S 3154ADDI IrAMTTn cI I IN IKIEnRMATInN WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL
BUILDING PROJECT ByKNPIFICATION .
PE IT NO; /I
VV
3154
BUILDINGADDRE S:
7 eo/n/ 15�
SANH'ARY NO.
APPLICATION SUBMI'ITALDATE
OWNER'S NAME kONF::
CONTRACIY)R:S NAME: LIC NO:
NIC
❑
((('''{{{��� CONIROLp
0 V 36.
ARCUITECTIENGINEER: LIC NO'.
AUDRIi55:
)N'FACT : PnON ..
BUILDING PERMIT INFO
�� 0
❑Coresultant Fees Paid by Applicant (Initial)
BLDG y ,HEC PLUMB ME❑CH
rLJ/
LICENSED CONTRACTOR'S DECI.ARA'UON
I hereby affirm that I am licensed under provisions of Chupmr 9 (voicanea
wim Seniom]INM))nf Uivision3 m[me Nosiness and Prnfesslnns Code, and mylicens,.
in full force and effect.
QTYi L•LF;C'PRIC PERMIT PEE
JOB DESCRIPTION
RESIDENTIAIG
❑SPOWI, ❑ KITCHEN REMODEI.
PERMIT ISSUANCE
License Class LichAI'1'LIANCES-RCS[DP.N'T]AL
Dao Contractor
[]ADDITION❑PLUMBING IPP, -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIIyCA'I'ION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
ARCHITECTS DECLARATIONq
nndersmnJ my plans obeli be usul us public arvnds
\NIi1.5
Il ')02fX1AMP5
Licensed Pmfesuinll
201- AMPS
OWNER -BUILDER DECLARATION
I hereby affirm that I on exempt from the Combectnr's License Law fur the
following reason. (Section 7031.5. Businesx and Pmf.cmus Code: Any city or county
❑ BATH REMODELIREPAH1 ❑DEMOLITION
❑ OTHER
OVER MIAMI'S
SIGNS IH. ','RICA].
which rt fmic, o Permit to construct, alter, improve, demolish, or repair any suun ce
prior to its i.waanre,imastmecsme applicant for such perrnirlo 111, usignademnnanl
Ohm be is licensed mane of to the pmvieions oflhc Contractor's License Law (Chapter 9
(commencing with Section 70g) ofEbolon 3 of the Business and Professions Cori
SPECIAL CIRN�IIIIFDMISC
FEMR METER O'I'OLE INS1.
COMMERCIAL:
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
Section 7031.5 by any applicant fora permit ahjaR+the applicant to. civil penally of
but more than Five hundred dollar, PISMP
LII, as owner ofthe property. or my employees with wages as theirsole c,mlmvadon,
1 will domo work, andtheunictimisnrn lmendedmoffered formle(See 70I4, Business❑OTHIiR
POWER DEVICES\
❑'TENANT [IFOOD SERVICE.
IMPROVEMENT
SWIMMING POOL LLE RIC
!and Poscomea Code: T'he Contractor's Larose Law does not apply to or ,watt of
Of, FLI U3 -SWITCHES- F� TURKS
groped who builds nr improves meremn, and who deva such work himself., through
his own employees, provided that such improvements are not intended ,r onered for
sale. If,however, the building (it Improvement is sold within one year ofnrmplelion, the
lder will have the burden nI' proving that be did not bund or improv, far line-
NEW RESIDENTIAL HIJTCTR SQ FF
SQ. F1 FLOOR AREA
S/SQ. Irr.
\
pnnerbui
e of noted.
❑ I. a owner of the property, em exclanb,ly canteen, with Iiceread cnmW mts to
TOTAL:
nrabeat me project (See. 7044. Business and Professions Code.)*Bw Conham0rs Li-
i-ul.use docs not apply to an owner ofpropany who builds mbnpmvcs thereon,and
cense [.use
QTY, PLUMBING PERMIT \ FEE ,
whocomracts forsuch projects with ecommcmda)licensed mountain the Commaa's
PERMIT ISSUANCE
Loame Law.
❑lam exempt under Scc. ,tl&PCfor this reason
AI:I'ER-DRAIN&VEN'P-WATP.R(P,A) \
Owner Dater
VALUATION
BACKFLOW PRQI'ECT. DEVICE
WORKER:SCOMPENSATIONDIiCLARA'11GN
p na y o g
hereby affirm underIt f perjury one of me bellowing declarations:
❑,have andwill maintainstion 37M of the Lahr Code, the Workersce of
ting as provided for by Section 3]00 of ,M1e Labor Code. for the performance of me
rk for which this proof is issued.
