S 3254 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..ELEcrRICAL PE RNO.
xWILDING DIVISION APPLICATIONQ'ERMIT PLUMBING..MECHANICAL 3254
BUILDING PROJECT IDFN'ITFICA'1'ION
BUILDING ADURIiSS�
SANITARY NO. APPLICATION SUBMITTAL DATI
ER.S NAME PHONE CUNT A'ZOy NAMIi: LIC NO:
U ✓J/�1N z5'3-Y3 a' UNEa�/ As L N/C CONT Rol
RCHIPECf/INGINEIA LIC NU'. AD FSS: ElC.4'gG"G /Cwi.J S5o C l iGr EA, TO
CONTACT_: PHONE. _ 11 HAJINGPERMIT'INFO
��
/( 2y ❑ Consultant Fees Paid by Applicant(Initial) BLDG ruicl PLUMB MCCH
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT LE
1 hereby union that I am licensed under provisions of chapter v(commencing lOB DESCRIPTION
0'rZ with Smion700(bol'Division 3ofNe Business and professions Cwle.anl my license is CYC RFSIDENTIAL
❑100 PERMIT ISSUANCE a.�
FLL— in full fimemal effect. ❑SPDWL ❑KITCHEN RIiMODEL
aVU License Class Lica APPLIANCES—RESIDENTIAL. ADDITION ❑PfAMBING RE-PIPE
NCL Dote Contractor
FO,a, ARCHII'EC'TS DFCLARA'FION I'ANF.LS ❑MULTI-UNIT ❑STRUCTURAL
Z O Z I undcomnd my plane shall he ua,dl le pablue record, MODIPICM'ION
OZ--'0 UP'I'0200AMPS El INTERIOR El CHIMNEY REPAIR
F4f—LL Licensed Professional 2014000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUTLDL'R DECLARATION OVER 10(IIIAMPS ❑BATH RCMODEIIREPAIR [I DEMOLITION
6 I hereby amrm that I am exempt plain the Contractors License Law for the
O6 V fnllnwing real(Section 7031.5,Business and Professions Come:Any city or county SIGNS ELECTRIC ❑OTHER
u13 LL y which requires a permit to construct,alter,bnprove,demolish,or repair any stmemre
�f9�6 prim to its issoneg ale'requiresmen,llmnl farsuch pennil,,Bleoeignedstatcment SPECIAL CIRCUI'I'IML
a� that he isleGensalpnoatnntill(he pmvisionxoftheOnntracto",License Law(Chapter 9 QPMMERCIAL
(commeneingwith Scetin i 7(007uf Di...inn 3nf the Busum,,lnd Prole....c,Cade),, 'I'FNIRMETERORPOLE S
S m c, That he is exempt therefrom and the basis fair the alleged exemption.Any vimmlon ofNEW BLDGIADDITION 1-1DIWOLI'I[ON
m Section 703.5 by any affluentfor a permit subjects the applicant In a civil penally1',of POWER ❑TENANT ❑FOOD SERVICE
ZY
not more Nan five hundred dollars 015000. OTHER EMIiN'1'
_Q �1,as owner of the pmpeny...... ge
employees with was as ohcirsnlecnmpensntion, SWIMMING( :LECTRIC
0 will do the work,unit the stmmure is not intended ontBered for sale(See.7044,Business ❑QTHER
3 and Professions Code:'Phe Con owun's Llccnse Law does not apply to an owner of OUTLETS SWI'fCHL. TURFS !r•
pmpeny who huilds air improves thereon,unit who doer such work flooell air through
his own employees,provided thin such impnrvaman,are Bol intand ii or offered for NEW BESIDE .Til >C'I'R SQ IT.
wIe.ILhowever,the buildingerimpmvemm�t ix sold within one year ollin eom,the SQ. >I'.FLOOR AIt AREA SISQ.IT.
owner-builder will have the burden of proving that he did not build or improve for pur-
1of sii
I,as owner of the property,an eactmivcly contracting with liceannl eontmmors it. TI
onsoua thees not (Sec.nan tner ofsandrtywhProfessions buids al or
Cnnmedor's Li-
cease Law noes not apply ic an owner of property who licensed
air imptovm thereon,and QTY. PL P MIT •Ff?F
who contracts for such Pmjeau with a emmmwmr(s)IiuenseA puesuunt to the Qimrudnr'x I A
License Law' PERMIT ISSUANCE Q p 3 8 1
1 am exempt under Sea P:. ,li& C I'or This reason
4091 1 ALTER—DRAIN&VENT—WATER(IIA( VALUATION
WORKER'S COMPENS PION DECLARATION BACK ROW PROTECT,DEVICE
I hereM1Y eRnn under penalty ofµrjury one of lbs following Jaiamtians: �LVJJJ J
✓ I have and will mainuin a Certificate n(Consent to self-Insure for Workers Compen- DRAINS—FLOOR,ROOF,AREA,COND.
