S 3902 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CjTY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
APPLICATION/PERMI T PLUMBING.MECHANICAL S 3902 A O 2
BUILDING DIVISION '4BUILDMGIPRO.IECT[DENTIFICATION. J .7
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'PTAL DATE
3 -2
OWNER'SNAMECONTRACTOR'S NAME,:
F.e£�ros NTLICN .
Y 3SS iTJ NIC COW #
i?in ,Toots U Gro g S 1
'HIT[CT/BNGINF.ER: LIC NO: ADDRESS: ❑ U ��
Ga D r7.v /.2--.7 -7
CONTACT: PHONE: :,.{' , i,',BUILDWCIPERMIT INFO 'I ++
/i•/1��y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
F,ee eras s/o 3oi D969 p- C3'- Cr�
LICENSED CONTRACTOR S DECLARATION T'Y -,'j ! ELECTRIC PERMIT' ! " / E
I horcb>affirm m t 1 licensed d p n. f Chapter 9(commending � r t . ....?t .. 1.' FF . ..,r JOB DESCRIPTION
OCZ with Section]000)of D ion 3 ofthe Business adProle„ton,Code and my license is
WOO PERMIT ISSUANCE
R
%W in full force and eitect. PDWL [I KITCHEN REMODEL
a-U License Class Lic.# APPLIANCES-RESIDENTIAI, ❑ADDITION El PLUMBING RE-PIPE
rF u1 Dore Contact
hprp ARI]il'ITiC'I"SDE ARATI PANELS LEC ❑MULTI-UNIT El STRUCTURAL
y ON7�. Ihnderstnnd my plans shall he use .public records MODIFICATION
OZ.,O UP TO 2INIAMPS E3 INTERIOR El CHIMNEY REPAIR
F`3 F'W
Lid en.ed Protricional 201-IMOAMPS map 9 IMPROVEMENT OSWIMMING POOLS
OWNER-BUILDER DECLARATION
ER (1W AMPS I hereby affirm that 1 am extr
empt from the Counselor's License Law for the OV [I BATH REMODP.LMEPAIR DEMOLITION
O d U following reason.(Section 9031,5,Business and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
F3 WO F. which requires a permit to construct,alter,improve,demolish,or repair any smeture 1%2 a.. -M_
�'7y� prlormits lssnance,also requires the applicant hhr such permllm Rloesigoed stnwnevt SPECIAL CIRCUIT/MISC. (-
F, y that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
dC) (ahmmencingwiW Serum.700OofDlvl,lon3eftha Business and P..founns Cods)or TEMP.METER OR POLE INS'T w'
M L Ooy� that he ie enempl Ihemfrom.lid the cosi,for Ne alleged exemption.Any violation of N11EW BL 1 ADDITION �0 yDEM ON
Xmty. Section 9031.5 by any applicant for a permit subjeenthoapplie.ntma civil pemlt,of POWER D VICES �'pNANT ICE
not more than Five hundred dollars($500). Ih1PRQ�CMP. �URV
=d El 1,as owner oftheproperty.ormy employees with wages as their sole compensation, SWIMMING OLELE IC
O olldemovamiir,and@ostrucm.ri,shintendedorolferedfors.[a(Seu 901 Business TRE
Lam and Poifes,im e,Cade:The Contractor's Lucie,Law does not apply to an owner of OUTLIUS-1 W I' I Ryir11 ES
pmpeny who builds or Improves thuum,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL R SQ Com.
sale.If,however,the building or improvement is sold within one yearofcompletion,the EIAOR AREA_-*- J S/SQ.FT
owne,ldilleno will have Oe burden of proving that he did not child or improve far per-
,we of sale.)
❑ I,as owner of the property and exclusively connecting with licensed contractors to TOTAL:
construct the p ivet(Sec.9044 Business and Podfics,ors C d )The Commi -sa s -
seLaw does not apply t fppny whuhld r improves thereon and QTY: Plt[JMBINO PERMP�! st l'"1' r� �r FEB:. f 8
who entracte for such prawns with ntth a conr(s)licensed pursuant to the Contractors ' /
License Law. PERMIT ISSUANCE.
