S 3384 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PET -�jJ
NO. w ^ 84
BURRING DIVISION APPLICATION/PERMIT PLUMIIING-MECHANICAL J "��l
BUILDING PROJECT EVEN I IPICA'I'ION
BUILDING ADDRESS: SANITARY NO. APPLICADON SUIIMITML DATE
l D l 00 DE ANaA &L v D. Z-ZS
OWNER'S NAME PHONE. CONTRACTOR'S NAME: I'IC�iO' NIC CONTROLp
R2mA01LLv WILL 650 848-4'65 DESi6N &1tl.D SYS—T, 4603,2,
ARCHITECT/ENGINEER: IC NO: ADDRE. ❑
S fell Assoc, R0• ox 236 6 s � 'is�s3 O
CONTACT: / PHONE: BUILDING PERMIT INFO
ALAW UR�10 /409) ZZf- I 1 STd ❑ Cansullanl Fecs Paid by Applicant(Initial) nu>G d.
LICENSED CONTRACTOR S DECLARATION 'fY ELECTRIC PERMIT FEF.
I nearby affirm that I at licensed under provisions of Couple,9(comtnamor JOB DESCRImON
nwz th Section 9(X0)ofDividon Sof the Businessend Professions Code,vnd my license ix RESIDENTIAL
�00 wt PERMIT ISSUANCE
�I _ mbullfmre.oul Re 460132 ❑SFDWI. ❑KITCHEN REMODEL
GUU License Lic# — APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RF-PIPE
FZW Dale�Comncmr
tn6s ❑MULTIUNIT ❑STRUCTURAL
ARCHITliLTS OECI,ARA'1'ION
PANELS MODIFICATION
ZO-c IunJersmnd my plans shall used usns puec
blic rords
OZc GY TO ROAMPS C1 INTERIOR ❑CI{IMNEY REPAIR
r--tw Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER BUILDER DECLARATION
1 hereby nlErm that I am exempt from the Contractor's h.irenw Law far tM1e OVER 1000AMPB ❑BATA RfiMOD REPAIR DEMOLITION
ippi55,�06 U following rcmon,(Section 70315,Business and Professions Code.Any city or county SIGNS ELECTRICAL. ❑OTHE
as 3 LL y which requires a permit m consumer.alter,improve,demolish,nr repair any structure
pFp.a'.Og Fixations issuance,also requires the applicant(orsuch permit o file a signed.slalnneal SPECIAL CIRCUIT/MISC.
2�y that he is licensedparsuain the,rockieuxaftheCoimmormesLicense Law(Chnptcri) COMMERCIAL
Im C (r0mmenringwith Smvon]0(0)of DivisiunloftheBminessandl'rofessians Ctde)or '1'EMP.MFTERORPOLF.INST. 01
6px..c C that he is exempt therefrom and the basis for ILe alleged exemption Any violation of EW BLDG)ADDII' DEMOLITION
W ern
Section 7031.5 by any applicam for a permit subjects theapplicam m a civil Penalty of POWER DEVICES ANT F SERVICE= not marc duan five hundred dollars($500) PROVE :NT
AZA ❑I,us nwncrnf the Pmpeny,nr myumpinyreswith wages axtheirude cnmFenvtinn, SWIMMING PWL ELECTRIC []OTHER
A 1.. will Jnlhe work,unJ lheswewmisnot in¢nJW oroll'ercJ Tarsale lScc.](FW,Business
{a�1�m and Professions Gde:The Contractor's License Law does nm apply m an owner , (IUD.ETS-SWITCHI3-PIX'1'URIS Z ..�J
6 3^ ,,,,Perry who huilds or improves thereon,and who ace,such work himself lir thrnnrb
his awnm
employees,wevided that such improveenls are not intended or offered for NEW RESIDENTIAL HLECIR SQ Ff. 4Jd'}
saJr.If,hoocia,de holding or imPmvemcen is sold within one year ofrourpltior.the SQ.F1'.FLOOR AREA C$ISQ.II'.
w
III owner-hvilder will have the burden of proving that he did not build or improve for par-
pave of mleJ.
