S 2071 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BIRLDING-ELEcrRICM, Plitt T NO,
IIUILDING DIVISION APPim/mON/PERMIT PLUMBING MECHANICAL AJ 2071
(BUILDING PROJECT'IDENTIFICA'f1ON
BUILDING ADDRESS: ( / DA- --- / /' D SANITARY NO. AP/.2-IONSU ItMITTALDA'rI?
OWNBR'SN PHONE! Cf CTOIt'S NAME: LIC NO.
9rSCA) NIC GGN'TRGLM
ARCHITECI'/ENGINEFR; LIC NO: ADDRESS: ❑
CONTACT: -�/-� PHONE(, BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) Lo IiLFCr PLUMB AIECH
- iia ❑ ❑ ❑
IJCENSHD CONTRACTOR'S DECLARA'T'ION QTY. ELECTRIC PI?RMIT FEL
MWZI hereby affirm that I am licensed ander provision.of Chapter 9 Ronttncmcing JOE DESCRIPTION
W0,L, wnh tI
Section 11s10fDlVl.u01130flhe Husincsstend Profe..I..,Coda PERMIT' SSUANCIi
county license is RESIDENTIAL:
WOO I
1-1In roll Oocc model pct 9.00 ❑SPDWh OKITGIIIiN REMODIih
ii I,iccnse la. LicK
FQ U `�4J-�"��^ +Uli/G API'LIANCLS-HE.SIDIiNT1Al. ❑AUDITION ❑PLUAIHING RE-PII'li
N 6 uu Dale - Cnmmcts
ARCHITECTS DECLARAI ION ❑MUhTI-UNIT [I STRUCTURAL
[..O H PANELS
ZO,y 7,.e, Iundnxumd my plans shall he useA ux public reards MODIFICATION
CZ—nLm Ut"I'O 910 AMPS 'IRYBN---�-Y JCCHIMNIiY Rf?PAIk
I-�F"kc Licensed lame,mood 201-Iqq AMPS IMIr- VEME,IyJ: i []SWIMMINGPOOIS
OWNER-BUILDER DECLARATION
. OVI7R❑s10AMP5 BA's If Eh10YF1 'PAIR �DEMOLI'11ON
C Q 1 hemhy affirm that l oro exempt from the Crnlractml Licernr Law for me t
O U ns - ❑OIIII:R
3 W LII b [Set 11111.5 Il e I f:, C e y ty nruc nY SIGNS ELECTRICAL
W y wh h req pe ton .t t her, p I Ilial p any stmewre i
F"LLO prix
to it, .are,also y ,he off ieardf S runit. TI :'gndxtalement SPECIAL CIRCUIT/MISC. DEC33 9 93 Go
}� 1 -coII
IThal he la Invented pursuant rot the provisions ofthe Contractors License Law + l
(commencing wim Sacnml 7shoof Di...inn 3 rents Ho6inuornl 11 caionx Code /
)Or TEMP.MCTBR ON POLEINS'I' COMMERCIAL:
.
d pl o C 11un he is exC;npl therefrom vnJ the basis for the ullceetl exr,tNliaa Any violation of ❑NIiW I31,DGIAODI'I ON ❑UEMOLI'TION
if Is. Section 7031.5hy:my applirmt far a permit subjcelaM1e applicanun a civil pdwlty of POWHR DEVICES
W-vs []TENANT [I FOOD SIikVICF.
FSDintonate ohne five ie prep)dollars y emp.
❑ Lasownentfinepmperly,onnyemPlendeswith feredi stheir wle 0s ,Buoine , SWIMMING P(H)I.ELECTRIC
F will dnlhc canto unde, atmctumisnal imm�Jed onrlhircJ lOmaapply o.in wa,te.f ❑0 'HI?k
3 laid Pmfesvinns Code,'ILc Contractor's License Late doe.nal apply to an owner of OU'1LhI'S-5001'1 CfIPS-11%TURES
pmpcny who huilds or improves lhemour and who does such work hot through
h'i own employers,pmviJcd that such improvements are not intended motored for NEW RFSIDENI'IAL ELECTR SQ 14.
.aIt.If,hnwcver,the haildingur intprovcmmt is",to within one year ofran tion,the SQ.FT,FLOOR AREA S/SQ.Irl'.
cr-buildcr will have the baNao of proving that M1r did no,huildor Improve irpur-
poa,of sale,).
