S 1843 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT RICA I, PH n'NO. 1 /I
BUILDING DIVISION APPLICATION/PERMIT 1'1,11MBINO-'MECHANICAL 1843
IIlILIHNC PROJXICIIDEN'B'IF'ICA'I'IIN
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SCHEMEFI'AI,MACE
OWNERl'NAME: PHONE: CON-El
CONI'RACr R'S NAMh;: LIC NO:
A NIC
ARCHI'I IICT/1!NGINIiEH: LIC NO: DDIRIESS. ❑
CONTACT': I'I IDNIi:O BUILDING PFRMI'1"INFO
Ha6 ❑ Consultant Fees Paid by Applicant(Initial) HE DO ELECT PLUNIH MIKE
Id1FJ5 ' C� ❑ ElEJ
LICENSIEDC(INTRACI'OR'SDECLARAOON WIAN
ELECTRIC PERMIT FEE
I bore,,alEftn that I aunt licensed milia pnwiamns of Cnnlner 9 a mtmeneing JOB DF-SCRIPTION
CWZ all Section7(XXBof Division 3of1he Husinev+und PmC,,i...Q.le,nndmylicenwi.. RESIDI;NTIAI'
W0 wt PERMIT ISSUANCE
FW n lull force and uftcc}y, ❑SFDWL ❑KITCHEN REMODEL
Z U b' L.,C.,e Che, 'ri/�/� Lic.p z ryr�f
C, U �" LIANCES—RF_SIDENHUAL ❑AUDITION ❑PLUMBING RE.1'II'Is.
1-Z w Dam Ce momor
Q. ARCHITECrSDECLARATION ❑MUI.TI-UNIT' ❑STRUCTURAI,
F y Z 1 undcrsaunJ my plurss shell he usN as public rcatnlx ELS MODIFICATION
Oz�� 1'021X1 AMT'S ❑IN'I HRIOR ❑CHIMNEYREPAIR
a ate... Ihereby.o al I(XXI AMPS IMPROVEMENT 0SW TING POOLS
iC d
following
Pales,
Q �J Licensed
OWNER-BUILDER RATION iR IIXXIAMPS �BATIi RIiMOUIiI/RIiPA1H 10L1'1'ION
O alEnnrhm 1 um exempt Brom the Cnnvunrs License Luw tar ta
Ilnwing meson.(Satins 7(ULS.Ntninesa and Professions Calc:AnY city or awntYNS I!I ECfRICAL ❑OTIIIiRkh,m repair:mynlruelu1C / cfig priunoiu i,suancq also rcquims the applicam for loch permit ro Ele vsigned,latemenlCIA'CIRGDG'/MISC.that he is licensed pu„a.,,( 0hopruvisionsoflhe Cnntncmi'chicema Luw(Chapur9
(cumauncinewith See, n7000)ofDi,,,wm3 ofthe BualnCs.nd PosfooiotaCode)arY MLTI3R OR POLE INS'I COMMERCIAL:a G eC that heis Cone,bro,r naand IM1e basis bothe alleged cxcntplioo.Any violuJon of ❑NEW HLUG/ADDITION f<DF:MOLIfION
xC Section70315 by any applicant for a permit subject+the applicant to a civil Penally ofER DEVICESW^u, Imam than Eve huvdmJ Jollurs[551101. �'H'.NANI' PODU SI!RVICI!I,us owner of the n OIHER IEMCNT
Q ndred oormy500). cw with wagesmlhcirwle campensminn, 1S1MING IXHl1.1EL11C1 RIC ❑IMPROC,L.0 ill Jn the w�rk,mal the sm OaN,,nal immde,t ser ul ItoCl han'11C(See?D4.Business
Giroand Pro :C Ie'M C I rr'sL W d sat pplyt owner ofILE IS "1'I CIES—FIX[DABS gg�kk �fpmpenY h b'IJ:or p Ili J 1 alt A h n.r Ihn'n 8nW HI iN'I IAh ChI CI'N SQ Irl'. r ID
h'.v n pl Y pro I J IIr r. h imp o nal r d J tfered forale.IC however,Ise building ar imprnvemenlluold vital a oneymao .v..... mb OneSQ.FC FLOOR ARIA $/SQ.FI'.cr-bilder will have the burden of penving Thar he did not build or improve for pur- ��( �� Q�I(Xf�1"seormm.). LF11p7UI,as owner of the property,am exclusively nmtrracting with licensed contractors 1. 'I(llnl.:nosimo Inc project(Sec.9(91 Im%acess and Pnufics,ions Code)Tho Conunlall" Ji 't-v,e Law mss not apply to an owner of property who builds or innparvev moron.andPLUMB �I'HI IT FEE G`I I Uf GWILMI[NO
lobo nnuaafnr,mh pro,,,,with a mnlraaor(s)Iivan,ed lurvuanl in the Ctmvucmi's
Liccnsc Law. PFRVU r ISSUANCE
❑ I am exempt under See. ,li A P C for this 1,
jCIR�S[UNDUS
AIN h VFN'r-WAE iR(IEA) VALl1Al'ION
Owner U:nc
WOHKEB;S COMPENSATION DECLARATION PROIECK DIEVICIE �0
I hemby allirm under penalty orryojury ou ul"the following Jccl ......
