overstraining With Sect 7000)of Division 3 fthe Businessand Pmfesviian CMe)or TIME MIi TER OR POLE INS'L COMM�CIAL: r
d C that he is exempt therefrom and the basis for the alleged exemption.Any Aelai ne of
c [I NEW BLDG/ADD;;'ION OUEM01.1'I'[ON
12PaPS.linn)11.,1.5 by any nppllcum forupcnnit.euhjcelz the applicant air civil pvnulry of POWER DEVICES 'I ENANT 1117001)SERVICE
ZOnot more than Five hundred dollars(45(10). IMPROVEMENT❑Las owner of the properly,ormY employees with sages us their sale comp.nsmion, SWIMMING POO,ELECTRIC ❑ TIER
F will do the work.I Idn"Inacwre is not wandod or Pilfered or sale(Sec.900.1,Business
W m vnd Profession,Code 7 The Comments License Law does,not apply m airowner of Oil(LEIS-SWITCI IIiS-PI%'I'URCS
pmpcny who builds or improve thenen,and who des such work,himself or through
his awn employ.,,provided that such Improv.mcnts me not intended or uttered for NEW RESIDENTIAL.ELF,CIR SQ FT.
side 11 hnx,vcq Bin buildingor impmwresm ix add wilhln enc yearofcompletion.Wc Q B, RAREA S/SQ.FL
owner builder will have the burden of proving that he did not build or improve for put-
is...of salet
TOTAL:
L us owner of the propcnY•ant exclusively contracting wdh I'tecnsed canm¢hvs to
construct the project(Sec.704L Business and I'ndessionv Coal,)Tim Common,",Li-
Omer,Law does not apply ht an owner of properly who builds or improves thereon,and QTY PLUMBING PERMIT FEE
Who comrna,for such projects with a eunvvanr(,U licenxal Pursuant m the Cnmmemr's
Liccnm Law. I'ERMI'1'ISSUANCE rQ
EJ1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT'-N'AIER(EA) VALUATION
Owner Dam
We'S COb11'ENSAI'IUN DECLARATION RACK FLAW PRO[IC DEVICE
I hereby affirm
under penalty of perjury one of the following declarations
Thaw and ideal
I...b ineCion 170."1 he
rosode.forthe Workers Compen- DRAINS-FTOON.ROOF,ARBA,COND. S"IONIE$ 'TYPE CONSTRUCTION
Ps.provided Ipe mi Section 9'!1X1 of the labor CnJc,for the hcdnnnanac of thea
work farwhich thh maintain
i.scored. ITS'NRICS-PER TRAP
37 1 have and will maintain he rdarker's Compermminn rl,I s which
h require)by Suction
3900 of the l,ubur Cuda tiro the per@mnance of the work lorwhich this permit Is izsuN. GAS-EA.SYSTL'M-I INC.JUDTLF'fS P OCC GROUP APN
My WorJ,ers pens'`y-{m laspmnce carier and Paicy numbers
Cumcr,ld�� }/ 'V_Policy Nn:FIIrC LW�yb/^O7 GAS-F:A5YSTEMOVERJ(EA)
CIiRI'IFIC IF,OF SKIIONIKSURANC'IINN FROM WORKfiRS GRFASIJINDUS'1'Ith WAST;;INTERCEPTOR
CUMPENSINSURANCEBUI.f NCIDI S I IN THIS
flTis.mainer need not be completed iftbe pemsirN forone hundred dollars(S lot)) GREASETRAP
or less.) PLANCIIF,CK THE
Iecitty that inlheperlimr;nnecof the work Far wldch lho"noillxi"a"fidull SIDNFR-SANITARY-S'IORMEA.20017T.
not anpiny ivy pcaonin any manner so.,m become whjca wthe W�rkers'Compen- Y ?I
Oz zmsPnlawsmC.ffn Pn.Dmr WATER BEAMS WNENT/ELECR GRADING FGI$
z Q npPllcam `
NOTICE TO APPLICAN'E IC after making Ih IP CeniOcale of Exemption,you Pit...IJ WATE
F' ? become mbjem to the Workers Compensation provisions of the Imbm Cale,you must SOILS FEE
Wforthwith comply with such provi,ima or this perms,shall be deemed revoked. WATER SERVICE '
UQ CONSTRUCf1UN LENDING AGENCY NEW RESIDENT PLM;{, SQ.PL PATH
IM1m.bynflinn that there VP.cemareion lending agency falls, rbmm
e peunceef Date kecc tp
" — the work in,,ImIm this Permit Is issued(See.319"1,Co.CJ Per, 'ICIAL
OV Lender's Nam,
LLL Lenders Address 3'\I"'
Q. I ccnify that I have read this application and scare that the above information a BUILDING FIiIi
.F.. pJ ...rea,I agree h;.omply ,In all dry and manly unboam.es and stela law,renting lm QTY. MSCI IANICAI,PERM I FEE
U Z hailbit,coelmnioru and hcreb,amhndm reporter........I his city to raret.income SEISMIC I'IJi
arrive mentioned propeny for inspection purry,¢s. PERMIT ISSUANCE
(We)ogre m save,"mdumnify and keep harmless the Cay of Cupenina against ELECTRIC FEE
Iivbilitics.judgerents,costs and expcees which may in any way retain, inzt said City ALI ER OR ADD I()MECIi.
in nscquence of the gmming of this permit. PLUMBING I'lili
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT IT 10.000 CFM)
MECHANICAL FEF.
SOURCE REGUhn'1'IOAIR BANTLINGNS
P 0 � ."a EX1ALJS FHOO (WIDUCT)NIT 10.gNI CPM) CONS M I ION TAX
Van—set pplicvHAZAmemr Dam 5%I{Al1S'r HOOD IW/Ol1CT1 {IOIJtiING MI'I'IGATIUN PPE
HA%AkDOlJS MAI ER DISCLOSURE
URE
Will the applicant or future building occupant,lore or haralloux material IIF,ATING UNIT(T O IIM).(XNI BTU)
a,)ennead by the C.pen'mn Municipal Coca,Chapter 9.12,and the Health and Smet,
Circle.Scatian 25592oP HEATING UNIT(OVER 100,000 BTIJ)
Ysa
�'No PAN(SINGLE RLSIDI PAID
Date Receipt# -
Will the appliem or more building ucerforn use equipment or devices which
emit M1amfin
rdaus air cralanumme as deed by the Bit,Area Air Quality Man.gement ItO1LER-COMP QHP OR It1U.g10 I1'Illl TOTAL:
Diznir? BOILER-COMP(OVER IN),(=it'rut
❑Yes El No
AIR CON Of I IONI:R ISSUANCE DACE
1 M1a d the h J t 1 y t:mr Chapter fi95 f tireCII
forrot II lm&Safic,Code,Sactions 25505 5533 and 255341 intruirmiand that The NEN'RES[DENT]AL MEC11. SQ.IT. (� 0.
bill61 currently have't 7fthtl yresponsibilityt (ly thens pa
offevoli voicnts wind,oma be met poor or u fa Catieam or UasPu).
Owner or amhorizeJ agent Us,¢ TYPTPP ISSUED BY: l / A
OFFICE