S 2938 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO pull DING-Hld!CI'RICA[. PGRMI I'NO,
IkUn.mNG UnaSlpy AI'1'IJCATION/PFRAIII' ..UNE unr..ao-:cuANIc,M.
"HIDING
I'N016CI'1111!Nl'IFIG\TION
11UIhUING ADDRESS: ]jSANI'ARY NO. AI"""A'1'ION u IN TTpA DDAAI'
�O /O C - _ It — 17
O 'IiR'S NA E A �� HONE:_/ CON'I'RAC'[OR'S NAME.. I.IC NU:
/+ ',F/ CUNllll'NOha
CHI'RR ENGINEHR: I LIC NO: CA ADDRESS'. �� %
Nc .�90 U
INTACT: PHONE: BUII-DING PERMIT INTO
` 1 ❑ Consultant Fees Paid by Applicant(Initial) 1H.U'D HLECT PfUMB MycH
V.4CK (ftl,-.S 3`1S— 1 1c�y(' IYS�(
I.ICENSI!D CONT AC'H)N;S DEChARA'1'ION QTY. IiLEC'I'121C PERMIT' FIiG
1 hereby aRnn mat 1 nn,licensed rude,provision.of chapter 9 echo enci.g JOB DESCRIPTION
Z with Section 701 Of Division 3nfthc Busine.,and Prafesxion,Code foamy license is R IDI' T1
m p PERMIT Is$u,wcE
F W� lull force and effect. IUN'1. ❑KI'1'CIIEN RI!hIOURI.
a U
i,-
in
Cloys Li,.e APPI-IAN S-RESIDI N'I'[At. 4DDI'1'ION ❑PI.UNIBING RE-PIPE!
F Z W Dmc Cnntracbn
N6a• ARCIi1TECTS UIiCIARAfION ❑MULTI-UNIT ❑S'I'RUCTURAI.
Z O`"Z I ardersmna my plan,shall he used n.,publie n coNx IpWI],S MOUIPICATION
OZr3a UP'f0200AMPS ❑IN'TF,RIOR ❑CHIMNEY REPAIR
W I.menncd Pn le"tonal 20LIINIOAMPS IMPROVEMI!NT ❑SWIMMINGPOOLS
hH
OWNERTUILDER DECLARATION OVER❑)NIAMPS' [I BATH RI!MOUI!IJREPAIk ❑DIiM01.1'f10N
C M Q 1 hereby alma Ihm 1 am exempt front lle Coula tot's License law for the
X 3 i U following mason.(Suction 7031.5,phone's and Pecdo ei.n,Code Any city.,county SIGNS ELECTRICAL ❑(Y I{I!k
W IL N which requires a permit In construct,alter,impale,demolish,or repair any sruaurc
F'1='Cpnnn t :. a Iso.,at.,flic.,fircromfor such pc it1 fi en J.tmcmcnt SPECIAL CIRCUIT/MISC.
rR then he . 1l) :nil It d P ns ftn C t t r's1 ce 1 ILhaPtery
p0 tc)n 6 Midis iii 7gXB fD :luso t'Ih B .' xsadl r :' Ced,)or '1'I:M P M E FCR OR MI ,INS'1'. 11 R I I 0 ���(1/�
M{Y e Ihat he is exempt therefor and the basis t.r the u1legicd una,a-Any vloh li...of ❑N H.Uci Ol QN t 1.' O
i =u, Section 7031.56,uny uI,llnam er a permitsubject,the fpplieanno u civil pamlty o! POWER PVVICES Of N'I' L)F(1(1D SE
1- N re than f vc hum lreddou...($50n).
�Mcnn,L as owner the n'.nr n, tares will sea thcirsnlc amt tion. SWIMMING POO]-ELECTRIC I OVEh11iN'I'
❑ prose ) temp v gds as Imnsi ❑O.f{Nt
F- will do the worA,unJ,he umcture Hnot in¢nJeJ or oliBmd for saleapply to an
of Y
S 3 0o Tend Profusions Code:The Contractor's License law docs not apply m un,»iter of OUfLEl:S-SWITCHES-LIST'UHES
property who builds or imp uses thereon,and who docs such work himxlI or through
his own employees.D.vided thin such Improvements are oat intended or uttered for NEW RESIDENTIAL PAM SO 14.
sale.ICh ca,m..thehuildingurintprovement 6'sold wifNnoneYurnf canipletionthe SQ,ITT Iq.00ft AREA EISO PI'.
,,.actrh.ildm will he'll,pro nnNen oI Facing that hl,did urnM1uilA nr improve Ear Pur-
ry,ent'Xalel. 3 0 7
❑'1,t, o1'Ihe property.a c xel....el, mtmuting with limnwd enfunc.m m TOTAL:
msio cl tM1cpmjcd(See.7044,liusines and Ponlcssi.no Calc:)The Contractor's L i-
selawdoesnmappiyl,w owner.1 progeny who builds or impmvesmene f.and QTY. PLUMHIN JIT PEIi / /�
who contracts for such pmjera will,acontmarn(s)licensed punuammthe Comracu,r's /`9 /
l,iecme law. PERMIT ISSUANCE
❑ I' foundcrS .B&PC Rallis mason
ACf1iN- AI VENT' WATIiR(EA) VALUATION V�
Dem
WOI1KIi.:(y MPI!I SAI'ION UI' .ARATIUN HACK ILON'PRO .D iV ICI:
1 thereby altun,underpunuhy if perjury.,f the following declarations
I have and isitHmfiall f Cenilicate of Conceit ell insure for Workers Cmnpen- DRAINS-17100 .RIXF.A 99.CO ). 'FORIT 'TYPE CON FrkUCI'10!
