S 3095 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUI'RKTINp HDH.DNG; Eu CrxICAI. PERC II*NO
RUILDING DIVISION APPLICA'1'ION/PERMIT TING iiitoip MECHANICAL J 3095
IfUll.l)ING 1'xOJE LT IIh:B'I'IF'IG\TION
BUILDING ADDRESS'. SANITARY NO. APPLE,'1'IONSUBMI'rl'ALDAT
1013► M;V(,% v.4 POCA /6-19 f
MMLIOWNI� E, 1 s+( an PHONL: CON'IHACI'OB'S NAME: LIC NO:
,L14, J,r _,r1^ �pi NIC CON'1'ROLX
ARCIHTECI'IENGINEER: rW LIC-N(V): 1 ADDIt15S: ❑ `•�Q /_ (/f
CONTACT 1' PHONE: BUILDING PERMIT INFO
Tan 4-34- $� ❑ Consullanl Pecs Pail by Applicant(Initial) RLI nu!Cr_ rift+ t[
Ila- s Q' LI LJ
LICENSED CON'rRACT(at S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
hvell,union 111.11 and licenved under previsions al Cbupmr 9l uminluneing
,d'Z with Se"inn]IXppd UivisionJnf Inc ltusinesn:mdl'nniszians Csde.and my license is r Q RESIDENTIAL:
,00 PERMITISSUANCE
FxWF in full fur land cffvG. ❑SFDWL ❑K11CHENREMODEL
QUU Lilvel.Class Lints AI'PIJANCILS-HLSIU1iNTHAI. ADDITION ❑1'LUMItING RI PIPE.
F Z W Dalo Conuaclor
HQL ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑S'1'RUMURAL
O Z N" I undcrxtand any planahall be used ax puhhe records HI
UP T021X)AMPS 2— 'Z (u- MODIFICATION
If ❑INTERIOR ❑CHIMNI!Y REPAIR
F-'4tW Lic—rd Ponowioonl 2111-HXXIAMHS IMPROVEMENT 0SWIMMINGPWIS
OWNER-HUH.DER DECI.ARKrIXI
10N OVER IOAMPS ❑BATH REMODELIREPAIII ❑DI!MOIJI'ION
C Q 1 hereby elfin.that 1 am emntpl front the Contmelor.,License Law fiv the
46x13 W U fallowing rano..(Section]11315.Business and Professions Code:Any city or county SIGNS ELELTRICAL — ❑OTHER
which tuqulrcx a
to pvrdlr to construct,aller.improve,demolish,or repair any sdu ion,
¢ prionditsissuance.aloe requires the applicant for such permit to file o signed uacmedt SPECIAL CIRCUITIMISC. 1
999 r4�],jJ thin is,is licensed puauam to the Tooiun,s of the Connacmisl iccnxc law(Chuprar9 t� ^OMMERCIAL:
apo (commencing with Sminn]DXB of Dorian 9ofmv Bwineoland[I I.ssions Cale)ur 'I'E,M P.ME'IT R OR PULP INS'I'. --
a E e C that he is cxc upl merefrom libidinal,basis for the aIh gvd catamaran.Any violation of — IV BLDGIADDI'DON ❑DENOLI'I'[ON
xmY. Scetion90315 byauy applicant fill a pedn't'.1bects the."Il :cot m,I tell penalty of POWER DEVICES •;'1' ❑POOH SERVICE
��� nnoa than Eve hundred Anllarx lSSIXB. - -'
SWIMMING Iv I:LECrRIC .dOVI!MIiN'I'
E_< woos ..nal Immn.lin nryemploynawimwugcsa 1.(Scde tom,14,anon' HER
xN Inthework,nodthe he Contractor
I Lwemoralle do Hdsola(SaJBXn,I.."I,
6 3 and 1'mfcainns Gde:The Gmvanor's License Law Jaes no,apply to an owner n OU'I'LISI' - ITCIII6-I%1%'I'UBIiS
pmpeny who builds or impnwea thereon,and who J«s such work himal!or mreug
his awn cnploycas,provided that such Intprova nous arc nod iinaxed or oxerW nor NEW 1,I7LECIR SQ 19'.
sale.If,howcsceme huildingor impno man sold Ahirmu,,r'in!out letion.lhe 1 (. SI'f Fhln)x AREA EISV.ISI'.
SQ.
owner-builder will have the burden of proving that he did not build or hupove for put- 1L` YIp,C Lill
luwc at sale.). GAL: q p
E 1,as owner of the Por, ny,am exdusis'dy cnnuucting with licensed amwemrs et
instruct the project(Sec I(Wa,Business and professions Gsde:)The Contractors Li-
se.law Joos nutapply man owncn of pro,,t,ly woo builds nr imprnvcs thervon,and QTY. PLOHI sP17 FEE
wnocontracb forsuch pntjvivwith a contractor(s)Iiccnrcipnrsuanun the Contmctnr's
License Law, PERMIT ISSUANCE
Ian v mptu ,See ,B&V C for this re.
