S 1827 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. I, PESITNO. 1827
8 2
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BUILDING DIVISION APPLICNHOWPERMIT PLUMBING.-MITCHANICAL `v
BUILDING PROJECT'IDEN'1'IFICA'I'ION
BUILDINGA DSC)(.l.in n./� (fie � SANITARY NO. APPLICATION SIIliMIFEAL DAT
f••PT^s1) R S _"CN I r- r
OWNE31{fi(•IA`I r n / PHONIi:
JR
'R CrUR'\N��@ll?: t1�.IC NU:
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(�ARCIIIIECTA NGIN HR .IC O: AO) 'SS: ILIO 0 O V /J
QS O�1 e
C TACE: 1. 1 PIION17 e BUILDING PERNM INFO
•Q� LQ C Ery WV 1 ��I^ ❑ ConSUIIlln1 EPfs Paid by Applicant(Initial) BLDG /ELECT I'L�B NIECCH
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Lo
CONTRACTOR S DECLARATION QTY 13LECTRIC P17RNIIT FEE
1 hereby affirm that 1 am licensed under provisions of Chupmr 9(conmboving JOB DESCRIPTION
Ga0 w1 Seer 7000)11[)i,,,i I loflhC Bu,hne,,;md P be..dans Crane,and my license in RESIDENTIAL
LL Op PERMIT 1s$DnNCE �,
Fly mfull lince and cRrml. ❑SI'UWL ❑KI'ICIIIiN It IEMOUIiI.
WF.UU Llcenw Class Lic.X AT'['].]ANCIS-RES HUHN'I'I AT. ❑ADDITION El ING BE PIPE
NZ, Duro Convector ❑MULTI-UNIT BUCfURAL
A RCI if'rl?CIS DECLARATION
1„p m PANELS MODIIBCAfION
Z O.z I unnesland my plan,shall he recd us pulik eecards UP 10 2g)AMPS OZ—n ❑IN'IPRIOR ❑CHIMNEY REPAIR
Lianwd Professional 201-1000AMPS LMPROVIEMINT C)SWIMNUNG POOLS
to F
OWNER-BUILDER DECLARATIONOVER I(XXOAMI'S ❑RaTH REMODMITEPAIR ❑DEN]OLETION
a S'a' I herch nOJrm that I it aamll from the('I teem",1-ccnm Law for the
X3aF following...sons(Sector 7031.5LBmina,.eard Professions Cone Any city of county SIGNS ELEC'BICAL ❑U'I'Il^liR_�/
W LLE` which q permits Construct. lis
Il improve, 1 licit p m
any amue
�N�� pr ort t 'I. 1 the a,dicantf lipscoal fl -6 J,mtement SPECIAL CIHCl11T/N11SC.
'qWQ�
man TIC lI tt the Niof the C t 1r'II I (Chaptor9 COMMERCIAL:
ClyaOO hettmnury,w tit SCcra..70gbaf Doo n3lf the Ions' sl dl f..' sCorlCor 'I'H."I.MITT]; Olt 1'OLIi
d i c a a he is exempt do efnmn
.rad the Torsi,for The alleged exemption.Any violation of ❑NEW BLDG/ADDI
LhemHON ❑DEMOLITION
W^m
Section 7031.5 by any applicant for a peril subjects the applicant to a civil penalty of POWER DEVICES I]'I ENANT 0F00 SERVICE
al marc Than live hundred dollars(SINE. IMPROVEMENT'
f=� ❑ L tsnwan'of the IF i...y.ormyen"luyces with wuga....heiruda conlpunxmlon. SWIMMINOF ml,
p., willdo the x.ok.md amort cmne is not intended,nlbard fornale(Sol,71134.Rusin... ❑OI'l1ER
W 3 m and profession,Code The Comaacmr's LEcenew law Joos not apply'to an owner of OVILEIS-SwIICIlES-I9 F_S
property who nullds e,improves themon,and who does such work himself ora through
his two emplaycex,Provided(bill Inch lmprovemmuts am not intended or Aired for NIEW RESII)ENTIAL ELIEC!'H Q PC
$ISQ.Irl'.
sale.IL however.the building or improvement is sold within one yearufeeirdeflol,lire SQ.PI'.Il.(k)R AREA
owner builder will have the burden o'proving dial he did net build or improve for put-
sawof,de.). 'r 1'A..
❑ Las owner of the property,am cwhuivcly contracting with licensed Contractors in
,n,Ifrcl the project(sec.7104.Basincs,mrd I'mfw.i tm Code:, he Coonsunork....
cease lrwdoes not apply toanowner ofpropcnywho build,or improve,thereon.and QTY. PLUMBING PERMIT iP
whir Controls file such pmjens with actino-etmP)Iicensed purvicaua the Contrdcmr'..