I]h uz owner til Ne propeny,stn encluxively contracting with licensed mntracmrs m �• U
construct the aides,(Sec.70 1 nosiness and Proessiun.s Cale:)The Contractors Li-
ase lave does not apply m an.won,of property who lolJsor impmves therein,and QTY. PLUMBING PERMIT F' J
who contracts for such Projects with a comracmrfxf licensed pursuant o the Contrvcntrs
License I.ew. P17RMIT ISSUANCE
I ata exentptunder5ec. ,B&PCfor this rcasmt
ALTER-DRAIN&VENT-WATER(EA) A
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 203 d o
I hereby uEno under Penalty of perjury one of the following declamtitim,
I have and will maintain a Certificate ofConscm to self-insum for Worker's Courtier- 1 DRAINS-FLOOR,ROOR AREA,C.ND KiTYPCC S9'RUCTION
cation,as provided for by Section 3700 of the Lubar Code,for the performance of the
work for which this protan is issued. FIX'IURIS-PER]RAP >�
��3 1 have and will maintain Worker's Compensation Insurance,as requited by Sectio
5](0oflhc l.aMx CndeW,battle tend manmof me wask for whichthis permitis leaned. GAS-EA.SYS'1'F.M-I INC.40UTLFTS OCC GROUP APN
My Canis:rkeiy nlnGn�Y+O`ance canner
Pol cy Noyf^-��—``� GAS-L'A.SYS'I'I:MOVER 4(EAU wrrs
S,A CTF.RTIFICATE OF EXEMPTION FROM WOR KFRS' � &k w\
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE IN'I.RCEPTON DB,DING DIVISION FEES
(This,inuumucednrnhecompleded ifthe pemtit isformahundrtddollan(SEXR GREASETRAP or lewd PLANCH 'K '
Irerify that in in any mmanceo a, work Rtrwhlijed Is,per Vorks'Ccampr- SEWER-SANITARY-STORM EA.2(0 FT
nm employ any person in any manner sn as m hentme mhjen a+the Workers'CBmpcn- BNER FtiE
zz mind Laws of California.Date WATER HEATFR WNEN'GELEC R
Applicant GRA 'Ei
NOIICE'DD APPLICAN'C If,after broking Wis Cenilic:ve of Gxenspnon,yon nhoulA WATER SYSTEMG-REATING SOI
abecame subject .,he Workers Compensation provisionsof the Labor Colli,you must
f3I fonhwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
Q p�
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMII. SQ.IT. 4J(.r PAID
V I farwhillinn tnunherei,wced(S..3M7,Clending agency foals perlmmantt of Uam Receipt#
LL H 'he work for which Ibis permit is issued ISec.1(Mll,Civ.CJ
Ixnders Name TA /
W1<ndcr's AJdns TOTAL;
ynify that I have ad this apPlicminn and state that the above info motion is BUILDING B
to cones.I agree mcomplywith alicity androunty ordinances and stale lawsremtingm QTY. • MECHANICALPERMIT FEE
V Z building construction,and hereby authorise representatives ofihon is city to enter upthe SEISMIC PEE
above-mentioned propeny far inspection purposes. P' MIT ISSUANCE
(We)agree m rove,indemnify and keep Imrmlesv the City of Cuperinn ugn'ns ELECTRIC PEE �pl
hahilives,jm3gmmays costs and expenses which may in any way accmeag Ial.id COY AL'I'H sR ADD TO MECIL PLUMBING FEE L�
be asequence of the granting of this pennir LLL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONTOIN'T
SOURCE REGULATIONS.
glAIRHAN NG UNIT(TO IglXO CFM)
1.01 MECHANICAL FEE
i
AIR HANDLIN UNITOVER I0.(XX)CFM) CONSTRUCTION TAX
SignatureufA fico 'mumemr Date EX FAUST HOOD( DUCT) HO 'G MITIGATION PEN.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant lir future building meopent some or handle retardates material HEAI'INGUNITAM)'
�e
as defined by the Cupertino Municipal Code,Chapter 9.12,end the Health lona Safety
Code,Section 25532(0? 1 HEATING ON]'F(
(]Yee �I NO q PAID
VIiM11,AT10NP Data Receipt#
Will the applicant or future building occupant use equipntens or devices which BOILER-C POHP OR 110,1X0 R'b
emit hazadous air contaminants as de0ned by the Hay Arca Air Quality Management 'TOTAL:
Dlstricl?
C]yes ❑No -BOIL+ COMP(OVER 100.000 RTU)
I have bead the hmaJons.,coal,tcgninumatn under Chapter 695of the Ceti- CONDITIONER ISSUANCE DATE
fomin Resell&Safety Cal"'
tions 25505,25533 unJ 25534.I undersand pelf the NEW RESIDENTIAL.MECH. SQ.F1'. -4-3-0-7
building does ntlyhar atensm,that it is my responsibility tit maty the occupant
of the rcyuir be mm prior to issuance of a Cmtifi ate al Orea may. —_ .
1t Z A
Owner or Lifli ages Dam TOTAL: ISSUIiD BY:
OFFICE