S 1352 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICA I. Pli 11T No
1161.DING DIVISION APPLICATION/PERMIT PI'DMBING-MECIIANICAL 1352
,tinea BILLDINU PROJE(if IDEN'1'IF'ICNFION
BUILUING ADURtrSS: """ SANITARY NO APPLICATION SSUBMI'FAL UAI'I
O 11 our l V
ZU., .k'S NAME PHONE: CONI RACa)R:S NAME: LC NO:
N/C, CON'IROLa
W;III I'EC'U17 FINEEH: LIC NO: ADDRESS: El
CONIACr: PHONE: E:1 Consultant
HUILIJING PEI2MI'f INFO
Consultant Fces Paid by Applicant(Initial) ItL-Iicr PLUMB MiiCx
/l�l—QI\ ❑
I ICENSIi1)CONFRACD)RIS DECI.SRA9ION QTY ELECTRIC PERMIT FEE
1 hereby ardor,mnce
at 1 am Troud ander provisions ofarder 9(commencing RESIDENTIAL:
_ JOB UESCRIPI'ION
Z -70s ni'Divinon 3oRM1e Buimevsand P..c,simo Ccde,andmy license is '
IQiI Q Q wort Semlul PERMITISSUANCE
W t, In Ibll License Cla s clTca. ❑SPIIWh C KITCfiIiN RIiMOD1iL
aUU Deta. ateChis. Lica APPLIANCES–RESIDENTIAL ❑ADDITION � O PLUMBING RF.PIPE
I-Zul Date-Commctnr
'D. ❑MUCfI-UNIT ❑MODIFSTRUCTURAL
CATIO
F.DO AHCIIITECTS DECLARATION pgNE14 MODIFICATION
OZ Ioal,,n lmiy Plnlle ofall hensedmpuhllcmc...it, UPTO 200AMPS
❑IN]'IiR10R
El CHIMNEY REPAIR
I=.'3 F-IQv Licensed Processional 201-1000AMPS MPROVEMEN'I' ❑SWIMMING POOLS
C x ; OWNER-BUILDER DECLARATION OVER 1000 AMPS .TH REMODEL/REPAIR ❑DEb10LITION
y C C 6 I hereby affirm that[am exemm from the Comortor's License Law same
x 3 d U following reason.(Section 91131 s,Basin... ,d inni...ionx Code Any cit.oo
r cunty SIGNS ELECTRICAL OTHER
a1 It.N which requires a Permit to construct.alter.improve,Eenmlish.or repair any[mimure
LLQ
F�'n.e,.1 prion: t. I: y m PPI tf M1n fl gcd.iui cm SPCCIAI.CIRCUIT/MIBG
a y that he is licensedP n the pravisions aftheContractors LL (Ch pmr9 COMMERCIAL'
��QQ (u,i , -,gw'IhSw1X1
tn 90) fD 1 of be B .' JI I ::' p
:le I ,t TEMP.METEk OR WILE INST:
M.a e K that he is uentpt thcrefnnn and me basis Int he alleged ucmPi an.Any Jet n,of ❑NHW BLDG/ADDITION ❑UEM01.1'I'I(IN
I%�y
Section 9031.5 by any applicant for alemat subjens thcar
pplicanto aeivil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
in more than live hundred dollars($510). IMPROVEMENT
C,yO Liu..... tbcpm{,coy,or my eniPloycm with wa6c^'as thcircnlc cumpcnxmion. SWIMMING POOL ELECTRIC
2 F., will Ao me wnrk.andtbc xtrumnreunm imm�AW nrnBlrnnl fnnalclSccJfW4, ❑OTHER
ILuincss
j3:
and Ihofessinro Code.'Fre Contractors Liecnse Law does not apply to an owner of OUTLE.IS-SwlTcros-FIX] s
pmpeny who builds or improves thereon,and who does%nen work himself or through
his own mapoyine,provided that such itnpeorments are oat intended our offered for NEW RLSIDENTIAL ELECIR Lot 4LsQ FT.
sale,II;bow q t he bu,ldi its a lurpro lss Id wi linnncyear of completion,the SQ.I Fh)](I�A 4 LSQ.Er.er .builderrwi 11 have the burden of piny ng that he did not hili Id or improve lor par- N
own
,are of sale.). T01'A pII��1Ip ANSI 1.as owner of the property,am exclusively contracting with licensed comments to I11MR I♦I,�'u
ronrue the pmjce(Sc,.9(114,Bron e,ns and Prnfcssi na Ch1 J'Ibe Contra, is I.,
rease Law Linen nm apply m ronwner of poupeny who buld.or Improv c,met con.and QTY. PLUNIBINGPF,RMI'f EF.
