S2703 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUH.DINc-ELF,C'I'RICA], PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMRrNC MECHANICAL L+ 2703—
[I
0
BUILDING PROJECT IDEM-1 IFICA'I'ION O L
[IWLUINGADDRIESS: SANITARY NO. APPLICATIONSUBMITTALUATE
OWN.HS NAME PHONE CONTRACfO N, fE: ? LI NO:
NIC CONTBDhb
A /ENGINEER: OIL
N / AnJ)Jy(F S: > ❑ /
R/ alll5iimc ,H
C.NTACI': PHONE: BUILDING PERMIT INFO
a ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
El
LICE\SFUCUNT ACI ORS CLARATION QTY ELECTRIC PERMIT FEF
hereby arrr n ill.,I 1 ens E I a pct .. s II Chapter m
9( ,m , clog JOB DESCRII'TION
aJ O p
WOO with Senn Tail ofDivision 3 Dhe[in.. d Profession,Code,canninn,licenseis RESIDENTIAL:I-V2- easeall ce andcWa PERMIT ISSIJANCF, ❑SIUW'L ❑KITCfiEN REMODELU F License Cl... Lis..b
Q U APPLIANCES-RESIDF.N'1'IAI. ❑ADDITION ❑PLUMHING RE-PIPE
F.Oy CiITECT'S DECLARATION PANELS [I MULTI-UN ❑MODE TURAL
Z O r"Z I e use as public records CHIMN CATION
OZ'm'- ons UP T0200AM1'S ❑IKI'ERIOR ❑CHIMNEY REPAIR
r�n t: rdesuon' 201-10XIAMPS IMPROVEMENT E]SWIMMING POLIS
yx.,_ .i en 1 hereby aliinn I N am BUhU[B DEfrom'LARntremor's License Law for the OVER III08 AAIYS ❑HATH RE•MODEURF,PAIR ❑DEMOLITION
x 3 y F following rr con.fSec rn]0)L5,Business and Podessio I,Code Any c'ty or county SIGNS ELECfIt I(ilL ❑OTHER
W li m which requires a permit m construct,niter,improve,demolish,or repair any amonce
F'VOQ prior,o its issuance,alsorendness the applicant forsuch carniuo fileacisnedsmremem SPECIALCBCUI'I'/MISC.
y� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
aCQo COMMERCIAL:
al CO (connnencingwllh Snctin 17000)of Emmet 3ol thH
e enan..and Prohevvion,,Cn felt, TEM It MET HIR ON POLE:INST.-
basis for,he alleged esem ono.An,vialotion of LW HLDGIADDI'I'ION DEh101.IT10N
0'.R.,a Thal io is excmpl therefrom and Incp ❑ ❑
R-
Section 7031.5 by any applicant fmaPermit subjects the applicant mncivil Penalty of POWER UEVICISS
no,more than five hundred dollars(5500). IiNANT ❑FOODSERVICE.
I. PRO\'IiMENT
�2n ❑Lmowner k,the proanuctunnyempluycexwith wagesaetheir sale compen,ainess con, SWIMMING POOL ELECT
L.- will do the cork,anA lheswmure:sora iu,cndeJ nnrffercdfur sale Der.704D.Rosiness El OTHER
W 3 m and Professions Gude:The Commcmr'.s License[.aw dues not apply to an nwnur of OUThITS-SWITCHES-19XTUHFS tl
properly who builds orimpnwes In.reen,and who dmre such work himxelfer through
his own employees.provided that such impm.enmms am not intended or,Remit for NEW RESIDENTIAL EI.IECTR SQ ET.
sale.If,however the building or impmvement is sold within one year ofcomple,ion,the SQ,IT.FLOOR AREA PSQ FT.
cltalilder will hone ono harden,(pct ing that he did not bald or improve for par
construct
o c f: ].