0 I,as owner of the progeny,am exclusively contracting wish licensed commnors to 10L
construct he arjecl(Sec.70,0,Buff rens and Ianfassions Craft.)Had Contractor's Li-
ac Law does an apply vsnn owner of m
nopy who milds or lniproves Herron,and Q'I'Y. PLUMBING PERMIT P
who contracts lir such projects with a contractors)licensed pursuanl In the Contractor's
License Law. PERMIT ISSUANCH
❑l am rxctnpl under Sec. .B de P C fonhis reavan
Owner Dnle AI,TEk-DRAIN,aVENT-WATER(HA VALI1AllON
ORKER'S COMPENSATION DIiCLARATION HACK ROW PROI ECT.DEVICH S
1 hereby of iWre under penal,,of perjuryenc of the following dedaretirm:
❑ I have and will maimaina Cenilicataaf Consent In self-insure l'nr Worker's Coni DRAINS-FLOOR.ROOF,ARHA,COND. ST RIBS TYPE CONSTRUCTION
don,a,provided for by Suction 31(1(1 of the Labor Code,for the p,tf ranm of the
R}for which this permil is i...do. FIxrUREs-PEIt'I'HAP C
I M1a.x and will maintain Worked Compcnvlion Insurance,as required by Section J
3100 of the Ldhor Code,for the permantrnce of the%ark for which this permit is issued. GAS-I;A.SYSTEM-I INC.4 OUTLET'S OCC GROUP APN
My Work�'CnmPerl,alienam'tyancc cn 'r and Rlllc number arc: .. G
Cdoorp /J-_T 514 yY/t �riv PolicyN GAS-EA.SYS'TIis-OVER 411iA)
CEHTIPICA'I'E OF EXF.MPUON ITtOM WORKERS'
COMPENSAUON INSURANCE GRHASF%INDUST RLWASTE INTERCIIIsfOR
BUILDING DIVISION FIiRS
(This xu:tion nenlnm be eompkmd if the pemtil is fnrnnchimdred Jollura($100) GREASE'I'RAP it,les] PLANCIIECK ITB
I verify that in the ltsrlttrmar.oflhe work far which his permit is issued.I shall SEWI;R-SANITARY-STORM EA.2U)FT.
not employ any Person in any manner st vs ro We do.object to the Workers'Camper- ENERGY ITE Clk
Z swion Laws nl California.Date WATI7R HEATER WNENTTILHCrR
OO Ap,dactal GRAUINGPEF.
h
NOTICE TO APPLICANT.If,after makingthis CCnilicvm of Euro t haul,)P ion you 6 WAI'lik SYSI'EM11?NEA'fINC SOILS ITPH
a ; become subject m the Workers Coons of this provisions of and cr Labor Code,you muss
W
forthwith comply with such previsions of permilshnll he decmW revoked, WATER SEkVICII
Q
Urz CatthemUCTION LENDING leading agency
NEW HESIDENTIALPLMI3, SQ.Ff. PAID
330 (hereby affirm thanhcreisanmamdirn lendingagency forthe perfnnnancc of rte Hnxiptp
P. the work for which this permit i.i.med(Sec.3091,Ci,CJ
O U Lender's Name 'I OTAh:
U larder's Ail Tfyl'AI.:
Iti y I cenify lhm I have rend this upplicatinn and elate drat the above offnnnalirn is BUILDI 'FEE
.F. h correct.l agree 10 comply with all city and countyormnances andstme law..].nog to QTY. MECHANICAL PERMIT - FEE
U � building construction.and hereby amturize reprcurreaivesnOhis city m emrrupon the SEISMIC I'
above-mondanW property for inspection purposes.
(We)agree a 6avc,indemnily and keep harmless me City of Cupvoino against PFRMI'T ISSUANCE ELECTRIC FL
liabilities.judgments.costs and expenses which may in any way accrue against said City AUIFR OR ADD TO MECIL -
in neeyuence of the gmming of this permm PLUMBING FEE
APPLICANT UNDERSTANDS ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO ILast CFM)
SOURCE Itr;GULA MSCI IANICAL FFI3
Alit HANDLING UNIT(OVER 10.000 CFM) CONS"I RUCfION'1'AX
Signature(it A ppc' frac'"' Date EXHA(ISTHOO)(W/OUCp HOUSING MITIGATION FEH
AZARDOUS MATERIALS DISCLOSUR;
Will me apptlevm or furore huilJing occupum store or hundlc haznNonx lnmerial 1117NI'ING UNI'('UD 100jmp0 B I'U)
as defined by the CLpenino Municipal Code.Chapter 9.12,and the Health and Safety
Cede,Ssaf n 255320)7 HEATING UNIT(OVER flutist)[ITU)
El Yes ❑Nu PAID
V IiN'I'ILATION PAN(SINGER RI35TD) Date Reedit#
Will the air emanlnrfmurc building reche ra use Bay Are.
Air Qualitincri y
Managcs ement
BOILI;R-COMP(3HP OR I(B.0011 FETED emir M1azaNnm tear conmmmanrc as JeBned by the Bay Area Air Quality Manogemem TOTAL:
District? ROILHR-COM('(OVFR 1()1,000 BTU)
❑Yes E]No
I have front the hasumius materials requirentenu under Chapter 6,95 ofthe Cali- AI R CONDITIGN17R ISSUANCE,DATE
fornin Health&Safety Code Serum,25505,25533 and 25534.I undrawnd that if me NEW RESIDFIPTIAL MECH, SQ.IT ! 2 3 (S
building do r not emrendy le vo wnan6 dol it i.lny wsrymsibility m notify the(Kctipanl 7
of the rryuircmcm6 which Ilmxt he mel prior to I5at1aI1CC Of a Cenilicaleof Oentpnncy.
Owner or authorized agent Dale TOTAL: ISSUED BY:
OFFICE