who commas air such prrjeeu witha enntman(s)Iicemcml Porsmmd a,the Crnleannr's
Liceme Law. PERMIT ISSUANCE 011Y Ur NVf Cf111NV
I nm exempt under Sec. .B A,P C for this reuan
At:(ER-DRAIN Pa VEN I-WRI ER(EA) VALUATION
net Due
WORKER'S COMPENSATION DECLARATION BACK FLOW PRO]FC`I.DEVICE
I hereby nf)rre under penalty of perjury one of the following declarations:
I have and willmaimaina Ccniticale of Q,tisunmu sol f-1rmm for Wnron,Cmnpcn- DRAINS-FLOOR,ROOF,ARBA.CORD. STORIES 'rYP[CONSTRUCTIOn
vninn,ax pmvlded for by Scctinn 391Xt nl IM1c haN,r Gale,tins Ibc Pcrli,m,nnac ofthc
work for which this permit is issued. FIXTURES-PER TRAP
lM I have and will maintain Workers Compensation Insurance,as required by Section
391XInl the Lnb Cade,fila the pcifnrn i ceof the weak for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLIA S OCC.GROUP AI'N
My Worker's Compcnsztinn hdnr:race carrier and Rlky number arc:
Carrier: Policy No.: GAS-InA.SVS'I'IiMOV ER A 07A)
CERTIFICMT OF EX Rod PTION FROM WORKERS' GREASE/I N DUSRI,WASTE INTERCEPTOR
COM PENS At[ON INSURANCE BUILDING DIVISION FEES
(fhi....liunnculnot be camgdmnllfthcpurmit is fnrore hundred lnllurx(Illad GREASETRAI'
- I'LANCIIIiCK Hili
on,b")I
I certify that inthe p ymor ana.,nf the work for which this o permitiloar,' oshall SEWER-SANITARY-STORM EA.21M)PI'.
oat employ any person in my nianncnn man beam¢subjen m the worker'Cnmpen- ENERGY PEE
Z .anion Lawsuf Cnlifnanis.Dae WATER HEATIE WNENT/IiLECTR GRADING FEF,
ZQ Applicant )
N., NO]ICE TO APPLICANT':If,after making this C nilicme of Exm,rpmom.You should WATER SYSTEMURIiATING SOILS FIJI
f" become sahjeet m the Workers Campeiaation l mvisinns of the"Nor Crob"ran matt
11i ti limhwlth comply with such provisiomonhis permit.hall be deenmd revoked. WA'IT:R SERVICE
CL
CONS'IAUCr10N LENDINGAGENCV NEW ItGSIDEN'I'IAh PLMI3, SQ.I'I'. PAIII
U Z 1 hemby Labor that there is a conloichon lending agency frobe"mra trcc of Ilvti.
Q.P the work for which this permit is issued(See.3092,Civ,C.) TOTAL:
O Lenders Name 'R UAL:
�� Ljauc sAddress BUILDING F
O. 1 cenily In.,1 have read this application and state that the aMwe inli,nnmion is
F (n amrect.l agree it)comply with all city and county oNinances and sure laws relating to QTY. MECIIANICAL PERMIT FEE SEISMICETE
UZ building nmuuction.and herchyauthurizeteprcamutivesofthiseitytoenmrupmthc
ulewe-muntion6l pmperty for inspection Pmryiccx PERMIT'ISSUANCE HLECfRIC IT
(We,)agree to.ave,maternal,and keep harmless the Cly of Casco lnn.gain,'
Iiibildics,judgments.costs and espences which may in any way accrue against said City ALTER OR ADD T(I MECH. PLUMBINGFEE-
in nsequenca of the granting of this permit
APPI.ICAN'I IJND17RS'TANDS AND WILL COMPLY WI'T'H ALL NON-POINT AIR HANDLING UNIT(TO 10,0X)CFM) MECHANICAL FRE
SOURC. ULHANDLINGATIONS. /yy/
4ZAt �/.= 2yU/iv� AIR HANDLING UNI'I'(OVI1R 10.000CIsM) C(lNS'I'HUCTI(lN'I'A%
Signature of Appbcanl/Cnntmtal WWW at EXHAUST HOLD(W/DUCT) HOUSING MITIGATION FTE
• HAZAIt DOUSMAI'ERIALS DISCLOSURE
Will,oaa,jicuntnr future M1aliingoccupant store nr handle haznrdouxnuleriul HEAfING UNIT(10 hoops)IITU)
our defined by the Cepcnino Municipal Coa.Chapter 9.12 and the Health and Safety HEATING UNI1"(OVER IIX).(XX)H'rU)
Cade,Seaton 25532(.)'!
❑Ya EJ No' VEN'TILAT'ION IANSINGLE RISID) PAID •�
Dme Hcccipt p
Will the applicant or future N:ilding occupant use equipment or devices which B011.lik-COMP 1311P OR IIXLIXp RTU)
,nit hazardous air contaminants as Jefned by the Ray Area Air Quality Management TOTAL:
Disnict? BOILER-COMP(OVER II01,I0g)BTU)
❑Vo.v ❑No
heiardems mmenals e,maks Chapter 695of the Cali AIH CONDITIONIiN ISSUANCE DA91i
I have read the
reyuireiun
fomia Health h Safety Cohn Seniors 25505.25531 and 25534.1 understand thin if the NEN'RESIDENTIAL MECII, SQ.FI.
1,unifing doe otavmmlly love a immm,tem'11 ivmy r:xpomibilaY no unify the"nern
our the na,mainnene,wldane,1 bcoun,'i nn isa:unee oft Cennicme of Ocealwncy -
Owner or amhorized ager Date TOTAL: ISSUED BY:
OFFICE