S 3143 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEWIT NO
BUILQING DIVISION APPLICATION/PERMIT PLUMIfING-MECHANICAL 3143
nU11.O1NG YHUJELT IDF.NI'1FICKfION
GILDING AD Z RESS: SANITARY NO. APPLICATION SUBMI'I'I'A1,DATE
f
OWNF:H;S'NAME: PHONE: ,�� CONTRACTORSNAME: LIC NO:
am& W L N/C CONTROL 9
.CI IIT!C'I'/ENGINEBH: LIC NO: ADDRESS: ❑
Pi—
BUILDING PERMIT INFO
L ❑ Consultant Fees Paid by Applicant(Initial) BLDG E1LEM PLUMB MfEC�H
LICENSED✓NP-0 CONTRACTOR'S DECLA ATO ^b u u u
1 hurchy allirm can I nm Iloomod antler provisions of Cm,t,,9(vummcncing QTY' ELECTRIC PERMIT' FEE JOB DL'SCRIPTION
WWW�O Zp with sordom8to0)of Division 3a(the Businessand Pmfe„ions Cusi and ntylicemeis
yl F- in full force and e(fen �S..g� 6� PERMIT ISSUANCE R�S,I1ENT_IAL,
U U Date Clu,s Lic,a JO( O ['$rFDWI. El KITCHEN RIiMODl1.
FZW Dae Commaor `� AI'I'LIANCE.S-RESIUIJJTIAI' C3 PLUMBING RE-PIPIT
rn Q 6 ❑ADDITION
FHN A HH'IiCTS DECLARAT ) PANELS ❑MULTI-UNIT ❑STRUCTURAL.
OZ4Clu duty also,sh:Jl he used us public records
O Z- MODIFICATION
W Licensed Pad n: 11PT02f10AMPS ❑INTERIOR ❑CHIMNEY REPAIR
s1 �` 201-1000AMPS E]SWIMMING 110015
-� O.,lam H)ILDIiR DECLARATION IMPROVEMENT
W Q Inreby ammt that I am exempt tram the Contranors License law for the OVER 10NIAMPS ❑BATH REMODEL,'REPAM ❑DEMOLITION
LL U following lean.(Scolio,,]031.5, mline,x unit Profession,Cala:An t t ❑Of HER
Y city nr coon y SIGNS I?LIiCI'RICAI.
which requires a penmt m cenuma,alma improve,Demolish,or mpa'v any structure M ,n
prior m its issuance,almre requires then aero gnu
y yu applicant for such +TOLElea,+signed SPECIAL CIRCUIT/MISC.
<i IhaheislicmtseJpnrsuamtnthepn+visionsnftheCnntrnnar'sLicenaeLuw(Chupmr9
W 40C (commencing with Station 7000)of IN vision 3ofibe Business and lhofessinns Cale)or TIME.METER OR POLE INST, I
4 q o y
that he is exempt therefrom and the basis for the niteged exemption.Any violation of ❑
iYCI lyi
Section 7031,5 by my applicant for u penal Isubjects the appl icam m a civil penally of POWER DEVICES Bl O DDI EMO
t more than five hundred dollars(3500). ElNT' ❑FOOD CE
=Q ❑ L-1—'allof'he Propiny,orIlly employeawall a,c,;,,their.wdewrnpcmvutlan. SWIMMINGPOOL ELIiCTRIC
F 'll do the work,and the structure is not intended or offered bootie Sec.]01sIT'p'a'�'g'�''r4,Business l HEROI O 1999
6 3 and Pofexions Come:The Cammleal Live ve Law doe.,ao'apply it,xw
o nacr or OUTLXFI'S-S WITCHES-RURES
progeny who builds or impnrvco thereon,and who does ouch work himself or Ihmugh
his own employees,provided that such impmvemcnt,are not inranJed or offered for NEW RLSIDEN'1'IAL ELEC:R SQ
sale.If,however,the building or improvement is said within one y<arof onntpletion,the 'Q F.
owncabuildaf wil l have he burden of proving that he did nal build or matin,far aur- /[(
❑pose as own. 'I MII�kAe TT S
I,as owner of the maturity70,1 ,B exclusively contracting with licensed eontrbnon m �7
construct the project(See,]IN4,Nosiness end Profes,inns Code:)The Contractors Li- C
crow law does not apply as an owner of Property who builds or imposes thereon,and QTY. PLUMBING PERMIT FEF: 22/b
who contracts for such projects with n amtracor(s)licensed prmrOnLls the Conlruclau s L/uIk
License Law.
❑ I am exempt under See. ,B A P C far this ream,, PERMI9ISSUANCE
tuner
ALTER-DRAIN At VENT-WATER(ITA)
Date VALUATION
WOR ad,,penalty
COMPENSATION DECLARATION BACK FLOW PR(TTECE DEVICE
I hereby allirm under penalty ml perjury ani ill the hollowing dcclarul...... >
]I have and will maintain uCeoificammConsennoselGim; fur Workee,Compen- DRAINS-FLOOR,ROORAREA.COND. oo L)
atka,as provided fill by Section 3]11(1 of the Labe Come,far the perfom+:mce of the STORIES TYPE.CONSTRUCTION
work for which this permit is issued.
