S 2106 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING PE'SIITNO. 2106 1 O w
BUILDING DIVISION APPLICATION/PERMIT• PLUMBING-MECUANICAL \V 'LJ I�.1�
BUILDING PROJECT'IDEN'I'IPICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SURMITTAI,DATE
ZO-135avavt 31v�. Ste. n —/-9�
O R'S NAMG: PHONIi: CONT A 'I OR'S NAME: LIC NO:
`iRPW`^kD GOC-01.3 COL NIC CON'I'HOI.a
ARCHITECIRNGINFFK Tl LIC NO: ADDRESS: ❑ e—
Cr1O�1INMACT. /k itONI.: BUILDING PERMIT INF
2-0-7-M ❑ Consultant Fees Paid by Applicant(Initial) nL ELECT PLUM MliClI
❑ ❑
LICEJJSED CONTRACTOR'S DECLARATION QTY EL_4CFRIC PERMIT FEE
I ficachy union that I am Gceoaad under provisions of Clmprar 9(cmnmenaing JOB DESCRIPTION
OOC) whn9ecwan 7rero)dDM,ion3.fda Rosiness nod Prof siou,Codeaa.tyncanxeix �� RHSIDENTIAL:
WOO a PF:IIMIT ISSUANCE
F�.+ n full force and affil f� .-kms ❑SFDWI. ❑K I'I'Ct BBN REMODEL
�UF Linn l.,s Lick cTC7-\S L
6 U _�-�—�— APPLIANCES-RISIDEN'T'IAI. ❑ADDITION ❑PLUNKING R6PII'F.
N Q a Dalc TIS DE nr 1 a7
F,Ow ARCHIT[CTS DECLARATION PANELS ❑MULTI-UNIT ❑MOSTRUCTURAL
O
ZOy Zz l undcrsmndmy dams,boll.load as public nxortlx MODIFICATION
OZ—W UP'I'0200 AMPS [I INTERIOR ❑CIUMNEY REPAIR
F4F"W Licensed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
a s1 mJ OWNER-BUILDER DECLARATION OVI?H 112 AMPS ❑BATH REMODFUREPAIR El DEMOLITION
�y�1 C eG 1 Inmhy of iml thus I.,it oxontlt from the Corms.' .License law for me
yj a F following reason.(Smninn Ztl3 L5.Ru,incsn anti Pmfwsionx Cndc Any cloy nr county SIGNS ELGCfItICAL ❑(YI'115R
y which q perm n construct.uhc P f m li M1 p Y l trucwre
I-"�O issuance al req _the SPECIAL CIRCUIT/MISC.
frit t t .. 'prT I f .recto i signed Chaplet')em
4f (fail cori licensedpursuantI th p mon. fob Contractors I 's (Clo,10in
W-p0 teat be is ingwimSeat mfirou.ndthba,is nr tof he allgad tesn,Wop fia'suAny,i CxleJ n' TEMP METER OIi POIJi INST CQMMERCIAL:
Q.a n K that io i.exempt tway.,n and for .Osis for me alleged exempnt to Any violation nl ❑Nii LDG/ADDITION ❑FOOD LITION
SERVI
m Section 7031.5.y any afplicant forapermil whjmts the applic:unmacivil Penalty of IroWI?R DEVICES
noununnor,that live hundnedde1W,Wild). IM ANT ❑FOODSERVICE
I,ow owner of the t IMPROVEMENT
❑ the shoclum is intended
wimwaagel tcale(See
7044.
SWIMMING POOL ELECfItIC
F will dmaework.Code.cbeCorcisrmtia Livens Cavi doesrsd rant.,,[, anusciar oc ❑0'fIIER
W 3 and,"y whionv CNo:'Ilac Contractors,and w Law dace,not apply man owner ofgh O(1'l1.FT5-SWITCHES-FI%'I'I1RF_S x 7
property who e,...or..kclvth thereon,r and wlua Anes such awork intendhionsOled
nreard Ra
his own wa,oarecs,provided that such improvements um nnl intended or.lido. fur NEW RF:SIDEMI'IAL ELIiCB SQ Ff.
sola.if,however,nhehuilding or imprnvvntcnFls wild within one yawr ofenmplcnion,the SQ.PT.FLOOR AREA $ISQ.FII
wnarvtluilder will have the burden of proving that lie did not build or impnme for poo-
Esse of m]e,).
