S 2162 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING.ELECT IDEA LIT
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BUILDING DIVISION APPLICATIOSUPERMIT PLUMBING: MECFIANICAI. J G
I{1111A1NG 1'ItO,H:Cr IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMIETAL DAIH
/e510 5r'o tf-:VS A ✓F I ( —/f -2
OWNER'S NAME: PHONE: CONTRACroR'S NAME LIC NO:
A4 3 M�� ` NIC C/O�YI^R(JI.p
.,ARC H ITECI IENG I N EIiIt p{`4f� LIC NO ADDRESS: ❑ H7
M f CLu
LD o IV5 66,5.-OE A(Zf► /
CONTACT Prom;: - -I 'BUILDING PERMIT INFG
4-a Q— -q G6 L�tl ElConsuhnnt Fees Paid by Applicant(Initial) ItLDG ELIiCf PLUMI{ N
LICENSED CONTRAC IOItS UI CLARAI'IUN nt}•1 ,'I 1" n
QTV FLFC 71210 PERMIT ( IL' ITh ,
I berry affirm let 1 licensed d P fCha"',9(co ar ung I J013 DESCRIPTION
Qd'Z wain See un]gXlJ nfD vtvatRfaheO . 'nW Profes.i n.Gtite,ammy license . 1 ^ RfSIDFNTIAI:
_ PERMIT ISSUANCE. G' �,/
tW-o, in full force and die ❑SII)N'L ❑KITCHEN III: IODE.
aUF Licemeclar" Lie.e h6 Z/s7
Q U APPLIANCES-RESIDENTIAL )DITIUN El PLUMBING RE-PIPE.
F W Da¢ Carats....
h 0. ❑Ml1Cl'I-UNIT ❑S'rItUC'I'UkAL
m AItCIIITECT'S DEChAIiAfIUN PANI3LS
F y Z I undenLnnd my Plus.dell be used uv public records CHIMMODNEY
RE N
ZOZ-N+0 UP 10 21NIAMPS ❑IN'TIiRIOR ❑CfI1MNEY REPAIR
FQ`=�'W License)l'mfcssi..nal 201-II9XIAMPS IMPROVEAIEIJT E3SWIAIMINGPOOIS
CY C OWNT:R-BUILDER DECLARATION
OVER RXX)AMPS ❑13AI'14 RENIODE1JREPAIR ❑DEMOLITION
lY Q 1 hcrchy affirm that 1 am exempt from m,Carmad is Liccnst Law for the
C.p WU ❑OI'llliR
W following,,'Isar,(Sacm ]031.5,Husmeus end Pmfessmns Code Any city ar carry SIGNS HLECTRICA I,
a W 1'^ wh 1 I permit t all' 1 demolish, I y structure
�W pri:rt t alt reduce,dic.pplilad,for p rmit 11,1re d'i'tuad st,,rent SPECIAL CIRCUIDMISC.
f�yhat he s licensedpursoam to the provioons(ifth Contractor La (Chaptera I F TAI'
W<rp0 (commencing with Section](M ))of Uivision 3 of the]business and lkolcssions C11d0or TE MR METER OR POLE INST.
d 6 c K that he is exempt Ihawfirn t and the basis for the alleged exemption.Any vidition or 'BLDG/ADDITION ❑DEMOLITION
{i Section]1111.5 by any applicant for a Ircrmia surea,the applicnnl m a civil penally of POWER DEVICES 1' ❑FOOD SERVICE
not mom nano Eve bundrul dinars(x500).
Las nwnundtuc n IMI ' 1, '1'
� Pr..pc y,nr my ompl..yeea wllh wages as Ncinnle cnmpennn,ion, SWIMMING POOL IiLIiCI'It
F will do the work,and the armcmm is not amendeder(,acted for ik,(Sec.]f)S4,Business ❑�1L'R
4�1 m anJ Pmfexainns Gde:Tim Cnmma..rs Liceme IWw does nor upply m an owner mf OUTLETS-SWITCH&S- ' `
6 3^ pmpeny who milds or improves,herein,nnJ who Aces such work himself or thnmg
his own employees,provided that such improvement are not intended or offered for NEW RESIDENTIAL FLECIR SO FT
suit.IL troevaq the builAingor'inpmvemena is sold within oncya,r nrannpletion,Ibu SQ F.FLOOR AREA S/SQ.t1'.