IEXTURPS-PER TRAP
❑1 hum and will maintain Wmrke(x Compensation Insurance,as required by Section 2 SFoo�.L
3]1X1 of the[.shot Code,for the perfornm,,mof the walk to,which thio acrotic is loncd, GAS-EA.SYSTEM-I INC.4 Guru..'TS
My Work p•matioafpum arricruad Policymmijamme, OCC.GROUP ANN
Cartier: m _Policy Nu.: GAS-EA.SYSTFZM-OVERAIFA) }�
CL U71oil XEMoI'[ON FROM
36927oti
COMPENSATION INSURANCI; GREASI%IN'DUSTRL WASTE.INTERCEPTOR
(This section need not M completed ifar Peron 1,far we hundred Jnllit,($101) BUILDING DIVISION RPS
,it less) CIR17ASIEIRAI' - - �sp -
Imrilythm in theperfmmanceofthewark forwbichthis PLANCHECK FEE Iv IJ1
permitiNi„ueJ,Ixhzll SEWER-. STORM EA.NX)FT. vl
zFor en+ploy uny pemnni annerso a,to become object to the Workers'Camper- SANITARY-: FNI7RGY TTI'
cation Laws of Calitbmia.Dn �.
z � Applicant WATER HEATER W/VF.NI'/L'LECI'R GRAI ��E
NOTICE TO APPLICAN'11 IL after looking this Ccrificntc of F.xcn rum,you should WAFER SYSTF.MOREA'I'ING
a ; hen+me subject to We Worker's Compensation provisions of the Labor Calc,you must SOILS
FOE
w forthwith comply with such provisions or this permit,hall be deemedmooked. WATER SERVICE
o // -Y o79XL
o z CONSTRUCTION LENDING AGENCY
NEW RESIDENDUAL PCMB. SQ.IT. PAID
UO Iis issuedherebyaffimtlhatlhereisaconsamction[endingagency(orthePerformanceof [)am accept )yJ66o
L, F the work for which l his permit (Scc.3097,Ci¢CJ
O U Lenders Name TOTAL
Lenders Amines, l r A
pW„ I clarify that I have mad this application and state that the above he...der is (/ BUILDING 12EE
UV) correctl agree to comply with all city and county on inancev sad star,laws relating to QTY MECHANICAL PERMIT FEE
buidingcamoruetion.trod harchyontm
bmiec mpronunives of this city ocmcrupnn lilt SEISMIC Finl
above-mentioned pmpeny for inspection purposes, ZZ b
PIiRMIT ISSUANCE / Q
(We)agate m sure,indemnify and kith harmless the City a(Cupertino s against ELECTRIC PFai
in
the rural and ft his expenses which may in any way accrue against said City ALTER OR ADD'TO MECH. /
m APPLICANT
UNDERSTANDS
SlANp WILL
PLUMBING FEE Q
SOUR CAN"f UNDERSTANDS AND WILL COMPLY WI'ffl ALL NON-POINT Alit UNIT LTG 10.01X1 CFM) L
SOIIHCLPI')CATIONS MECIIANICAL F'cE r O O
AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTION TAX
Signa IA"Im Conlmcmr ])are E%HAUS'I'NOOD(W/DUCD
tIAZAHDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE O
Will the applic,in or future building occupant Nomor hanJla bazardurx motorist H HA'T'ING UNIT U 0 I(XI,IXXI B I'U) -_
as dclinW by the Culmina Municipal Coadc,Chapter 9.12,and the Health and Safety
Cale,Section 25532(a)F HEATING UNIT(OVER ladt )PTU)
Fl Yes [-1 No qp /Ji/(N_(_
VENTILATION PAN(SINGLE BESIDE PAR mar ��'� t
Will the applicant or(inure building occupant use.Air Qu or Mina which Dae ecetpt p
til haseNnus air enntaminanls as JeEned by the IJay Aree Air Quality Managimenl BOILF.H-COME'(3HP OR 100,000 BTU)
Dismin^ T L:
[_1 Yes ❑Nn BOILER-GGMP(GVEiR IfN1,INX)13TU) /f
I have mad the observers materials requirement;under Chapter 6.95 of the Cali- AIR CONDITIONER $S 9 E ATE
famin Heallh A,Safety Calc,Simians 255(15,25533 and 25534.1 uudcmmnd Lha if We NEW RESIDENTIAL MECH. SQ.FT
building does not currently have a mount,that it is my responsibility u+near,the accepts
of the requirements which most be met Friar I)issuance,era Certificate of Occupancy.
Owner or authorized ager, Date AI' (�
ISSUED BV: R
OFFICE