C] A
1 f@ p peny h i ly c m fig th licensed comments,10
"Iasi tIh project(SBusiness 1d9and Code:) C I Li
s doesn't,appiy,oars .rte-oTp p ty 1 6 IC p h Id
QrY PLUM PERMIT PEE 2J
who contracts[ suchprojects Aa communist licensed pursuantn
the Contractor's
License La, PERMI T ISSUANCEf
❑ 1 am excmpl under Seo. .B&P C dbnhi,reason
Owner DateAE:I'ER-DRAIN&Vli - VA'lR - VALUATION
• WORKER'S COMPENSATION DECLARATION BAC ll/
i Lcichy allinu under"coaly of Perjury one of,he fallowing deda anni
�Ihuvc and will nminlamoCenifieme ofConvm m,nlf-insure for Worker',Cninprac 'S-Emit( ) I.AR. 'D. �
S ORI FS 'PIPE CY)NSTRUCTION
w1mr,as pct tied f r be Section 3700of the Labor Cod,.,for the perfornmorI,of be t
workf which ihis per t issued, F ES-PERTRAP
❑ Ih d ll 1 iW k (x
'C :, I : y ' dby S,rot v ��
3700 of the labor Code f the perfloniance of[lie work for which lfiip,mtit-s rxued, G 4.T 1-IANC. 01 �� v OCC.GROUT'
My Workers Compensation Insurance carrier and Policy number am:
Currier'. Policy No: G tEA.SYSIEM-GVFR XA)
CIiRI IFICAI IE OF EXEMPT ION FROM WORKERS' CN iASF%INUUSTRL ' STE ISO iRCEPD)
COMPENSATION INSURANCE? BUILDING DIVIgiONFifS _
('Enssec,iun need not N completed iUhepennit is forme hundred dollars($100) GR
or less.) PLANCHECK FEF; Y
I rtify hal in die pe rt i..mann,of the work lin whiclidt,permit isicmP1'.
ed.I shall SEEWER-SA 'PART-STORMIA.210
nm emplocey any person in any manneno u,m Mamie object,,)the Workers Cumpen- IENIiRGY FHB
oz ..anion Law,of CaWirms. WATER :A'I'ER WIVIENTIELECHR GRADING EE
z O Applicant
F ? NOTICE 10 APPLICANT:If,after making this Cornice,of EXemptinn,you should WAT SYSTISM/IRIEATING
become subject m the Worker'.Compensation provisions you ions of the labor Cu must SOILS FEE
bcd,thcuntply sidbac,l,pct i,i le,reran,shall bedcunted revoked- WATER SERVICE?
6. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.ET. PAID
U O (hereby aliirm that hem on construction lendingagcncy forthe pcHunmance of Receipt#
❑., 1.. the work for which this retain i,iswnl(See 3097,Civ.C.) TOTAL:
C) ULender,Name
Lenders Addri TOTAL:
1 erdify,hal I have read,his tmpllcauoread stare thin the above information v, IC0,11INSTRUC,
ILD 'G .E
E' LG correct,i agree m comply with all city and county ondinanecs and slate laws relmingm Q,Fy. MECHANICAL PERMIT FCL'
Uz building ocnamotion.and horrify authorize representative,ofthis city m enter upon the SMIC1JE
..trove-memioned property[or inspection purposes PERMIT ISSUANCE 'to IU
(We)agree l,, a,c audcmroy and keep harmless Its City if Caperton ugail",
Cr 'IEE
liabilities,judgments.cossand expenses which may in any wary ucerueagainst said City ALL ER OR AUDIO MECH.
]MBIN LEE.
�IC,, ce o'l)ER of this Permit.
APYLIG NT ')ER.' n SAND WILL COMPLY WI'T ALL ON-POINT AIB HANDLING UNIT(10 10,000 CFM) 70
CHANICA liF.
SOUL 1E J Afl
AIR HANDLING UNIT(OVER In,IXO CFM) iON TAX
r of ppllcan Co rani Dam F.XHAUSTHOOD(W/UUCP) I IOUSINGMITIGA'I'ION FEE
H '.A BLOCS MATERIALS DISCL IBE
"All applic Iorfmumbuilding nccupam Wore or handle honcrelou,material HIEA PING UNIT G O I(X),(M BTU)
as defined by the Cupertino Municif d Code,Chapter 9.12,and the I leal,h and Safety
Code,Section 25532(ap HEATING ONI'I(OVER 100,000[11 U)
C-]Yes QNo PAID -
VIENTILATIONFAN(ti1NGi.EHItS1U) Dae Recelplb
et W ill,he applicam m raceme build'arg weapon,aw equipment or devices which
becomm ux air con dn
o uts as detailed by the Buy Arca A.,Cash 1y Manm
ageem BOILER-COMP(3111'(1R I Ofh11fH)BTU)
nit
District'! T L:
Dyes o IlO1LCR-COM1IP(OVIER IW.(NXI BTU)
liumessad,hennot us material%req r d, ChpI f.)5 offlicCal AIRCOND I'I'IONER ISSUANCE DAT//F''�1 �J
tom 11 ITh&S'het C i ,:255052533 d255111 d .wadlh Iifthe NEW RESIUfNT1ALMECH. SQ.EL � �/� �/ `/
Hanot r<u yI I tilt, y ry nbl,yl ifYh ,.pain ( ( /
n e r elf u�be trot pa f uenEa CEIuw dOwpn,y -
Own m n vcJ age Date T TA L:
ISSUED RIC
OFFICE