e,hoddle,will hme abs bemlen of pre,mg,hal he dirk not build nr improve for pury
111 eofmle). Tom'
LJ I,as owner of the moN.y,am aselusively'nnlmming with licensed corruoo o,
aomo-uct Bm project(Sec]M4,Business and professions Ccdca'Ihe Currour ata Li- .1 - - - (Av/
,rose Law drws act applyo, nwnu of property who builds or i.,rwa@emoq rod QTY' �,PLUMBING PFRMIT I t' �' FEE'
who contracts for such projects with a contremr(a)live nxed purwomt to the Conlraalnry
I Ir
License Law. 111 11 I'I'ISSUANCE
❑ tum Lamnpr undu Set, ,I{&PCfor this reroan
ALI];It-DRAIN&VEyl'-WATER(EA) VALUATION
• Owner Data e�
WORKERS duOMot clurI ON DECLARATION BACK PLOW PROI'IiCI'.DIiVICE
Ihcrchy al marrod.o pcnuh'mrol uryone ofthe fn-a,I..g declarer.. V V
nIlmveuinal oide faints nu C'mili700 orGe ahoy ode,1urctun Wmkcrswa or h- UItAIN$-ELOOR,ROOF AI<I?A,COND' STORIES 'I'YI'L'CONSTRIJC'I'ION
_ e mk f r phich his
for by$,,tion 3]00 of(he Luhnr Code,fur IIs{mr6rtmnnm or the
work for which rM1is Mrmil is inwcJ. PI%'x1RES-PER TRnI'
1 have and will maintain Worker's Compensation Insurance,as reynireJ by Seninn
37W ofthe Labor Code,for the performance of the work for which this permit is issued. GAS-IiA.SYSTEM-I INC.4 OUTLETS OCC,GROUT' APN
My Worker's Compensation In-rnceca and Pnitcymnn ram: CAS-IiA.SYSTP.M.OVIiR4(13A)
Carrier—r}- 11olsey No.:s
CI: IPICA'li I Ii IV
"I'IONFROMWO KIi1IS'e6 ,WAS'I'H INTERCIiI"11)R
COMPENSATION INSURANCd ' /a I{UILOINO DIVISION FHIiS
(ThisscctinnnmJ nor lcm,npleaed it the pcmoit isfor ochandadid..11 B �y kS13 TR P
or less.) PLANCHECK FEE Z Lei !z
I amity that in the parforneeceofthc work tin which I icpennitisissueI I I SEWIiR-SANITARY- 'I MEA.NAI FT
not employ any person in any n,unner so nsm Mnmesubjeermahe Workeru'(„ _ ENERGY FEE
0 ,7.: sabot Lnwy nr California.Dim SE nr�'l&B- TVI ,EGTA GRADING tee
F7NOICE11)APPLICAN'P.Il:after making l his Ceti ificatc of Exemption yo ouIJ Wp'rL'R SYSTIN/RE SOUS E=BB
F ? Frame xobjed m the Waka^s Coml'ensalma provisions"find LuMr Cale„m nmst ION
lonhwith comply withsuch provisions or this permit shall be decnmA revoked. pV WATER SERVICE
Pa z CONS'I'RUCTION LENDING AGENCY OJ SQ.F, PAID
I hcrehynhloo bhuhcrc lenmmtrecfiu I lending agency lin IIIc Paid nrman'md arc Receipt
the work for which this plmait is issued(See NiG,Co,CJ
Q U Tl]IAL:
Lenden's Name
{L) LenAera Addrcm T AL: _�
I cattily that I have read this application and saute that the above information is a BUILDING E r
F+. tq corectingrec e:comply wim all Illy md,ouny oNinunces unA soma laws,'losing e. QTY. MECf{ANICAL PERMIT FEL'
(� Z huildin,,on,amction,and hcrchy awhoriz,mp,esamwives Ill'this city mart.,11111-1 the
SH15MICI 3H
m9ce-menlinnad prop,,by inspection parposes. PERMITISSUANCE OO
(We).,,aco,save,indemnify and keep harmless the Cly of Cupecona also" IiLI1C'I RIC 'EE
liabilities.judgments,costs and expenses is hich nosy in any way aeente against said City AUI HR OR ADD'ID MEC11. PLUMBING 'E
n rnmequence of the griming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH At.[.NON-POINT AIR HANDLING ONI'1'00 IBM)CFM) ...
H CAL FEE
MLC ANI
50111tC1i REGULATE)IS
AIR HANDLING UNI'I'(UV PR 10,000 CFM) CONS'I'RUCTION'IAX ,
Signature of AppllcanJComrro, Data EXHAII SI GOOD(W/DUCT) I IOUSING MITIGATION FEE
HAZARDOUS MATERIAE S DISCLOSURE
Will the applicant or future huildingwx ipant store or handle hazardous material HEATI NO UNIT(TO I(dd XX)BT U)
as detine I by the Cupertino Municipal Coda Cbap rr 9.12,tad the Health and Sufcy
Code,Scan....25532(a)^ III?APING UNIT(OVlIlt II1lI,W0 H'fUl
Yea VHN'I'll.Al'ION FAN SINGLE RES]D) PAID
Date Reedpa p
Will rhe applicam or Imurc builJing ce,upam use eyuipmem or devices which
emit hazardous oremr
air cinas as define)by the Bay Area Air Quality Manm
ageent BOILI{N-COMP(3DI'OR 100.00(1 ETU)
District? O
❑Yea r-1 No
IOlhliR-COMPfOVIiI<Itm INNI BTU)
I have rwdthe huznnhms mareriWs m:paim,ncnta under Chapter 695 oC Ire Culi- AIRCONDI'11UNER ISSUANCE DAI'E
From.Derltb Is Safety Gal,.Saint...25505.23533 a-1d 25534.1 rndertrd that If the NEW RESIDENTIAL MECH, SQ.FC .,�//•�
building does not currently have a tenant.thar it is my roe, miblliay e:notify the axupmt
of the rapromoena which..abs met no,to issuance of a Cenilicam..f Occupancy. 6/ U
Owner ,,ardau zed ager, Data 'TOTAL: ISSUI3D 1{V:
OFFICE