S 3186 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHS 3186
BUILDING DIVISION APPIACATION/PERMIT PL=IING-MECHANICAL
J
IRALDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMI'IT'Ah DATE
106M 5, QF-Af,) ZA, $L_V io is / —,Z ,r .y
UW 'S MI?' PH Nl's COMI'RACTUR'S NAME: LIC NO
r y NIC CON'I'I20LK
.ARCsHI`fECf :N' IN :� I.I ,IOr�b �6`I'1U4W 5—,420' El O
CONTACT: 1 PHONE: _ W EUILDING PERMIT INFO
•�1b/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEC PLUMB M[CH
❑ ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
I herehy mm tom RrI am licensed under pnwi,mm of Chapter 9(commencing JOB DESCRIPTION
O0Z with Saotion](I(plofDivisirn)rfthe tlusiness and Rafecsions Carc,ard my license is RESIDENTIAL;
00 PERMIT'ISSUANCE DSPEWI ❑KITCHEN REMODEL
'n full fora and effect.
�F.UU Livenm Class Ciour APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
NQi Dam TSDECr ❑MULTI-UNIT C]STRUCTURAL
ARCHITECTS DECLARATION
F4Z IundersmnJ my plana,hall be used os public records PANELUPT02S MODIFICATION
QZ[?,^O UP T02(X)AMPS []INTERIOR ❑CHIMNEY REPAIR
r4tW Licensed Professional 201-11N )AMPS IMPROVEMENT 0SWIMMING POOLS
gmF•'� OWNER-BUILDER DECLARATION OVER HIR)AMPS ❑BATH RIiMODEL/REPAIR C]DEMOLITION
C C 6 1 hereby affirm that I am exempt fortune Contractors License Law for the
igqi5500.0 following reasou.(Sxlion]OJLS.Business and Professions Care:Any city or county SIGNS ELECTRICAL [I OTHER
u+3 LL F' which requires a permit it,construct,alter,improve,demolish,at repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIALCIRCUIT/MISC.
f } that he is licensed pursuant the faints of the Contractors License Law LL upmvCOMMERCIAL,
(commencing withectir therefrom and of basisof rth the eged es and option,Any vi Csde)or TEMP.METER OR POLE INST.
d Oo e' that io is caumpt angap and the oasis fits the alleged applicant
in Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
min ne am Shy hundred
dolllfor a rs($50nnit subjects the uppllcanunucivil prnnity of POWER DEVICES IM'hANPROVEMENT [I FOOD SERVICE
m t more Nan five M1undrtJ Jollars(YSIN)1.
F C ❑Lo the
pestruc,mmyemntendes or
044,Bsinen, SWIMMING POOL ELECTRIC IMPROVEMENT
R. w d Profession,
sion,Code
The Con is not intended or aw do for sale illy 1.am Business ❑OTHER
and Professions Code:impooex Connector,Llccmend o do Anes nm apply himself owner of W'fLEI'S-SWITCHES-PIXTI1kP.S
his o ny w ploys s.pr improves thsucom prover nts mch wnte dedoo though
his own employees.provided that such mentis old w are not intended or rBcre,L for NEW RI5IDENTIAI.L'LECTR 'V tT.
sale,If,baweveq the building or Improvement is sold within one year of completion,the SGFr.FLOOR AREA 1JSQ.FT.
owner-builder will have the burden of proving that he did not Wild or improve for pur-
ptxc of soled.
