S 0827 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BNLDING-4R.4:CfRICAL PE 11'NO. O
BUILDING DIVISION APPIACATION/PERMIT827
1'COMBING-MEC11ANICAI. S
BUILDING PROJECT IDENTIFICATION
SANITARY NO. APPLICAf10N SUBMITTAL DAII
BUILDING ADDRESS:
84P� 2ot3.w�o' `l_ w
OWNER'S NAME:- ^,... PHONNEE:fCONTIIAC'I OILS NAME', LIC NO:
M2 OFLC�LIZ� Cp S!y k-ry ®�1 �17 1�f10g �J�L �O riL] N/C CONTROL#
�ARCHTTF.Cf/ENGINIiIiR: LIC NO: ADDRESS T�� �(�% `-"�� ❑
CONTACT: liPHONE: BUILDING PERMIT INFO
/' ❑ Consultant Fees Paid by Applicant(Initial) BI❑DG ELECT PLIfMH MECH _
I.ICIINSF,CONTRAC'IORlS DECLARATION QTY. ELECTRIC PERMIT 17E8 JOB DESCRIPTION
I hereby ulBmt that I am licensed under pnwisiom of Chapin 9(commencing
WpZO with secti.n]Bary nfDivi.xioniofthe Nosiness and lknfcssion+Cade,and mylicense Es PERMITISSUANCE �S� RESIDENTIAI:
FFr-U_j in all a Cle.rdc rot. Lic.N 4P-a'Sl,&q ElSFDWI. ❑KITCHEN REMOUIJ,
t Ut Date Li,If ll)r�'J'u�� lbs APPLIANCES-RESIDENB'IAl. ❑ADDITION ❑PLUMBINGRE-('Hili
ARCHITECTS DECLARATION C MUI:1'LUNIT C MODIFI AT16
RAI
I„p rn PANIi1.5 MODIFICATION
I understand my pions,bm moods
he used pnhlie wrtJs
OZr�'gZuq UI"I'U 2(NIAMPS 2-P-0 CINTIiltl012 CL'I IIMNF.Y REPAIR
I � W Liccnxedprec innal 201.1000AMPS IMPROVEMENT [SWIMMING POOLS
�'+1 ..•..]]3I OWNER-BUILDER DECLARATION OVER IINNIAMPS ❑BATH REMODEUREPA1R 0DEMOLITION
OC 6 I hereby affirm that 1 ant exempt Eton the Common's Liamsc law for the
a�XC)wj llowingmason.(Section 7031.5.Bminesz and Rolcsai.m Code:Any city orcountY SIGNSELELTRICAI. CO'fllER 611�Xt/�V"
W 3 LL F which requires a permit Bs consumer,aIle,,improve.demolsh,or repair any structure, �a . •QN P/G
L-ii0 prior it issuance,also requires the applicant for such Permit file a signed statement SPECIAL CIRCUIT/MISC.
gp!!(V� that he is licemsd pursuant the provisions of the Contract.,',License Law(Chapter 9
ce (commencing with Section Wltlll)of Division 3.f the Business and Professions Code)or TEMP.Mf!1'IiR OR POLE INS'1'. COMMERCIAL:
L y o oC that he is exempt(bereft..and the basis for the alleged exemption.Any violation of ❑NEW BI-DG/ADDITION ❑DEMOLI'RON
iLLC1 4• Sectlon70315 by any up,icum for a permit subjects the up mannan civil penulty.f POWIIR DEVICES El HNANT CFOOD SERVICE
ret amore then five hundred dollars($50(r.
CSQI,esowner nfthe n,nrm In ccswithwo es ax theirsnle compensation, SWIMMING PO ,CfI11C OTHER IMPROVEMENT
D pmnc y temp Y s ,coxa El OTHER
F- will Bothe work,enJtMstructure i.+norintended nnrRemJ far mle(See.]Ban ovnoresn
u�13 end Professions C,de:Tire Commdnh License Law Jces oat apply m an owner of UUTLE'LS-SWI H - I%'I'URE.S
S property who builds or improves thereon,and who does such work Mmaelf lir through
his own employees,provided that such improvements are not intended or offered for NI7W RESIDENTIAL ELEC SQ FT.
sale.If,however the building or impmm
veem issmil within one year ofemaplcrion.the SQ.FR FLOOR AREA
SISQ.FT.'
ncr-budder will have the burden of proving that he did not build or improve for pin,
p se ill sa e.).
1,es owner ol'the aclicemms
tively,ant exclusively contracting with licensed coclum to T L
:
consumer the project(Sec.7(M4.Business and Profusions Code:)The Comruemr's Li- - -
cen.se Law does not apply to an owner of property who builds or improves thereon,.and QTy, PLUMBING PI2RMIT FEE
who romract fur such projects with a comrecmd,)licensed pursuant m the Contren.rs
License Law. PERMIT ISSUANCE s.