I have and will maintain aCCnifcate ofConxm n,self-insert far Wnrker'z Con.No- 'I.00R.Rf )F,AREACONIY,'IURIIIS 'I'YI4:CtINSIRUC'I'ION
cation,use pr..d1d I'orby Section 391X1 n1 the Ia bo,Code.for Ill,perionn roc of'he
work for which this varmil is issued. -PERT RAI'
I]I have and will main am W..kO,Cnntpen,num lumnmcq use rtspJrsd by SIO'oll
370X1 of the Lams Code.file the performance Uflhe work for which this permit is issued. YSTITM-I INC.J(lU'I'LE'CS OCC GH(lUl' AI'N
My WorAcr' C Exrtsu In.w INA Polity nunthc
�l nn n mi Ccauncr,
camcPnheywrJ� A/UF zb// vsllanl.ovERa Dant
CIRCIPICA'CI!GET IEXI!MPHON FROM WORK17RS' DUS'I RL WAS'1'E IN T, CIEITOIt
COSIPENSA'1'ION INSURANCE. IEUILIlINO DIVISION FEES
(This c,,oroc,mab:cmnplcted itthcpemniO,En'one handled dollars(S IB)) GREASE'I'RAP
,or Icxs.) I'hnNCl II!CK Il!E
I ocery that in the performance of the work Rm whichth,vermit`u....md.I shall SIIWEIR—SAN I'E'ARY—IS I ORM HA.20017,
not employ any poise:'ioay,manners"m 9�,eunjca lu the Worker'Compen- ENERGY RICOones,Dole z ,urian laws al Cal"oniW,ER HEIt IEArW/VENT/ELECI'R
z Q AppBcum� ' GRADING FEE
NOTICE"D1APPLICANT:ICa O.o5klg�,Certifat
cc al'formal o,you should WA'fCR SYS']E VICBEATING
y SOILS PEIi
a ?
become subiccl br the own revisio nen,mmn pm ,ion,of the fined rCsdc,you must
I'onhwith ennsply u'ilh wen previsions t+ rt this pcnnll shall he JcmneJ rcvnkcd WATER SERVICE
d7CONSI'HUC'IION LENDING EW BESIUEN'I'IAIPMIESQ.FIPAN
z
Data Receipt#
U 0 1 bereby affirm that here i,a construction lending agency for the ped'ormance of
I+ P IM1e work far which this Yoil in issued(See.9197.Civ.C.) i I(YI'AL
London,Name TOTAL
WLeach's Address BUILDING FREE �•
6, I comity that 1 have read Ibis application and state mat the.Move information is
rq cmmn.I age.no comply wool,all City and county ordiwnccx and swan law.niallaem Q"rY. MECHANICAL PERMIT 17EE SEISMIC FIE
U Z building camwetion.andhereby authorize representativesefdascitytocmerupnn'he GX
rMue.memianed p,.,Gy fill Inslxcoon purprnes. PERMIT ISSUANCE IE.EcrRIC.FEB.
(We)agree,.save,indemnify and keep hooters the City of Caperdno again
ElabiIaes.jodgmenn.mtms vndcxpemcx whichmvy many w.yoa'mC.,alr,f,a,i City ALTER OR ADDT(I Iol PLUMPING FEB!
it nsequcnec of the granting W this permit.
APPLICANT ON DEHSTANDS AND WEI.E.COMPLY WITH ALL NON I'OIN'I' ABR II AN I(LING UN IT IIYI IU ilm CFM) M IECI IANECAI.IPE
SOURCE BI-v^QUI ATIONS
AIR IInNDI,IN(1 UNIT(OVER 10,000CFM) CONSTROCfII)N TAX
Signa notApplinoa/CooIacrar , , Dmc EXE[ALSO HOOD VODUC) I IOUSIN(1 MHIGAI'ION REE
HAZARDOUS MATERIALS DISCLOSURE
Will lhcapplicard nr l anne building(ecupent sonvorharele hasmdommmcrial HEATING UNIT(to IW,I)(XI BTU)
as dental by the Culxninn Municipal Cate.Chapter 9.12,and the Health and Safety BEATING UNIT(OVER 1001,(X)0 HTU)
Cada Scninn 255320.11
El Yel �No VFNIILA'1'ION CAN(SINGLE BESIDE PAID Ilaw HcceiptM
Will the applicant or future building occupant use equipment or Juices which BOILER-COMP CEHP OR I0B000BrU)
emit ha m ou,air Confrontation,us leffiu ll by the Hay Arca Air Quality Management TIMAL:
Dlstrictl BOILER-COMP(OVER I( .000 EIV)
❑Vic, Aj
Il
II have read the hvuNoamneridsrequirements
under Chapter6.95 of Enc Call- AIR CONDITIONER l
ISSUANCE DATE
vnia cehn A Safety Sections 05,25 and 255E I understand that the NEW HEMIINIAISECIISQ,I '
nuitJingacsnm cunealymveamvnl.that iDa,rtrytmibilily it ntilythemca'pum
m ore rnnoe mans wman n.q,. eye_ 7yy
Ownd�or,ut urncd nee hale
I OTAL:
' ISSUEDBY:
' OFFICE `l