N 'I'1 <owner of the property,em exclusively convncting with licensed counselors,to
'fAL
stran the po jert(Sao.VITT,Business and Professions Code)Tho ComractMs Li
cause Law does not apply in an owner of posperty who builds(it improves themoti.and QTY. PLUMBING PERMIT -E
who comntcts such Imss with a contractors)licensed parsmono the Contrumor's
].love,Irw. PERMIT ISSUANCE
❑1 ancient, uneeis •. .B&r c for this mown
1 F���-11ALTER-DRAIN&VENT-WATER(EA) VALUATION
D
WO nd R'S CUM PIiNSATION DECLARATION BACK FLOW PROTECT.DEVICE -C
I hereby affirm under penalty of perjury one of the following declarations: J
❑Ihave nnd will for
Se Cion 3700 of Conservr Code,scree performance
of the
DRAINS-FLOON,ROOP.AREA,COND. STORIES 'TYPE CONSTRUCTION
smirk,as provided for by Section J]1NI of the Latin Code,for the peRormance of Ne
work for which this pcmJt is lasuul. FIXTURCg-PER'1'RAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3740 of the labo Code,for Nc performance of the work for which this permit is issued. GA'-EA.SYSTEM I INC.4 O(1'ILETS DEC.GROUP MIN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-Eej,SYSTEM OVER 4 IEA)
CERTIFICATE OIt EXEMPTION FROM WORKERS GRE 5J'IN SI'RI.WASTE IN'T[RCF.ITOR
COMPENSATION INSURANCE 'a BUILDING DIVISION FEES
(Thivuaion need not he<ompludiOhc permit isforonenudred J�llarslSIO01 ',RLAS lT2AP
Is,,.) /1 PLANCHECK FEE
or Ie
I certify that In thepsurformarecorthe work for which this permit is issuG�.[,bull _BpNf NY-. ORM P.A.2O(IIT.
not employ any petxm in any manner sit as to become subject the Wakens'Chu pen- ENERGY FEE
sation laws of Califamia.Dam WA TER W/V `CTR GRADING FEE
77 O Applicant ` ~'
a % NOTICE TO APPLICANT:If,afar making this Crodivi m of F.nemption,you Shaul WATI7R S G SOILS FEE
f~ 5 become subject to the Worker's Compensation provisions r11he Lthar Code,you must
Wforthwith comply with such provisions or this permit shall be tlaomed revoked. WA'I BR SE
O
CONSTRUCTION LENDING AGENCY RISIDE IAL PLM B. SQ.FT. PAID to Raoeiptp
1 hcrchy affirm Ihad'here is a umxtmcdon lending agency for the performance of
Wthe work for which this permit is ixmN(See.J(X)].Civ.C.) NV
Q V Lenders Name TOTAL:
W Lenders Addmss TOTAL' O
LL 1 cenify that 1 have read this application and slate Nat Ne above information is BUIL G PCE
L ii DO correct.Iagree m comply with all city and comity onhnancesand.wme laws relating a QTY. MECHANICAL PERMIT FEE
U ,Z building conswction,and hereby nwhorim representatives of this city m enter upon the SBIS CPEE
above-memioned pmpeny far inspection pm ow, PERMIT ISSUANCE ELE IC FEE
(Wc)agreet s c,indemnifyvndkeephmMess Ne Cityaf Cupeninnagaimt
Iiabilities,jum,ran,ndsand expense,which cony funny wayoccmc against said City AM UK OR ADD TO MECH. PLUMBI FEE
in rnsequ ccofth gmntingrfthispermit.
APPLICA UNDF tSI'ANDS ANU WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0j"CFM) MECHANICALFEC
"GORE', :GULAT )NS.
_ _ AIR HANDLING UNIT(OVER 10.00t CONSTRUCTION TAX
amrell p ism/ mmcto, Date EXIIAUSTHOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDODS MATERIAL3ilmom handl
Will the vppliHAVARDOUS MATERIALS
DISCLOSURE
handle tunzaNnus mamriul HEATING UNIT(TO 100,001 HTV)
us defced by the Cupertino Marielp are,Chapter 9.12,and the Health end Sefery
Code,Scetirn 255J2fe)'! HKA'I'INC,UNIT(OVER 100.000 BTU)
C]Yes ° VENTILATION BAN(SINGLE RMID) PAID
Date Receipt
Will the vpplicam or future building occupant use equipment or devicea which BOIL ER-COMP pHPOR Iffit"BTU)
emit hazardous air conlambmms as de fined by the Bay Area Air Quality Management TOTE
Dilliill? Yes BOILER-COME(OVER I00JNIBTU) T
C Ibse read the hnza msmm ala q ' Inerts un der Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Heuhh&Safety Sxit s 255 .SJJ and 255)4.1 understand that if the NEW RESIDENTIAL.MECH. SQ.FL 4
building docs' haven nam ivny msprnsihili am�notif the tx,cuPam
of Nc from sw must n faC tT up:myy ^
Ownerory nrizedagent Dote(((( TOTAL: ISSUED BY,
OFFICE