B 0443 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELECI'RIC,AL SOOOI PEHMI'1'NO
APPLICATION/PERMIT PLUMBING-MECBANICAI. 90443
BUILDING DIVISION BUILDING PROJECT IDEN'FIF'1CArION
BUILDINCADDRISS. SANITARY NO. APPLICATION SUBMI'1'I'AI.DAI
'73300 till -3-
OWN" _F.R'S NAME: PHONE: CONTRACTORS NAME: LIC NO: N/C CO,YI ROI.#
•AHCCU�IT[C✓-I'/IENG1NIi13H: 'sJ�� � LIC NO: ADDRESS: ❑ NG P `� Z
CONTACT: �n,y PHONE BUILDIERRMMIT INFO
IOA(V*Wp ( I ❑ Consultant Fecs Paid by Applicant(Initial) BLDG- ELECT PLUMB MI i
I � l IJP/ IJP( L^dam LL,I/
LICUNSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby amrt mat 1 I linen.d under rrovi,ivm of Chapin9 ce,mnmem,d„g JOB DESCRIPTION
QOZ wise Scclinn 7rNX0 nl Divixinn3nDhc lluxincs nnJ Profe„inns Cosierdn,yllcenwis p1iRMl'1'ISSUANC[i R ID NTIAL:
❑ I,
��� In toll tercel 001”"001"" SIUW ❑KI'ICIIIEN RIEMOUIiI.
aUV License Class LIc# APPLIANCES-RF.SIDENDAL �)DI'I']ON ❑I'LUMBING RE-I'll'II
,-Z W IGm Conm
aacr
¢4 ARCIII'1'ECI'S DECLARATION Zo PANELS MODIFICATION❑S'TRUCI'URAh
ZC) Z Iunderstandn,plan shall be used a,Public record, MODIFICATION
OZ�O Oil 1'031X)AMPS ❑INTPRIOR ❑CHIMNEY REPAIR
�14 t:W 4anscd Prale,out l 2II-10KXIAMPS IMPROVEMENT SWIMMING POOLS
OWNIEH.BUILUERDECLARATION OVERIDXIAMPS ❑BATHRGA10DEIlRI?PAIR ❑DIEAIDLFI'ION
6 1 hereby nRmt that I am exempt from me Cunaannr's License Law for the
F following reason.(Section 70315.Business and Professions Gds:Any city nt county SIGNS IELECfRICAL ❑OTHER
w which requites a pertain to comical ager,improve.demolish.or repair any nmmure --
F•�•�j Priarm its iasu.s.al.so memos lie applicant for such pertain m file v signed statement SPECIAL CIRCUIT/MISE. n
Ery that he is licensed punuanno the ImAisiomof Ne Commemrs License Law(Chapmr 9 I
uI�00 (commencing winhSmion 7gNR of Division 3ofthe Busirress and Profeavions Crdc)ur TTFIvIR METER OR POLEINST.
a a c C that he is exempt therefrom and the basis for the alleged exemption.Any violation of rt�rtS NEW BLDG/AUDITION ❑UEryryttIIO 'ION
X^, Section 7(31.5 by any applicant fora,matsubjects theapplicann macivil pcoulty ulf POWER DEVICES 8-FENAh(Tl•tVlCli
F
W;,
not more man five handsel dollars(550(11 r IMP Q FIT 9 19
SSC ❑Las owner ofthe property.or my employees with wages as their sale romrenwtion. SWIMMING POOL ELECTRIC IOTHER
F will do the work.and mestrcmre is nntiumndcJnrofPeml forsale(Sea 7000,Business U L-/
G 3 m and Profession,Code:The Contmelle"License Law does not apply to an mune!of OUTLETS-SWITCHES-FIXTURE. Af
property,who bund,or improves thereon,and who does such work himself nr through
his own employees,provided that inch Improvements are not
intended or nffcreA urn NEW RESIDENTIAL FLECTR SO 1' _ _ _
sale If.however,the huilding or improvement is sold within one ywr of"complelam the SQ'I'1':FhOOR ARI7A QSQ.FL;--•
wn
cr-builder is love the burden at proving that he did not build or lnipmve nrpur- �3
pn so-w 'rt Yl'A L: 3S
I,ns owner of he pce.704 vilynal exclu,ively mnlmeting with licensed I tomrumay.'I, \`
mmmct he pnnuet(Sea]Hiro wner Ill and Pmwho bui Code.:)The Canuaaor,Lt-
twlawducanmapply movownarofpmpeny whosedp mhnpmvhe Comov.ond QT'Y. PLUMBING PERMIT FEE
who contracts lin such project,with a ennrunnr(,)licensed pursuant m the Cnnmanor's
License law. PERMITISSUANCE.
