S 3151 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER9'INO BUILDING-ELECTRICAL ITIOMIT NO.
BUILDING DIVISION APPLICATION/InERMIT INAJMRINO-MECHANICAL S 3.151
: MUILDING PROKr
AECr IDH1FICA1'[ON .
BUILDING ADDRESS" SANITARY NO, AITLICAI'(ON SUBMI I IAL DA'I'li
s-7a-f v, 2 _QB
OWNA ::NEkS I'llf�li: CONTRACTOR': Mli: LIC ):
�} C NIC CONTROL It
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ARCEIRT:CT 'NGINFEW LIC NO:� 1 Allay IS ST 5 S/LS ❑
CON FACE rnoN1 ✓ „ BUILDING 11FRMITINFO ,
�6� R �.�d ❑ Consullunl Fee.Paid by Applicant(initial) BLDG ELECT IT CR
❑ m y❑
LICENSED CONTRACfORSlyl C1 DECLARATION QTY ELI CTRL PERMIT } 1 FEE: /
GC II by tfit'nth I h J p fCla1t y( ,g _ ' ',
, 0C, xshs r ](X0)dD "m3nnhe¢as n+ores%stn cde,andtnrEee .•', ` ' JOB DESCRIPTION
FWD urfullforceundeneef PERMIFIISSUANCL RFSIDENTIAI
� 1- License Clns ` C' Lic% 1 ❑SFDWL ❑KUCHENREMODEI,
F-ZW Date Qsmmcmr AI'I'LIANCIS-KESIDE:NTIAI' ❑ADDITION
H Q 6 ❑PLUMBING kH-PIPE
p„❑m AKCHI'I'I!(T6 DFCLARM ION PANELS ❑MU11 I-UNIT ❑STRUC NRA].
Z O,�/y'Z 1 ndelEln deny pltnesh.IHw.scda,m tic records
O z-GOP TO 21X1 AMPS MODIFICATION
r'4, w Lleenwill11 nle..tonul El INTERIOR [I CHIMNEY BE'AIR
Y ,, OWNER-BUILDER DECLARATION 201-IIXIDAMPS IMI-ROVEMPN'I' E]SWIMMINGPOOLS
C W Q 1 hereby union that I am exempt from the Csntraeasr's License Law for the OVER 100DAMPS ❑RAIN RI:MODEIIkEPAIR ❑DEMOLITION
aO L U following meson.fgedinn]Ip LS,Business and Pint sums Code:Any ratio r an ah, ❑OF HIT
U.- x',,J y R if f t h D d I'h p"an y-1 intoe SKINS ILCCI'RICAL
~y N.Q.I Prix t I. q h OpI f : hp. n fl 'g Istructural SI'ICIAI.CIRCIJI'I]MISC. �Pt-TZ
fhtllc licensed Esu rte the pr ve
sn.'If'he C. atcloev Due—Law(6mupr ) ' 1 f
C->tc (colnmencingxith Seetinn]lXX))of Division 3ofthelloone%ssndl'rel...ion,Crde)rr
u1_p0 TEMP MITER OR POLE]NST. ER 11'
d W o C That he is exempt B'crcfmm unlike bnsis for the allege)cxclnptil o Any viulmiun of ❑NIiW BI.UGIADDITION ❑DFMOLI'I[ON
m Section]11.1.5 se any red dons fin a pu'lnil whjccts the uppllrnnl m u civil Prnslly nl 1'0001?R DEVICES
z< not more loon five nunJreJ Anular%(S5f0). ❑TENANT' El FOOD SIiRVICIi
❑ I,Iwtwncr of thin pmpeny,onn 0,xe punas IMPROVENIEN'I'
SD ycmpoyces wi gu toroda(Sol,7044.ane ties. SWIMMING POOL ELECTRIC
Fo will dmhesiork,ColCodo: sfeCmarar I.IlmoJe La,dofi:amvEp Y1.mr —actor {{ER
63w
oildatywhob hko,Thin Comnranh Liacnvs Laxdoesnmapplym It —act of OUTLtiLS-SW'1ICHGS-IIX 1'IIRES
progeny who binds or improves thsuch u pr whn does wen work himself er fwd let
his own employees,providedbuilding ]nal prom mentnvemnm thin not intended or offered I'or NEW RLSIDHN'I'IAL ELI?CTR SQ II'.
sulc.IChlder clip sethn andennrvemem is sold within one nuor andplle ilopno - StT Fy FLUOR ARBA $/SQ.Cir L
s ur-huuWer will harvethc hunlen of pmving that he did tun huilA lir Innpmve for Pur- liJ1�
Pow nl vsle.).
