S 0801 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIIIIAINC-ELECTRICAL l PI IT No '
BUILDING DIVISION APPLICATION/PERMIT PI'DSIBING-NIEC IANICAL S 080-1
e . RUII,DING PROJECI'IDFNrIF[CATION
BUI NG ADDRESS: SAM FARYNO APPLICATION SUBMITTAL DATE
-�( � lea-( e � s �c�(`-� �/ �?-s
l N 1 1'HO CONTR.�roR'S NAME' LIC NO ,
�I" N/C I CONTROI,a
•'A CHI !CT/1iNGINIIF.R LICN(O ADDRESS I ❑
uox ("YC!f 'it 27
CONTACT PHONE. BUILDING PERMIT INPO -
R(r ���, ,F�IA' ❑ Consultant Fees Paid by Applicant(lni, IF B :1 liE:1 PLUMB MCl 11 LICE BD CONTRACTOR'S DECLARATION QTY 1 ELECTRIC PERMIT, FEE' .f JOB DL"SCRI I'TION
I hem by auto,than I um I.u'Ined under may cans of Chapter 9(commencing
Z with Sequa7(XXBOf Drvtaon 3.11)m Bti,mvsand Profe ssion,Com,and my hcenso s RESIDENTIAL:
u 'r PERMIT ISSUANCE
yIOU License Class c0eci Lr9 ❑SFHWL ❑KI'I'CHENNEMODEI.
IOU AI'I'LIANCIi$-ItESIDIiNTIAh l ❑ADDITION ❑PLUMBING RIiPIPF.
FF X W Date - - — Ctmmd^•
'DoT ARCHGFCF'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
O
Z FpyZ Iunderstend Try,plus shall beusedes public re,and, PANELS MODIFICATION
__4_ DP TO 200 AMPS
[]INTERIOR CHIMNEY REPAIR
E—t: lacemed Prolesoorad 111-I0NIANIPS IMPROVE ENT C]SWIMMINGPOOL
S
OWNER-BUILDER DECLARAI ION OVER IIXp AMPg I ❑BATH REMODEURITIAIR 0DHMOLTI'ION
I herehy afOnn that I'am exempt tram Oho CananUnr'n L¢enne Law far the
xS 6 V Iollowing reason (Section 7031 5,Itasmas and P n"Ina(,Crxle:Any cry nr cnwnY SIGNS RLEC'I RICAL ❑OTHER
41}+1+•ye who,h unpor I a Fenno m former,A.,impose,don mh,h,nr repnv any+tmnw
OJ Prmr nn it,nnamnce,nhn rcyuircslhaupdcmtfo.such FCrmdln 131eavlgneJ nuncraem SPECIAL CIRCUIT/A11SC
a <� that hills licensed pursuant it,the pmvaaon.of the Commit Lmense iw(Chapter 9' l COMMERCIAL;
W..�O Icnmmcnamg with Serrano 71NIN aI D.,I,!ors l of,he Be,.ness and Proco,mn,Cu,E)o l I ENIP Ed ETER OR POLE,,INS'1'
L 4 e C that he is exemmt themdnnn and the Mss for the alleged cmnI,Any violation of ❑NEW BI.DG/AODI'1'ION ❑DFMOIA PION
xly Secu mn
Section by any applicant for a pet objects the appscnnuo a rn.I Tel of MOWER IIEVICM ❑TENANT ❑FOOD SERVICE
W Z} nt more lhun eve hundred dolls ($5001 IMPROVEMENT
G (]I.mownerufthc properly,many employees wnh wsge,mticalote mmpen,amn, l SWCIMING POOL ELECTRIC
wIIl Ju the wok,and the strucwrc s not lnteadd aroferod fur s.,le(Sce 7044 Holmes
❑GTHEN
�_ mid Profesunm Code:The Commmnr',Lsenw I:nw A:ws nth apply In an owner oI OIl'1 LI I'S-SWFFCI II?S-FIX'NltIts
a 3 property who build,or Impnnes thereon,and who does wch work himself or @snug:.
In awn employees,pmvWal than such nnprovenann me nol mtendod or nllcreJ Inr NEW RIiSIDliNF1A1.IiLF.C9R^ SO FT. -
sale If,however,the building onmpmventenns sold within oneycarofcompletlon,the SO ITT.FLOOR AREA S/SQ IT.