I,nc owner of the proferty,it.eeahaomly a norwaing with liatoed contractors m OTAI
enavuoa the pmj¢cl(See.90.14,Business and Pou,,,inns C dal)The Cnnvacan s Li.
cause Law does not apply to an owner of propeny who buifids or imprnvcs marcor,and QTY. PLUMBING PERMIT FEE
who contacts for such projects with a contrumorfx)licensed pursuant to the Contractors
Liccva Law. O-DRAIN
SUANCE ( O
❑ I um oc ula under Sm. .it X l'C for this rc ono
O Da
RAIN de VENT-WATER IRA) O VAI.UA'IION
WORK17R'S COMPENSATION OECLARAI'[ON (RECTI DEVICE / O O
I archy nlGrnt under panalyol'peJury oe of the followlag daahnations: l�J❑I have and will maintain.Catifimtcuf Conxonnusalf-insure forWokera Cnanpen PLO ,ROOF,AREA,CONT. STORIES TYPIE1CONSIRUCIION
,mina,as provided for by Section 3700 of me LaMn Code.for the performmore of the
wnrk for which this permit is ismd. S-PERT P
❑ I have and willainionain Worker',Compensation Ins.mnce,av requir¢d by Seatin
3700oftheLaborCoic.hrthe 1,11toawneeoflhe work fn-which this periali ix issued. .SYS'I'IM-I OUTI.:'S 01GROUP MIN
My Workers Compensation Insurance lamer and Policy nu rdarart:Cartier: Policy No.: .SYSTEM-OVERCGRIIFICKI'E OF EXEMPTION FROM WORKERS' INDllS'FRI.WASTE . EPTOR
COMPENSATION INSURANCE BURIDING DIVISION FFFS
(Thin section need not be completed ifthe tannin is for one hundred dollars($100) OR BASE'FRAP
or
]as,.)(This
I4T
I certify that in the Knorm.nce ofthe work for which this permit is issued,l shall $IiWER-SANI'T'ARY-S'IORM EA 200 R.
oat cmPloy any pervnn incy Ioun."-sau
t ,lq hum c su 1•M mt in e Worker,Compun- ENERGY FEE
OZ Wlinn Lawsof California.Data �e� `- WA'1'ERHENUERWNEN'UI?LEC'1'R
z O ApPicanl NA®A GRADING FEB
NOTICE TO APPLICANT:If,after makin6 this Certificate of Exemption,you should WATER SYNTEM/fREAI'ING
E~ ^ ca,.n.subject to the W ak,es Congen...too provisions of the Lu.or Coca.you mal SOILS FEE
forthwith comply wiIhwch prnevanm rte this permit shall hu dccmul revokal. WRPCR SERVICE
o.
CONSTRUCT construction
[ON LENDING AGENCY NEW RESIDENTIAL PCMB, SQ,PP, PAID
U� work
which hit.allhereiancolNay.Nn lending.Kency for me pertinmanca of I re Receipt
the wont for which his nems.is issued(sea MP)7,Civ.C.)
U. F" Lander,Nam¢ L:
SLenders Address L: ( F.li
1 certify that 1 have read Ihi.wWpliention and mate that the above infomtalinn is If 1 Q
F.I (n carract.l name mcnantly wimau ciayund urunly nrdtnanmvnnd-swtoluws ralatingm QTY. MECHANICAL PERMIT" F`EE
U z huilding ennstructinn,mid hereby.01 rctrcmnmtivesufthis city menncfupon the SI!ISMI I!li 1�
shove-mcmioned prnpcoy for inspection purrytscs. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harndess IM1e City of Cupenino against ELEC PCI:
Ilahilitics.jndganenq co<fs and expeneas which any in OnY w.ry nttmc uguin.0 said C'uy AMERORADDTOMECiI.
in concequenr'e of the grunting ofthi,permit PIA 1 NG II?I! „
APPLICANT UNDCRS'FANGS AND WILL COMPLY WITU ALL NON-POINT AIR DANDLING UNIT('ID BLEBI CF.Mb
SOURCE REGULATIONS. MFC NICALFEE
AIR HANDLING UNIT(OVER I0,000 CIM) CON16RUCI'[ON TAX
Signature of APPEcara Centractm Dale EXHAUST IIUOD(W/OUCI) 110 . NGMITIGATION PER
HAZ.ARDDUS MATERIALS DISCLOSURE
Will theapplinmt or future building occupant store or handle hamrdnm marerial HEATING UNIT(TO i XE00I BT U)
as defined by the Cutcrun,Munle 1pul Code.Chafe,9.12,and the Ilea,.and Safely
Coda Section 8532hd? 1I17.AI'ING UNIT(OVER EXI,11(XI RTU)
E3 Via, [I No VENTILATION PAN(SINGLE RE-SID) PAID
)al¢ Receipt is
Will the applicant or future building occupant eau equipment or devices which
¢min hamnlons air cnnmminants m defined by the Bay Area Air Quality Mnnngemen ROIhF.R-COMP(JI IF OR Ig1,000 Il'R77
Dislria? 11011 ER-COME(OVER 101%000 BTU)
❑Yes L]No
Ilmve prod the hen..,mmynirrnen under Chn taried,r is o,695 oft he Gal h AIR CONDITIONER ISSUANCE DAT_,
P
Gamin Health&S.fety Cole,Section,25505.25533 mid 25534.Iunderstand that if the NEW RESIDENTIAL MECIL SQ.FF.
building does not currently have a mount,that it i,my resrytroiion ily to unity the occupant
of the raquirentams which mum he ran priouo ivu.act of.Certificate of Occupancy. Q
Owner or enhanced agent Dale TOTAL: ISSUED By: r
OFFICE