Lost nuc Law. PERMIT ISSUANCE
I am cxrmpI under See .It hl'C Gm Ok rcasm
ACllik-DkAINh V13N'1' ATTR 0A) VALUATION
Owngr Dae O
/I /l
WORKIER'$COMPENSATION DECLARATION PACK FOT
LOW I'RECr.Up C/ to
I henry afim...... pce,hyel parjuryonoof lira following Jcelurntions a Q
�1 have anIwill mainsio.Certifcatcnf Com,cntmeclt-m,m'e fur Wurkcr',Co all DRAINS-FLOOR.ROOEAR1i ,CO OIIIP,S 'TYPE CONS'IRUCHO'.
cation,a,provided for by Section 3700 of the LaMn Cole.Lha Lha Naboneinve of the
work for which this permit is issued. FIXNHF_S-PER'("RAP
0 I have:nd will maimain Workers Ceminmmian Insurance,t,N,rind by Sectio
170fl ofthe Labor Cade,for the perlbnnunCecil tire work fur which this permit is Issued OAS-EA.SYS'IEM-1 NC.4OUTI.FIS OCG GROUP APN
My Wnrky(,�;(pJ��,aunryfewra9ePol'icy No.: One- 4•' 9'/ GAS-EA SYSTIiM OVEHJIEA)
Canicr —�F EXH
CIEHTIIlC OMPF IEXIEMPT'IIN PROM WORKERS' GkIEASPIINDUS'1'RL WAS'1'IiIM'ERCI[19UB
GGMPIEN$A'D(1N INSURANCE
BUILDING],DIVISION f9
?ES
('Ire,oOionnnd nal he completed H un,permit i,fannre hundreddellnm($I(XB GRI?ASIETRAP
nr leas.) rLnNCHecK PEI: /J7• qS-
Iverify the,inthcperfeemnvenfthe Comic for which this permit is issued,l shall SEWER-SAN]TARY-SI'ORM EA.bed 14,
nn1 cntPlnyuny pcnon in uny Tanner an a,m hcennm x.bj,v(to the WodcrF Confer- ENERGY FEE
,Z suborn law,Cl Calilirmiu.Ome WATERBEAT'lilt WIV17N'1'/IELI7CI'R
2O Applicant OIOAUING 19Eli
NIMCE'TO N'PLICAM:LL afar making this Ccnificntc of Havarn ,you should WAITER sYNrEEM/rREATING
y SOILS Il?E
F't ImEwisuM1jcvlm with
Cangmnsmi'lernvisium ethic .,,,d crol,,you must
RXI y forthwith unnmly with such Prnvi,ionx ar rad,permit shun be Acetmrd revoked WATER SERVICE0.
p
CONSTRUCTION LENDING AGENCY NEW RESIDENT AL PLMB. SQ.17. 1'n1U
1111 affionthat there is a consmmtion lending agency for performance of U m keccipU �07P 9
� � the work for which lhispcmnit In...ucd(See.3047,Civ.C.)
I'Bier,Nance 'IRI'A L:
LJ TOITI,:
Lender',Mines,
} a 1 cenify that I have read this upplivnium and state that the above information i, BUIIDI' 'ai
Currecl.I gran to comply with:dlIII,and county nhllnamcce and stmt laws Clmingw QTY. MECHANICAL PERMIT FEE SITS C 'EI? V
V Z buildiagcon,uudinn,rand bcruby unthnrim rcprcscnanivun ol'IInkcirylocnanipoolhc
aMnvementioncd pmleny lnrimpeCtian puHxnes
PERMIT ISSUANCE FLEE C Ji
I Wel ugme to em's indemnify and keep hannlese the City of Culmina againm or
Ichilitie,lul,no,or..calls and C,,e Cs which stay in ICY waryaaemengaina said City ALIfER OR A DU'TO MEC II. PLUM IN .19EE?
In cannern6 nllb ln �
APPLICAN"I'UNDIERSTANDS AND WILL COME' Wlr LNON-POINT' AIR HANDLING ON]'FIT)10,(XN)CI:MO MFCIL ]CAI,FLEE
SOURC- ULAT 'S.
AIR HANDLING UNIT(OVER 10,0X0 CPM) CONS'IRU l'ION'IA%
41-�
Stgaalrre of Applicandi...for )ate EXHAUST HOOD(WIDIJC'I'0 III011SINOM 'IGAIION FEE
HAZARIR)US MATERIALS UISCLOSURE
Will the applicant or future building occupant store or handle hamNnus material HEATING UNIT(TO](XL0XI BTU)
C.defined by Ne Ctp,rd Municipal Code,Chupmr 1).12.:rod the IICa111,and Safety
Cuda Seenin I25532fa0" 111?APING UNIT'(OVERIIX),INNI Ii'lLl
0 YC, E]N° VIEN'I'II.AI'ION FAN(SINGLE RGSID) PAID
Dare R ecipt4
Will the applicant or future building overlent use ectupnmm or devices which BOILER-CONU CHP OR 100j)(XI n']TI)
Til notation,air eonanunudefined
m,rax by the Bary Area Air Quallly Mm a,c not T I.:
Diurictl BOILIER-CONIP(OVIER 100,)(1113'I'll)
❑Ye, ❑No
have rcad dre lnvurdou,mer"A'myet Is ruder Cha ln'h.95 of Jim CuCal, AIR CONDI'DONER ISSUANCE DATE
4tmia
.JIh A,Safety tenn25505.25533 and 255Y1.1 tmdcotand to.,it NEW kESIU1EN'1'IAl,MSCII. SQ.I'I'.
building doesnots,hi,h have ate et o,tit ismyce of a Cllhymnotifythe oempam
nfthe ngnirements which,math met prinnnismanee rfaCmificam of(kcupancy. �-3.
Owncror count agent Dac TOI'AL< ISSUED BY: I
OFFICE