C] [am exempt under Sec. ,B&PCfnrthisma,m
ALTER-DRAIN&VENq'-WATER(EAI VALUATION
Owner Onto 00
WORKERS COMPENSATION DECLARATION RACK FLOW PROfECR DEVICE
I hembyufBrtn under penahy of perjury( not the following deelurutlons: �y 00 V
❑ I have and will maintain a Cerificate.f Consent to self-insure for Workers Courtier- Q DItAINS-FLOGR,R(IOF,ARIIA,COND. a ' S'I ORIES 'FYFE CONSTRUCIIOy
cion,es provided for by Section 3700 of the Labor C,de,for the perform.ncc of tits
xh.k ,which this permit is issued. FI%TURES-PER TRAP
e' Wallace,
and will nwinmin Wall ce,Compensation Issuance,as required by Section
37Mafthe Labor Code,for the performance offer work for whichh,his amft is ismcd GAS-F.A.SYSTEM-I INC.,OUTLETS OCC.GROUP APN
My Wo�rs pInsmmcecomeroad PolcSo
mGZ ' � GAS-IiA.SYSTEM-OVER 1fIiA)
Carie.: Polls,N.,n �
.� 362./9e�3o
CERTIFICATE OF EXEMPTION FROM WORKERS' GItIiAS191NDUSTRI.WAS'I'Ii IN'I IiItCF.PTOR
COMPENSATIONINSURANCE BUILDING DIVISION ITHS
(Thin coon need urn hcwmplmedil'In
permit is fnrone M1undmJ Jnllms(SIIXp GHEASI?TRAY
or less.) PLANCI IECK ITC
I certify than eperfmannowe nfthe work for which thispermit isissued,IsM1all SliWfiR-SANITARY-SIOHM EA.2W FT.
nor employ any person in '.manner sous m panda subject n the Workers'Comptar ' ITE
0 z scion laws of California.Dao- .. WATIiR HEATER WNENT/ELEC R ADI NG
O Applic
NOTICE TO APPLICANT:IL alter Allg this Ccnifca¢of Exemption,you should WATER SYSTEMIfREATI NO
Cil
hcrome-subject to Ihe Worker's Compensau rovixions of the Labor C.Ayost ILS p1lli
c, u mu -
�i Iorthwith comply with such provisions or this le r vhau hedeunod mvnked. WA'TBit SERVICE MAR 0
0. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PL.41B. SQ.FI. PAID
Q Iherebya i alIhz
ereisconswmiun leadingagcncy forthelwrformncrm'
V c. c tN
U the work for which thisName pc matind(See.309).Civ.C.)
0 U Lender's t
Lenders Address s TOTAL: s
1 certify that 1 have read this appllc n and store than the above inLnnmtion is B
Li rA career.(asreemnnnnly wimnll city undenun dinancesand sone lows rdmingm QTY. MECHANICAL PERMIT PEP.
L) 4 building Imstmction,Imd hereby authorize representative,of Buis only us cmc,up..I rho SEISMIC Ig1H
above-mentioned property for inspection purposes. PERMIT ISSUANCE,
(We)agree to ave,indemnify and keep hurnle,s the City of Conciliar,against ELECI'ItIC FE[ 7,?n
liabilities, costs and expenses which may in any way accmeagainst said City' ALTER OR ADD TO MECH.
sconsequenon t egamI gof this permit PLUMI{ING PEE y vo
ICA I UiRSTAND AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT fIY)10.00)CFM) MECHANICAL FEERCE . '10 . 62 t /o
3 AIRIIANDLING UNIT(OVER 10010CFM) CONS'IRUCFION'I'AX
Signature, /Cu actor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
1 ZARDOUS MATERIALS DISCLOSURE 11
Will a Tic niorfutumbuildingoaupantsmrcorhandlchawNeusmntcrial b HEATING UNIT(rMj,UNXIIi'HD �L•ZO
as defined by the u Wino Municipal CMe,Chapter 212,and the Health and Safety
Code.Section 255. W? HHATINC,ON]T(OVER 100,001 BTU)
❑Yex IVa.*' ch VENI'l1.ATION PAN(SINGLE RESIDI PAIDDate Rovein N
Willthe air contaminants
infurore buldbeide theStumea AirQuarell lirdevicesement
emit hazardous air asmnminant as defined by the Buy Area Air Quality Management BOILER-COMP 13HP OR IBB.IKKI PTU)
District? TOl'AI:
❑Yce ((aB� BOILER III(I,IN1111{'I'U)
Ibm r he hazardous materials requirements under Chapter 6.95 of the Cali- AIH CONDITIONER ( ISSUANCE DAT
foci.Her a by"are,Sections 25505.25533 and 25533.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET.
building d�. cn.1,havcatenant.the it is my responsibility to ami the parr
.Oita rtqu t u t he met pdorlo issmnce ofa Cenificav�n )t' T
ower ora t tem 7 Been TOTAL: 6.2s/0 ISSUF,DBY_70e �N7JN(,CC.
OFFICE