ion,as provided for by Section 37M Of the tabus Cole,for the performance of the 4
xk for which this pem,it is issued. Iq%TUNIS-PER TRAP \ 1` 1 .(
❑I hove and rill n,ainmin Worker's Compcmation In,umnce.as required by Section d �V/ 'Na
3710 of the Labor Cxle,lot pedommnce of the work for which this permit.issued. GAS-EA.SYSTEM-I INC.40II1'1.. . OCC,GROUP APN
My Workers Compensation Insurance currier and Policy number aro: GAS-1!A.SYSTHM OVI!RJ(I!N
Grier: 1'fgicy N..: 3 6x7-616-M,
C6RPITICAI'IT Oil I!XI!MI'IION FROM WORKERS' GRI!ASIDINDUS"I'RL\VAS'I'I!INTI LiCIiP'i OR
COMPIeNSAITON INSURANCE WILDING DIVISION FEES
(Thi eclumnculno.bemraq,ed il'Ihcicrmit is l'.nme hundreddull.n($IW) GkpA513 TRAP
fPAH
Ter les,.)
I certify that in the performance Tithe work for which this permit is issued.I shall -SHWER-SANITARY-ST ORM HA.210 FT.
not employ Tiny peoun in any manner so as to Mcome subject 1.he Wo Los'Common-
Z smirn laxzof Culii'muct[)ate WAVER IIEATERWNF,NTE!LETI'R
Z Q AFplicfn,
N(7TICIi TO N'IR.ICAN'C II:after m.king this Cenilicntc of Exemption.you xhauLA WAI'ERSYSTEMfTREATING
N
1'+ , be ntwi,uhjcn y n,I Wa,km'x C.mpn..Ibi, pit nit a.I the Labor Csxle,you nnlM
wi n
forthwith um, ly wlll'C(INS9RUCTIONIhiv penult Shull the AemneJ revnkeA. WA'fEIt SERVICE
p
hIiNUING AGI!NCY NEW RESIDENTIAL PLh10. SO,LE I hereby affirm thatthere is a consrunion lending agency forthe peffere:ace of Reccipta
V.F the work for which,his pcm,it is i...ed(Sec.FMD.Civ.C)
(�j'A. If
Q U Lcndvh Name TOTAL:
} Lender's Address
ly I Teri toot I have road this applicmmn and Bene that the Tenure into,,
Is BUILDING Iq!Ii
N conect.Iagreel.c... p,wllh nd all city aco.nty.nlaonces fll amu law,relntingm QTY. MECHANICAI,PERMIT PEE SI?ISMIC Iq!i. 'e'5
C.J b.Edie,cmonari..l'TIbefell,aillad,e rnnrc"nmatiw:".loris dry focuserrpm,life
.b.vc-rwnioacd pngseny lin inpretion Purpnex PERMITISSUANCE EI.1! C
(We)agree to nose.indemnify and keep ha,n,lew the City of Culuarfino against
IiaM1ilitic,.j.Jemems,corsandespenw,.biehmay l,,any way acenteugain.wsfid City AIJ I!R OR ADD TO MECH. PLUM GTHE 2
in nsequenee of the granting of this penin.
APPLICANT UNI *RS[*ANUS ANO WIl.l.CONI PIA WITH N1.NO N.POINT AIR IIANDLING UNIT(T 010.000 CFM) M; MANIC AI.1:1. 2
SOURCE RE Of /IONS. A
I AIR HANDLING UNIT(OVER 1110)1 CIM) CONSTRUCI'IONTAX y
Signrmm ofA JirnnVCu roclar Dat, EXHAUST'HOOD(WIDHCI'I IOHSWO MI'TIGA'TION il!
IIA'/.fl ItDlID5 MATERIAL..' ISCLOS URE
l Will the applicant Orl'umre M1uildingle,alsan nm,e nr handle lounamoneurd.l H HATING UNIT(H I1NL1N0 B'I'UI
as defined by the CoNnion Municipal Come.Chapter 9.L2.and the health and Safe,y HEATING UNIT(OVER 100.000 II'I UI
CWc.Section 255321a1:'
❑Yes ❑N. 5 VENI'ILAI'[ON FAN ISI NGLE RIS ID)
AD—Date ReceiplM
Will the applicant or future building'ecup.nt use equipment nr devices which HOII HR-COMP 13HP OR 100.001HITU)
far fecund—air eonau vale as detinet by the Pay Arca Air Quality Management )IA
stria! HOH.1711-COMP(OVER 1(YOX)R I'U)
❑Yaa ❑N.
I have residua,ler rdo-naderial,m I,under Chale,ti 95nf Om Cali. AIR CONDI'I'IONHR ISSUANCE DATIi
Head, yatrcmcn p
bumia gdoes&Sefee COR.ea tena 255115,is my and 25534.1 to nomand than it tM1e NIM RESIDENTIAL h1ECl{, SO .7 �j
buildingace,nmcrr hich h:,vcamnano Iit.
my mrimnsinilitymramifyvertone,m Z
nOn•require .which mux nmdnr In iswnncc cniticme o((kcrpfnq�. ...mss
)wnuo a tori dugu Dam Toi ISSUED IIY: ~ y
OFFICE