28125 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ,PERMIT T NO.
BUILDING DIVISION APPLICATIONAIERMrr PINGPRNGEMF, ENT MECHANICAL 28125
BUILDING 'R(gfA;l'IDRNTIFIQnTIQN
BUILDING ADDRESS: SANITARY NO. AI.14.ICAIIONSUItkll'I'IAI.DA'l1i
AVNIIO '10 � J 6t, i LOT%
CONIRACIOR:S NAME: LIC NO: Z —
S ` `Lk r'.ti WMISNC CONTROL
ARCIIIIELI/ENGINE:IIR: LIC NO: ADDRESS:
CONTACT
❑
51
allurncr: rnGNl?: TSC >4,'y"r';�', E��CI'RIC ,oda;•IiB8 1. - BUILDING PERMIT INFO
a;G 'AW k", 6kc, �Q� 1- I�OS PERMIT ISSUANCE DLD
0 1!0LECP1f9�I-LUMB M[:
CD
Sl
LICENSED CON IRACIPR'S DECLARA'I ION APPLIANCES-RISIDEN I'IAl, JOR DUSCRIPI ION
emz hereby olimiih.,lnndicenxd undcrpmvisinnsof Clmpar 90'ommmaing will,
Ir0I0q Seaton lnMn of Di,khm Sof lire IT inessand Prdessimt,Carl a and my license in in PANELS T'
6zw NOTLikernsU'lne�a� 3� M `� u UP t02rxIAM1:5
y26 Dare t -J -�.e_ Cnnnu /ZiAf�J, NII-IIXXI AMPS
F-yz An(I IIT ECTS DECLA 'ZION SQ 19'.IiDOR AREA t/SV.PI'.
OZ-0 I understand my plans%hall he nslrieapid,; rnr� rlc�� OVRR IIXMIAMLS
c4EJWJ SIGNS ELECTRICAL
hfJ Licensed ltofesitmal o
66 OWNER-BUILDER DECLARATION SPECIAL CIRCUITIMISC.
Xx60a V 1 hereby affirm that 1 am exempt fnan the Coa
nOvot'n License Lew for the
W36N !allowing reason.(Section 0031.5.Businces and Professions Code:Any city or county TEMP.MITER OR POIA INST.
C ri: which raprires a permit to construct.after,improve,demolish,or repair any structure POWER DEVICES
prior m its Issuance.also requires life applicant for such Permit filesnignedsatemem
y/Ka0 malheis Rcenscdpursranlmlheprnvisimmofdm Cnnlmclnrsi.icenul,rw(CM1apter
9loSWIMMING IK)f31.ELE:C TRIC VALDAI'ION
6X 6' o...... f
np with Section 11XX11 of Division lnfohe Business and Pramsiram Gxlfl
m-m ter lhit,he is cunmOLerefmmnnd the hank for the alleged exemptinn Anyvialationof
�z4
Section]nll S by any applicant fora permit subject,the nPplicit to.dvil pennitynf OUITLET!S-SWII CIHIS.FIXT URES
$ onnunell 0live I idr<ddollor(S51X). NEW RGS DIiNIIAI.ELIiC1R S ,FT.
Cm ❑ I,oenwnanfthcponpeny.onny nnpmyeeswithwagcnnvthvirsoleaonrpcn%olum. Q SI ORII:S 'I'YT11:CONST R IICIION
63- will do the woo it,and the et,acture is not intended or offered for sale!Sec.70,14,Business
and Pfofra.sionn Code:The Contractor's License pow does not apply to air owner of
properly wbn hni his or improves thereon.and who does such win it himxel for through his
r < r IJThmxucM1im <memsvre nmimrndednndferal furmle.If. OCC.GROUP RIS.UNIS
Wildecnp1hehud owe poor
r will havc Ito, urdenfememiearmwithinaneyen of improve on,Far theowner- TOTAL:
.If.), will have the burden of proving that he did nm build on improve fm pnrrynse of
. m.l. QTY. PLUAIEINO PEEMIT FEE F1.DOD ZONE ArN
❑ Lan owner if*,re
mifica velycmnrassio. lona Ile Commorm
mrmm�a fhc pmjea Ipply oarro Business seal Profession. cirimo The Conton,am
Livnose Lrwdasnat apply urenownerofprrryeny wbn lwilJna infprcwm Thereon,am PERMIT ISSUANCE 01
whocommas her such projects with acnntnaoon)licensed Pursuant t( hecommmoda
Iicem,Iew ALTER DRAIN VIINI WAIER(HAT FEE SUMMARY
❑ 1 not exempt under Sec. .U A P C for thin motion BACK DOW PROTECT.Unvia -UITlS F:FEES
OG) SAND 1'ARV YN
owner Date DRAINS-1'LOUR.R(IOR AREA.GOND. RFC'II.1'X
WORKMAN COMPENSATION UECLARA'I ION SCIRXII.'I'AX YN
❑ Iloerclry effinu timtl M1nvcareni0cam of mnxnuo rel Flnaure,o.nrerfi0cnm of FIXTURES.PERI RAI' RECEIPT
Y\ Workro'Cotopeosatimt Wsrrrou eorncatifedanpy thereof(Set.3900.Lah C.)wldcf.h PARK IY. Y N
INliriyplonplp ,v i Ipr Rrivmrmly GAS-ITA.SYS I I:M-I INCA )H ILE I'S RIICLIPI'd
I d�0� 7 _ BUILDING DIVISION FlipiS
Cor ill 4 GAS-EA.SYS'h?M VI' (I' 1 PLANCBHCK FEE
❑ C<niBrd copy in hereby rumiahcd.