sminn,as provided li,r by Section37(NI of the hsWr Curie,fin
flue perform...of he STK 'fYPH CONS'kRUCfION
work for which this pennil is issued. FI%TURBS—PER'1'RAP
Q 1 have and willne...tam Workers Cooq,muadon Insurance,as required by Secon3700 ofNe Labs Code,to the peforman.ol the work for which l his wroul is issued. GAS—EA.SYSTEM.I INC.4 OUTLETS OCCI' APN '
My Worker's Compencnion Insurance carrier and y numMr arc: ..a
Catnco PolicyyNo,No.:
CI7kT11HCA'I'EOFE%EMTTIONFRWORKE /RS' TEINT R'EI'PO f S
COMPF.NSA'fION INSURANCE
GRI NDUS
BUILDING DIVISION PHS
(This section Iced not he completed If the pcnnit is for one hundred dollars($100)
air less.) GRI t if I PLANCHECK PEP,
I"of,Ihut in lhe,mlormancenl'I Im work for which lhispurmi(ix lsxual,Ixhull SE —SA — T PI'.
out employ any person in any ormar o ire ,become subiem In Il®Workers'Campat- I?NP,RGY FEE
ZZ scion Laws of Culifomlu.Date W HEATER W/VENT/ELECTR
2 Applicant GRADING FEE
NOTICE TO APPLICANT If,of er making this Ccnifted,of Eaemptium you should W I' SYSTEMOREATING
a , become subject to the Workers Compensation previsions of the LUMrr Gide,you must SOILS FEE
GU forthwith comply with such provisions or this permit shall he deemed revoked. W
Q
CONSTRUCTION LP.NDINCi AGENCY NIiW RF.SIDBN'I'IAI.('LMB. SQ.PI'. PAI
J 'z Yarn lO,nation
fullpe there isaconamc.i30leading agency Gar theperfnnnsnee of
W. the wow ser whmh Nla permit is lowed(ser,von,cis.c.)
Lender,Name
U Lenders Address
1 cer ify Nal I have mad this application and some that the aMwe infamutien is B G FE
to, correct.I agree ret comply with all city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
building construction,and hereby authorise representatives of Nis city reenter upon the
above-mentioned properly for inspection purposns
(Wu)agree I save,indearmly and carp hunNess flue Ciry ul'Cupcnino against PI'RMIT ISSUANCE .0 ?E D O
incoqueneofthe
craning of this esnot. cony in any way accrueuguinv sail Ciry ALTER OR ADD'IT)MECIL
InamseANT NDERS AN Sthisp WILL
1'hU FEC
APPLICANT UNDERSTANDS AND WIL1.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO III,000 CPM) Do
-
APPLICANT
CE t 1 ONS. ME:It .AI.PEIi
/— /-9 AIR HANDLING UNI'1'(OVER M."CFM) CON, UCfION TA% '2
Signumre of pplicunl/Cnnomcoor um EXHAUST HOOD(WIUUCf) HOUSING 1'1'IGgfION FEE
HAZARDO71 IL,
US MA'I" (ALS DISCLOSURE
Will the appllana or I'umrchuilAing nccupsm score or handle bs ;...ous mmeriul 1117NI'ING ON IT('PO 1(X1,000 BTU)
as defined by the Cupcnum Mm ieipld Code.Chapter 9.12,and the I IUJN and Safety
Cede.Section 25532(a)' IIEXIING UNIT(OVER)(0,000 BTU)
El Yes �No NIPAID -
VE 'ILATION PAN is RESID) DateWill rhe applicant or future building occupant use equipment or devices which 8011 ER—COMP(311P OR IW,IXN)BTU(
emit baccrdous air cournam anri as defined by the Bay Area Air Quality Management
District? BOILFR—COM('(OVER 000l
❑Yes KIN.��R[[
I have reset the hacudous maurials myuiremmts under Chapter 95 of Ne Cali- AIR CONDITIONER ISSUANCE DATE
fomes Health&Safety Cede.Sections 255115,25533 and 25534.1 understand that if the NEW REMDENTI AL MECH. SQ.14. l (�
Iryildi rine n)cum By have a terum,that it is my responsibility to notify the accupara 7
hIb GRA w h t ut betot prior In iswanec Bra Cem ate 9( cupancy.
Owner or a5morized agent `� r/ Date T L: ( ISSUED BY:
OFFICE 1