❑ 1,as owner ofthe property,am exclusively contracting with licensed canlmnnr%fo 101AL:
list- tJ F,,d,,I(See ]111111 . dPf CJJl Ill,Cts sC
ttaa La J t pply l f p pony h b I I ) n uW I '
who t ca for such pr QTY. PLUMBING'PERA7IT;' FEE
P Iwt w th n coon mr(v) toed nm to Cr mrtaars
License Law. /1 am exePERMIT ISSUANCE
Ej nnpt under Sec. B R 1'C tin this re:.ann
Owner Date ALTER-DRAIN k VP,N'I'-WA'I'ER(EA, VALUATION
WORKER'Sntlyol.NSATION PIiCe 6.11—ON HACK FLOW PRITIECT DEVICE
1 hemhy slur,m unJer penahy of p July one of the Billowing Jcdurumme
❑ I have and will nmintain a Certificate ofConsenu l.11huuvre for Worker's Compery DRAINS-FLOOR,ROAD.AREA.GOND.
satins,as provided for by Section 3701 of the Labor Code,for the irrfom ounce of he STORIES I PI?CONSTRUCTION
wed 1'or which dr,pcnnil ix,yard. FIX'I'ORES-PER]RAI•
1 lime and wdi fea r mi r Walker',Compensation Insurance.as required by Section
3000 of the Labor Code,for the pe,fornmomenfthe work for which thus perm is issued OAS-EA.SYSTItM-I IKCx011'TLETS
My Werke CuIn veto rantl Policy OCC ONOIII' APN
wax...hie �1te�ar�
Carrier: 1Sail y Nn.. X66 GAS-EA.SYS31?AI-OVIiR1(1eA)
Cp.RTIFICA'I Ii OP EXE.MI'I'ION FROM WORKERS'
COMPENSATION INSURANCE: GREASDINDUS I III.WAS FE IN I'ERCEPI OR
(Thio seelftn need not h rma,ilfed film permit is borrow hundred dollars($kX) [HOLDING MVISION 19BiS
Ill less.) GREASE'I'RAP
Icenif Ill.' PI.ANCHIFCK FEE
y pnfomenccoffMwmk for permitr ir,'Contactl UNITARY-STORM 17A 21X1 FT
,Z noten,Law very Carlon in any manner%on%m becona suhjecun the Worken'Cnmpem SEWER ENF.kGY FEE
%mien laws of Cullfnrniu.Uulc YY
z Applicant 1 NAT ER H FAfER WOVEN'I/ELE(:I'K
D`J GRAVING FET?
NO'T'ICE TO,,to he ANTWork ,,C pala'arvan pr visions at of E aboplinn.Centro rl you null WAIF,[SVS'fEM/I'RIiA11NG
a bechusilhouno dnc Workerskion—smionmooth hal oft he Labor ko younal" SOILS Fee
femtwiln celn,ply rant phren pmdsn,x..m mi.,perms.ran be deemm reeked.
Q WATER SERVICE
ow
CONST RUC'I'[ON LENDIN
.7 z G AGENCY NIiw RESIUGN'1'IAI.FILM B. SQ.PI'. PAID
us work
Itaby ali Oil,rm uhereisacnn(Sea3nl7,Cim.agency for perfnnnanew of Des Reaipfp
us Nthe work for which This pcnnil is i.venvJ(Sm,309].Civ.C.)
Lender,Name
O U Lenders Address D TOTAL:
y M1W, I slylkl l l' ad thi 1pl' on I 1htE ab r 1i.s - I1111LId NO FEE
N cerrcm I agree in coniply Mill all city and county mourancesand state laws belf.filigx'
C.)
building representatives QTY
worebyamnarzeoflh 'lyftemer upon the , MECHANICAL PIiItMIT FFIZabovo-reenlrnGd pmolaric Inr impwtirn purrynev
L SEISMIC FEE
PERMIT ISSUANCE I
(We)1,am ,,it savq indemnifyendkeep nay ina.One City of Cupertinoid City ELECTRIC FET:
inhilitiaftereof are may in any wiry uumwgainsf said City AMERORADD'I'OMRCIL
nsCANIc Nfoegranting SthusD WIL PLUMBING FIiIi
APPLICANT UNDIik$TANDS AND WIh1.COMPLY WITH AL1.NON-POINT AIR HANDLING UNITCIO 10.(XX)CFM)
.SOUkCF III' MEC MEClln I AL 12.
AIR HANDLING UNIT(OVER 10,000CFM) 4 NST[ ION
Signal v it ApplkunJCrntrndor Date EXHAUS'FHOOy(W/DUC'n
I IAZARDOUSMATP,RIAIS DISCLOSURE - 110 SIN A I 'EE
Will lheapplicmfl lir future bundingwcupant%term lir handle hazardous material HENFINGUNf1'ITO 10000OBTU)
m)dined by the Q llmin r Municipal suit,Chapter 9.12 and 0e Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100,8(1(]111 U)
❑Yes ❑No
VENT'ILA'TION FAN(SINGLE RESOD) PAID
•
Will the applicant or future holding occupant use equipment our devices which ci t 4
mil h:manlit air confammant,mdufinedby the lCm All,Air Quulhy Mmmgunat HOILER-COMP(TUIOR 110,1111E BTI)
Dr,ana:'
E]yes C]No BOILER-COMP(OVER 101.000 BT U)
I have real the harudous mmelals redromomms under Chapter fi 95 of the Cali- AIR CONDI I'IONFR
Tomas Hoaa k Safery Cale.Sections 25545,25533 ani 255,U.I understand Thal if the ISSUANCE DA//'PE
hullrlingdo rall1. Ylnlbeatrnunl.thatlO'm pons Y Y Pasant NEWkP51OI1Nl1A1,MIiC11, SQ IT. 2
Y yres Imillt In omit the mine J
of Nin regn�\ @r r t M neral prior u.......sine of.a Ceniljca of Oce rync
Own au Lnrizerl agent ( 1 we TOTAL:
ISSUED BY:
OFFICE