❑ Cenffred copy in Fled with the city inspection division. GR ASFlIND '1 IE CEPTOR (TRADING FPF
CHRTIFICATE OF EXEMPTION FROM WORKERS' G P1' SOBSPER
COMPENSATION INSURANCE;
(Thissscfinn mrA nm hernmpleTW if@e permit in fm ane hundreddnlDa(SIM) SEW! NITAR VSTORM F.A.200FT. ENERGY ITB
or tcuf
Icerdfy that in the perfmmancc fthe weak for which thin permit in imoed,Ishall WATER I TATER W/VENT/ELECIR
not nnploy any person in any manner of as to hemmfe subject In the Worker' PAID
Z Compenmtinnlownnf Cnlifomie. Dam WATER SYS TEM/1'RFATINU r Dal Receipi0
nppliewd
zC NOT IClz TO APPLICANT:If,after making this Certificate of Exemption,you Onuld NEW RESIDENT Al,PLMIL SQ.Pr. TOTAL:
t--r V) become subject n the Worker's Compensation provision of the Lawr Code,you mot BUILDING FIT,a. fnthwhh comply with.such Provisions or thin pemfit shall be deemed re,nkfd,
437
CONS'IRUCI'ION LENDING AGENCY Slit SM IC ITT;
Z I hochy olRnn flim there in a construction pending agency for the petGnnmvce of
C) O the work for whirl,this permit is I...ted(Set.1091,Civ.C) 'TOTAL: ELECIRIC FEE
tr Iendris Name + x f
[U•o Lind...Add.... QTY. MECIIANICALPI?RMIT , a' , :'PEt. PLUMBING H.E. rte.
W I certify Run I hove read this application and stem that the above infnanalion is n MECI IANICAL ITE
0. correct Iag¢n)roniply with all city and county ordinances and state laws rdming to PERMIT'ISSUANCE
hoilding ummmalon,and hereby motorim representatives of ddsaiiy in enter upon the CONSTRUCTION TAX
U Z eMve nienimcd n ! re pt,
V Z poopen,indemnify
nimt close. ALTER OR AUDIO MIiCII.
fwd agrccntwoe,andexpe and kapmayinnthe City ofe against
id Cilt nn I-�
incoiticajude,of
flooding expenses ayinanyway aaru<egainst uidcity AIR HANDLING UNIrITU 10.(XXICFMI U
in mnKquer¢'c of Re grinning of this permit.
AIR IIANUhING UNIT(OVER Io,fXXl CPM)
Signuare of Appl icam/Cummam Date EXHAUST IIOOU(WIDUCO
PAID
I IA]ARDOUS MATERIALS DISCLOSURE HEATING UNIT'IND IW,(11X1 BTU) Don, Receipt N
Will file upplinm or future wilding occupant nI i,lir handle Iramrdoas muterial
es droned by 11'c C9peninn Municipal Cala C.hnpn,r 9.12,end the I lealth and Safe,, IIF.ATI NG UNI I'(OVER I WLTIIXI RTU) TOl'AU 1 Z�
GMs,Satins 255 Q0I1)KNVEN I ILAI'ION PAN(SINGLE RESI D)
❑Venn
BOILER-COMP ISIIP OR R 0,0100 BTU) SS(jA�C�fJATE
Will Ne npplic:nn nrfwurchuilJingorrvpnm us<aryipnoent nr Jevlcen wltl<h moil
h:aanlmt,air contaminants an defined by The Bay Arca Air Quality Management ROILER-COMP(OVER I(BB)OTIU)
District? s�lo
❑Ye% NEW RESIDENTIAL MECII. SQ.PT. MAY y'7{. '1990
I have marl the her nun mmenala rcquimmrnts under Chorda 6.95 of The / MAY o/r 1 �1
Cditnmiep :dthh$vBTy ale.Scumm 2351 253)1 and 25534.1 undersand That ylly VI" lrUl'Cf1I11V1)
it @f huilAio Jresnmcur Tlyh ee Nninn.ilatilisntyretmnslbililymnoRfy The
cupam of mpoirenfrn whi mus M1e net prim m ivunnce of v Cenifcaa of
Occupancy. < r�
Ownaer nr amh Tal ug T Dem TOTAL: ISSUED B)': S _
OFFICE