0laneeres,u berSw. ,B&PCforthiSwmun
Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
r
rte WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 0 O O
I hereby affirm under peauto,of perjury one of the following declarations:
I have and tui 11 anainmin it Ceni frontal Coastal n self-imme for Workers Cooper- DRAINS-FLOOR,ROOF,AREA,COND. TORIES TYPF,CONSTRUCTION
,Ilion,ae provided far by Section 39(10 of the Labor Code,for We peruchumed oY the
Work hich this Permit is issued. FIX TURES-PER TRAP
woo
ave Ina wit l ode,fon Workers Compenmance of(be w Insurance,h required by Section
My of the Lahey Code,fonhsurance caned,and work for which this permit is Issued. GAS-EA.SYSTEM-II UTLETS OCC.GROUP APN
My Workrn Compen��Ii.,AInxuranw comerand Policy nu h
Carrico GY. FVAIo Policy No.: GAS-P.A.SYSTEM-O R4(
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCEGREASE/INDUSTRL WASTE IN ERC TOR r
117 d st m it a s 'B'" f3Tll
(This section need image complete if the permit is formic hundred dollumd$loop GREASETRAP q
ter les,J PLANCHECK HE 3Vl 7- 0
Leann,th.tin thepedrearchoo floe work for which this pumit is issued.Ulundi SEWER-SANITARY-STORM EA.200 FT. C
not employ any person in any manner so as m m
hecoe subject to the Workers'Curacao- ENERGY +BE / 3J
Z pLaws of California.Delo WATER HEATER WIVBM/BLECTR
Applicant
O Applicant GRADIN P,
to NOTICE TO APPLICAN'C If,after making thin Certificate of Exemption,you should WATER Sys'rF.M/fRGTING SOILS
ecubecomesul+jo the Worker's Compensation provisions ofthe Labor Cade as
you most
4S7 forthwith comply with such provisions or this permitshal be deemednvoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FI'. PAID
;Z) p Iherehy affirm lite Here ivawnswaimn lending agency Tonic peH'nrmance n( Dare Receipt#
V. F-t the work for wh leh this permit is issued(Sec.3099,Cie C L f Q
O ULender's Name TOT L. f
Lender's Address TOTAL
1canny that l have read this application d statethat the above informal is - _ h ,1j BUILDING PEE
�i-0 m
cmrtt I vgrce to comply 'tonall city d ryordinancesone sora lows rola) g mQ7,Qi MECHANICAL PERMIT s t•PrBE� +'
V Z build ng emnewctimn and hercbymthorm pesemodves of this cirymemerupon the + `f h ' SEISMIC FEE.
above-mentioned properly run inspection purposes- PERMIT ISSUANCE
(We)agree to save,indemnify and keep hornless the City mf Cupertino again, ELECTRIC PEE
Budd hies,judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the gmraing of this permit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WIT 1.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL FEE
SOURCE REGII IONS. � 4,/v,1
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Si`ore of App' nOC moms Data EXHAUST HOOD(W/DUCT)
HAZARDOUS MAI ERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle hazardous material HEATING UNI'I'(TO 00,11011 BTU)
as defined by the Copertinm Moruipai Chapter 9,12,and the Health and Safety
(Add.Section 25532(0)1 HEATING UNIT(OVER 100.00)BTU)
Oyes VENTILATION FAN(SINGLE,RESID) PAID
Will the applicant furore building occupant B ase equipment of dwitch Data Receipt If
dt hezwcontainmencontainment,dous air ncontainment,as define y the Bay AreaMana Air Quality Management BOILER-COMP(3HP OR IOO,fgO RTU)
fah T
E]Yes BOILER-COMP(OVER IIN1,000 BTU)
1 have read Oe hoeerdous materials requirements under Chapter 6AIR CONDITIONER95 of the Cali- ISSUANCE DATE
fond.Honda&Safety Code,Section,25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.EL
bulltlag dme_<ma Imre ly hnveatenant.that it is
ofmy responsibilit mnmtify the occupem / �. i�—
the�aireme hich via it, , oICa policy
..�� L!O \ ) l 7
ow ,an't, iesWgral Date TOTAL I I IssueD BY:
OFFICE