ALTER-DRAIN&VEN'r- AT .A)
Q "rDate
WOItKIIH'5COMI'IN5 ON DECLARAI"ION RACK I:LOW Px(YI'IiC'P."o,"".❑ 1 hereby aRnn under penally of pe Jury one o1 the fnlhwing Ikclarations:
I have and will maintain a Cenifica,of Consent to sal(-insure for Workers Comped- DRAINS-FLUOR,ROOF.AREA,CON S9i)RI 'IYPECONS'I'HUCr10
sation,as provided far by Section 971X1 on the Latin,Colic,t the perfnnna I,-of the
work for which this permit is issued. PI%Tl1HES-I'IiR TRAP r 0
F1 I have and ,It nntintain Warkle..Compensation Insurance,as required by section
3]1X)of the Labor Cnade.fur the petlodnan<c of the work lin width this permit is issued, GAS-FA.SYSTEM-1 INI 111U11,Ii1S OCC,GROl1P APN
My Worker,Compensation Inmrence carrier and Policy damlcr are:
Currier: Policy No GAS-L'A.SYSTEM"OVER d(EA)
CUREIFICA'1'1:017 EXEMPT ION FROM WORKERSf
COMPENSATION INSURANCE GRE SUDUSTRI.WASTE
ININTERCEPTOR BUILDING DIVISION FEES
(l'his section need nut he completed it the permit is for one hundred dollm,Dlgl) GREASE'TRAP -
PLA tCK Igili
or In,,.)
toy ary mains nanrhsri r, ofthe n,,,bek for this he
-all SEWIiR-SANITARY-STOHAI EA.2W 1"I'
naI eltlpl.y:.nty he„nn i.ably lnumwr.n baa beano 'e t la me � 'cntnnell. - nett Z 0
Z notion lsws of Califomia.Data '1' RUHAHERWIVENTIELECI'R G )ING FEL
z 2 Applicant
NO TCH TO API'IJCAMd':Id:afwr bulk ng Ibis Cc c t f lixcntptinn,you should I !R SYSTEMfFRl!ATING
Fren IISFFE
become whjecrto the Walker's Comlcnsation meli s of theb/Ttp 2.din 3
� � fnnhwith comply with such provisions or this pend 211 be tkLllkA�e QreJ 'f0 GRSEHVICE
WC
C '7 AIU
.� z CONSTRUCTION LEND[ G AGENCY RESIDENTIAL PLMB. SQ,ET. Dat, Rampt h
UQ Ihcrchy ul'lirm thin there i,wcnnstmni9nl rAa•gency for the performance of
U 1-•s the work her which this pantie',,i...ed(See 3119 , O
l-'l 'r0'" L�
O ULender's Name /b
Lender's Address A
r Q, I canny dun I nave rwd this upplienion and sem that lbe above infu....un o ix OU .0 G 'L
,F. ZZE core".)agree nt comply with all city and county unhumtees amistme laws rclmingm QTY. MECHANICAL.PERMIT IIiE m9ilSh Ei O
Uz huilding aroun,hum,dna hereby malmno,o,o,cndthvesufmLsaly ht enter ill*til e
aMwc-mnninneJ popery Jurinslnvtlnn purposes. PLRMI'I'ISSUANCIi O [LEL RI FITE Z TC
(We)agree m save,indemnify and keep handless the City of C.1mun ugaimt
Iiamduc%,juJgmets,cosisard expenses which may in any wayacme ugaimt sdd City !/r ACrl:R OR ADDTO MECH. PL' I.Gbit eO
in asequence of the granting of this permit. fI�
APPLICANT UNDERS'I'A NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON IT(To 10.0)0 CPM) MECHA [CAI.FEE O•y
5\tURCl,lf li%(f)1.6r10YS
L�L__ 1/ l/U/ AIR HANDLING UNIT(OVIiH I11,I1tN)CFM) CO I1C'I'I(lN'I'AX
.$gnnmrwd Applic;nn/Cundagor Dmc / EXHAUST HOOD OODUCI) HOUS 'G MITIGATION PEE'
HAZARDOUS MATERIALS DISCLOSURE q
Will the applicant or future building occupant store or huddle havardrm,material l HUxrING UNIT('FO l W.E(X)BTU) L� O
as definal by the Cupertino Municipal Odo,Cholla 9.12,and the Ilcolm and Safety HEATING UNIT(OVER IIXLfNXI If IL)
Calc Section 255320)?
QYesVENTILATION FAN(SINGLE RESID) LVDv p .0
Date
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP oR Ind0f0BTU)
m t ha.ardnus nmtun
it mami a nv d'f5cal by the Hay Arcu Air Quakily Management
� District! L_Te// BOILER-COMP(OVER W.0t 3m)
Yes
I have reek the hu ardon"" Po nunJer Cha der b95 of the Cali- AIR CONDI r10NIiH I DpTI:,
4uircmm� t
forma Health&Safe; de.Scc t 5115 5533 and 255:34.1 uta aromd main the NEW RISIDESTUAL MECII, SQ.rL
JJ
buiWingAce ryy ndy hasu-tuda th smyresWnxinil'ny m unity the occupied
oflherdrryirenututGrMth nose c
pr
nt l's tce�Cearet- kr}I[taryyt ( ( 7
owner or INln��an/lf///d a //// �T T' 1.: Q ISSmiD Ely
OFFICE