E] Ion es-TY-1 let Sec. _.N&P C for this reason
ACT IER-DRAIN&VENT-WATER(EA) VALUATION
Owner 1 Dam '
WOR KER'S COMPENSATION DECLARA'I ION BACK FLOW PRCTECF.DEVI'E
AOL,
❑ 1 hereby affirm under penalty of perjury one of the following deelamtiom: C/ V
! Ihove anJ will maintain aCcnificatc of Conxnuo ulf-insure for Worker's Compcm DRAINS-FLOOR,ROOF.AR ). STOR S l'1'PIi CONSTRUCT 10
sation,as Provided for by Sectio 37W of me Labor Code for the performance of the PE ,�
wok far which this permit is issued. FIXTURES-PER TRAP C/
I have and will maintain Workers Compensation Insurance.as m,mrs.1 by Section
3700 ofthe labor Code,for the performance of lie work for which this permit is issued. GAS-EA.SYSTEM-1 INC.r OUTLETS OC GROUP �At
My Worker's Caminmation Insurance carrier and Policy number art: CAS-FA.SYSTEM1f-OVERr(EA) 3
Carl Policy No.: 2
CliRTHgCATE OF EXEMPTION FROM WORKERS' GRF,ASETsDUSTRL WASTE INI'ERCHPIUR
COMPENSATION INSURANCE BUILDING DIVISION FEES
This section recdont Fccmn,icts!ifthe permit is forme hundred dnllats($1(XB CREASEI.RAP •z
rh„) PLANCHEC iE
IcenilYmm in the perti...na,,..tlhe walk for which his Pecat is Uxocd,I Ilan NEWIER-SANITARY-STORM EA,21X1 FI'. / O
molc IsN,aay pp non in any mmlnerso as to became subject m the Workers'Onapum ENERGY tE
Z ration Law,of OOikoina.Dat, WAFER I II;AI ER WHEN-UHLECFR GRADIN z
Z2 APPlicunt \
'4 NO['IC1S TO APPLICAN'C:IL m
eller masking An,Cerificc of ExcmPlmon,you xhoold WATER SYSTEMl1REATING
F ^�'l become mbject m the Worker',Cum,moion provisions of the lather Code,Ynu mus SOILS F i
t^ hoposim comply with inch pmvisiom or this permit cbull M deemed revoked. WAI'FR SERVICE
u 0
0.
CONST RUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SV,PF. PAID
Dale Receipt
U 0Iheroby off nn tba mcro cn
i,vcon>truion lending agency for the perfnmmnce of
IL F' the work f a which this permit i,ismel(Sce.3007.Civ.C.) U'1'A1 OC
Q U Landers NameT(ylAl.:
r
Isomer,Address ILDING
`—
�•" 1 maify that 1 have rad this application and state that the above information is HU
0. J
� 6 TY, MECHANICAL PERMIT' Pf:E 0
UZemcm.l agree oiontand withyoutyan/couotyotatives csand start entr mining u, Q SEISM1IIC E r
U z building construction.and hereby aumnriXemprewnmtivcs aOhis tiny to enter urym the
move-memioncd pmpeny for inspection purposes. PERMIT ISSUANCE ISLE I .E
(We)agree m save,indemnify and keep Females,Ne Cayof Cupertino against
hahlliniesjudgmems.costs and expenses which may in any way accme against said City ALTER OR ADD TOMECH. YL EtiE
Am,equence of the grating of this permit.
leCAN'T UNDER,'ANIS No ILL COMPLY WITH ALL NQN-POINT AIR HANDLING UNIT(TO HF000CFM) MECH, ICAL PER
OF CH REGULA1'I <
AIH HANDLING UNIT(OVER 10.000 CFM) CON:RUCT[ON FAX
ignulur pliewnlConhamr Doe Six]MUST HOOD(W/DUCT) IIllU51 NU r10A'FION IIB?
IIA%ARDOU$MATERIALS DISCLOSURE
W III me appllnnn or for rc hulldi,a ncctmom more orhnndlc[tortillas matcdal IIFA'1'ING UNIT('IO 100.000 BTUI
a,defined by the C'npomino Mnniclpul Code,Chapter 9.12,and the 1X.111,and Ssdmy IIIEAI'INQ UNIT(OVER 100.000❑'IV I
Code,Section 25532m)?
❑Ye., ❑No VENTILATION FANS I NOTE RI?SI DI PAID
Dmc Hceeipt#
Will the applicant or l mare building occupaat use equipment or deviant which BOILER-COMPUHPOR 100,000BFU)
mit harurdou,air comaminams as defined by the Bay Arca Air Quality Management A
•District! BOILER-COMP(OVER 100,000 BTU)
E3 Yes ❑No
I have read the hvr.Won,mncrivl, ts-antler Cho h95of the Cali AIRCONDHIONER IS
LIME
myuiremen 1ra'r
fomiv ITtalth&Sakty a Sections 25505.25533 and 25511.I understand man if the
("LEE
MUCH. SQ.FE
m eJoe,A safety Yhvvca mrxma.that it is my responsibility to notify the ov"Pson
oft napircra taw ,Ase nP ,r at icaance of.Certificate of Occupmmy,
wn<r nr vmhorircd ngcm Dam TOTA 1 ISSUEDBY:
OFFICE