UItAIN5-FLOOR, ItOOP,AREA, GOND.
STORIES'
'PYPECONSTRUCTION
FIX 'I'UltliS - I'ER'I RAI'
-J 1 have and will maintain Workers Compensationmeantthw Insurance, as required t issued
3700.1 the labor Clde, lint me pul'urmunuenf the work for which this pcnnil is isnucd,
OCC. GROUP
MIN
OAS -CA. SYSTEM -I INC. 4OUTLETS
My Worker's Compensation Insurance carrier and Policy number are:
Currie: Policy No.:
GAS -EA. SYSTEM OVER 4 (EA)
CERTIFICAT E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCI?
OREASI%INDI15'rRL WASTE INTERCEPTOR
-
BUILDING DIVISION PEES
(This section nein am hat completed ifne permit is barium hundred dollars(SIM)
or Icssl
GREASE. TRAP
.ANCIILCK Mf?
SEWER -SANITARY - STORM EA. 200 FL
I ocnify that in me pednnnance ofthe work for which this pambit is issued, lshall
no employ any person in anyneanneraons to become subratto the Worker, Coir,.-
E GY FEL.
".R HEATER W/VENT/ELECI'R
'anion Laws of Culif,miu, Dam
Applicant
GRA NG FEB
NOTICE TO APPLICANT. If, after making this Cenificate I J
become subject to the workers Compensation provisionsal .a nr Idc, yea one
forthwith comply with such provisinm or this permit shallM deemed reduce. •
forthwith
t
FF SYSIRMGREA'ONG
��� (yO
SOILS I B
sued prior
CONS'I'RUCTION LENDING AGEN n [[pa^a��r^S �j
I hereby a0irm that mere is a constraclion lending igen ;IY victor W
the work for which this permit is issued (Sce.3097, Civ. C.)
PAID
m Receipt4
�tl�pR,pppp
o rmiLraGea lip"p.
p
erecting
lender's Name mGnnnele[iity
TOTAL:
visions On 'I'OTAI,
Lenders Address /�/�pk pCC
1 cen'dy that 1 have rend mr, application and sole that
BUILDING FEE
ytYryY�Jj '�1.�1I�
Gree. l agree m comply with all city and county ordinances and 0state anY�"'T4"
building construction. and hereby aulbmriae mprtsemmivc.mrd 11
�p
"� Tr�ntS. MECHANICAL PERMIT FEE
-
S171SMIC FEE
ahove-mentioned property for inspection Puymces. p ��a� /�/�a�
(We) agree m save, indemnity and keep Onaless did C1�8FM15wIgIigMTM
Or C'
ELECTRIC FEE
Iiabilitics.judgmenw, costs and expenses which may in any way accrue against saiJCi
in arm ...uence of the grunting of this permit.
I'E F32GD U .H.
PLUMBING FEE
('TO I0.000CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITCMI�f1N-POI T
SOURCEREGULNOONS, ff �M
R LING UNIT (OVIiR II1,IIfgC
CONSTRUCDON TAX
Signature of Applicant/Coamobir
HAZARDOUS MATTRIAI.S DISCLOSIIRI?
FOOD (W/DUCO
HOUSING MITIGATION FEE
Wilt the applicant or future building occupant store err handle hazardous materialWiiaer_
as defined by the Cuper iso Municipal Code, Chapter 9.12, and Dow nd SI f
Cale. Section 2553201] Dowand
HIiATING UNIT (TO❑XI
UNIT (OVER 100,000 BTU)
E] Yes El No
PAID -
Ua¢ Receipt
VENTILATIONFAN (SINGLf:RESID)
BOILER - EOMI' (3HP OR IIl(hIXXI BTI,)
Will the applicant or future building occupant use equipment nr devices which
mil h:mrrdous air contaminants as Defined by the Huy Arca Air Quality Management
�)is tricR
❑Yes ❑No
17 T
BOILER- COMP (OVER 100.00 BTU)
AIR CONDITIONER
I have mod the hurmdnas mumri0ls regmmmems under Chapter 6.95 of the Cali
Lrmiu Ig does&Safety Cldc,Sections25505, is my i,a25500,lead eomnd ,hatifin
building does not maillywhich have amnant. to
it ismyof
mcpancy.m
/ISSUANCE
1 iC1�J
NEW RESIUCN'I'lAL MI'CII. SQ, PT.
caleofy
pior I, any
of the myuirtmenu which must be and prior to issuance ofnCenilicme,f Occupancy.
1/ -
ISSUED HY:
TOTAL:
Owner or untrimmed agent Data
OFFICE