• erbmlder will don the her den of raising that he dal no,build or Improve fur pur-
ame ad sale.) _4p�
Ai
El its a%acr of the property am exessncly urmracting with annowd contractors m l
consul the action(See 71ALL Bu all ad Plaiesvnm Gde:I The Contractors LI {.)y / �l JT
se Law dots ellyanana ofpropeny who builds or imrowes thereon,and 'Q'fY. '•PI,UMBINC PERMIT Eh' ', I X11,U V E
ehoc mina I..I,nn use mti.GOrts)lynwd punnumm the C....na rs '
Lm wW !6 PpRM1 l'ISSUANCE I a
pXrn der See. B&PGfnmhisrca,nn l 1 5-0 I NOV 17 1997
ALTER-DRAIN&VICO-WATER LAI I VALUAI ION
Ow Dr'^
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT DEVICE BY:
1 hereby affirm..,let acr ally of pcpu0 one of the following d"Imauon, 'a•
.Q IMrec and wall mamiulne Cemticme tfCnnunim,elf.tinsum tar Worol Compel DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TYPI?CONSTRUCTION
+anon,is provided ltr by Section 3700 of the Labor Coll,far the performance of the
work for which this Learn is issued FIX'NRES-PER TRAP
7 1 hove and wdl omartual Worker',Ctmaen,atum bnmanse,n,rtrptired 6y Section _
370(1 of the Wlwr Cole,far the wromalre of the work for which this Fenno is tssucd GAS-I?A.51'S'fEhl-I INC. OU'I'LI?TS I OCC GROUP AI•N
hay Worker's Compensation lnmnmce carne,f ul pnhey numMr are
Cartier Policy No CAS-FA SYS'I'F.MOVERJ(EA) -
CERTIFICATE OF EXI?AIPTION FROM WORKERS' _
COh1PENSA'I'ION INSURANCE GREASIUINDUSTRI,WAS'I'1i INTERCEPTOR
BUILDING DIVISION PEES _
(Thrsacmnneed not M:cnmpleadlfthepennn is foronehundmddnllers bllN)1 GRF.ASIi TRAP
or lens 1 PLANCHIiCK FEE
I ready that in the performance of the work forwhmh this prow o is Is,ted,l shall tl -
notempttry any peconmany mmner.n as m biamine hjenwthe WUrLCn'Compen- 51iWElt-SANI'1'AI2Y-STURh11?A.MNI I'r IFNI;RGY FEE
0 z won Laws nl Cliff me.Dme WATER HEADER W/VEN'I'IFLECI'R f;RADING hEE
7 0 Applicant
NOTICE TO APPLICANT If,after making this Cegtieam nd Etu mptual you should WATER SYSTESIG R17ATTNC
f•-' become suh)ect m the Workel ColnlMn+aeon pooscrs of the Labor Cole,you mud SOILS FEE
forthwith comply with such pmvninm or this pemmshall he deemed revoked. WATER SERVICE
A
d
CONSTRUCTION LENDING AGENCY NEW RI5IDIN'I'IAI.1'LMII SV Ie1" (PAID
U O Ihcrchy affirm that lhcre nnconngcaon lending agency for the Derfoman
ncc n( 1 Date Receipt D. F the work far wh¢h this peral its i...edsce 3097.Civ.C) 1 X-f 1
QLendel Nam- 'Al.
U
Lender's Addre -
- TOTA I:s
�, DJ BUILDING I7EE
I cagey than 1 have mad t this application and ante than the abuse mmnnmmn its _
F' y .I rein Iugseercn,and with lit uty:mdwumymdmunc-I and morelows,Epnme IQTY MIiCHANICAI.PERMIT FF:E',
V •� hulling ronagcuon.and hereby authmn¢reprosemmives nl alias ny meaner upon the - SIi1SM111C PILE
above-memloned property for uslea n Impose, I'ERMI f ISSUANCE ELECTRIC(We)agree m sane,Indemnify and keep humill Nil Coy nt Cupor, fainsl ELECTRIC FEE
r.. budiabties,rydgmenls,cost,and expens es which may in any way wcge against said City in
mwyuence tf the grmtmg of this wmrl ALTER OR ADD TO MECII PLUMBING FEIi ��a✓,+/
APPLICANT UNDERSTANDS AND WILL COMPLY Willi ALL NON-POINT AIR HANDLING UNIT TO 14g10CFND
MECHANICAL ISIS
SOURCE REGULATIONS -
AIR I]ANGLING LINE"I'IOVI?R 10.000 CPM) Gl1N$TRGOTIGN 9A%
Stgnmureof ApplicmNContraemr Done l EXHAUST HOOD I W/DUCT) HOUSING NIITIGATION FEE
HAZARDOUS h1ATER1AIS DISCLOSURE -
Willtheapplicantorf uture buddangoecupant,mrcorhandle hamrdouv mammal HEATING UNIT(10100.X)0 BTU)
as delined by the Cupenmo Mumnpal Curie,Chapier 9 19,and the Hall and Salety t _
Cola.Section 25532(31' HHA'I ING UNIT(OVER PERINNI BLUE I
❑Ye, ❑Nn l (PAID -
VENIII.ATIUN FAN ISIN(iLF:RIiRIDI D.IIC Rcsclptk
Will the applicant or future building occupant we equipment or III whirl -
BOILER-COMP(HIP OR IXI I EYE Of ten hazardous uir mmanunamn as refined by the Bay Arco AIr Qaminy Munagemem I TOTAL. � '1
Dlauct^. BOILIiR-COM (O
PVER I(X),WX)13TU) '
❑Yes 0 N 1 '
I have I the hvatdous mmerial,m9arrical,under Chepmr 6.95 of the Call- AIR CONDIT TONER l ISSUANCE DATE
fomiu Hamill&Saecty(7ode,Suvons 25505,25533 and 2553J.I androm I Ohm it the NEW RESIDENTIAL MECH Sp.IT _ .
building drwa not currently have a tenant.that n s my re,pm lhty m notify the corral l lL) 1
ofthe re9ulrcmi Isrmh mu+I be met printm uwanec ofa CCIffcalent OCUmancy.
TOTAL _l_(�_I 7
' Owner or uurhon oJ.,fill Dme ISSUED I{N _
I OFFICE