S 3069 -APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT BUILDING
R PROJECT
-MECHANICAL, S 3069
L' EL'T IDENT'IF'ICATION
BUIL1)IN AD ESS. I� � SANITARY NO. APPLICATION SUHhiI'ITAL DATE
OWNERS NAME: PHONE; C R . 'S NAM- IAC NO: �/, �^G
NIC CON'IROLOr
MP AR.II TF. T/I? GINEER: LIC NO: ADDRESS: ❑ Q P1
CONTACT: �� PROM;; BUILDING PERMIT INFO
Kaeffe ❑ Consultant Fees Paid by Applicant(Initial) LD Ea t.F,yT PLUMB EC
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
"cub
dfnm 0t,1 am EcensM aader r vixb,ns nr chapmr 9(commencing JOB DESCRIPTION
�aZ msectinn 1(X107 of nividnnJonhe Brines tdirof,,smrtaCMeaaderyllcemscis REMU NTIAL:
IA00 w PERMIT ISSUANCE
in Gill fora and eRe<t. ❑SPDWL KITCHEN REMODEL
GUU Liccnse C���s/�- Lice AI'PLIANCIS-RI!SIDENT]At. ❑ADDRION ❑PLUMBING RE-PIPE
FZyR )are Co./T� Conwcm
N G u' ARCHTECES DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F.,O m PANELS M0DIFICATION
OZViZ lundersnnd my)tons xM1Tll be meA as public cords
oQ UI`R0200AMPS [I INTERIOR [I CHIMNEY REPAIR
pQ-�1❑"4] Licensed Professional 201-10)(MAM1'S IMPROVEMENT ❑SWIMMING POOLS
gC OWNER-BUILDER DECIARATION OVER IIXXIAMPS ❑OATH REMODEILREPAIR ❑DEMOI.IT'[ON
O W U I hereby affirm,hot I am exempt from the ComnrIou',License Law fnr the ❑0T7{ER
�qq�55 d following reason.(Section 7031 5,Business and Pmfesaions Code;Any city ar county SIGNS ELECTRICAL.
us'31is y which,a,cirri o p<•rmit in cions....,,altar,improves Jemnlish,or repair anY mmaure /
.�.�; prior lars isnuancq:dso reemo,the applicard forsuch psneriuo file a signcdmammenl SPECIAL CIRCUITIMISC.
mat he is licensed sprmamre the provisions of the Communes License law(Chapter 9 COMMERCIAL,
Q� (Commeneingwi,hS,,IiOa7U0)of DivimonJolthcliusinesxand Pio(evunnxCMc)nr 'I'I!MP METER OR POLE(NST'.
S S o K mat he is«empt therefrom sad me basis for me mleged exemption.Any vioinion of ❑NEW BLDG/ADDITION [I DEMOLITION
Section 1031.5 by any applicant for i ,mil sabje,w the applicant m a civil pervalty of PCEVER DEVICLSXdafENANT ❑FOOD SERVICE.
not more man five hundred dollars(5501). 7 MI'ROVI?MIiNT
Fx0 I,xs owner of the pmpcnY,or my cmpioyees with wages ux,hcirsola compensation. SWIMMINGI .ELE ❑OTI{F:Ii
RIC
$a will do the work.andthe strucmrc is not intended oroffcred for sale(St .]UYI,BusinicSg�
a 3 m and Ro@scions Craft:The Comractofs License law roes not apply m xn rrwner yil OUfLITS- T tS-FI Rfi Q 3 D
property who builds of improves thereon,und who does such work hunttlf nr through
his own employee,,provided that such improvements um ern intended nr offered far NEW RESIDENT R SQ FT.
sale.If,however.the buildingnr improvement icsold within one year nfcompletioo,the SQ.FT FLOOR AREA SISQ.14.
owner-DuilJcr will have the huNcn n(proving tits he did not build or impmvc fnr pur-
pnu,of sale.).
❑I,us owner of the properly,am exclusively.anteceding with licensed rnnttaetms to AI"
mumar t the project(Sec.10,11 Business and Prafesslons Coda)The Counayor's 1.1-
ewho contracts for such projects with cove Law does not apply tounowner ofpropcnywho huildsornnpeavesthere"..and QTY. PLUMB( PERMIT FEE
a counwou ls)licensed pursuant to the Commeors
License law. PERMIT ISSUANCE
❑l um exempt under Sea ,B&P C Ga this reason
ALTI!R-DRAIN&VIN'I'-WATER THAIJ VALUATION
Owner Date �N
N WORKER'S COMPHNSA'I]ON DECLARATION BACK FLAW PROTECT.DEVICE .•J�1(.(.�/'a�/'C) y
1 hereby all!,.mer penahy of perjury one of the following deduraiens: Vim/
I have and will maintain a Certificate of Consutuo self-insure for Worker's Compo D FL !A,COND, SpDEBTS TYPE:CONSTRUCTION
salon,to provided for by Section 37M.1 he LOW,Code,for the perfnrmance of t
rk for which this panni,is issued. PIXTUR:. PER' P
1 have and will maintain Workers Compensation Insurance,as required by Sect
J lofthe Labor Code.learn.perfnrrwnceof the work in,whididusperan,Is iso - . YSTEM-IINC. C 'Curs OCC.GRs1UP APN
Aly Workers Compensation Inxarmmc carrier and policy namhcl art
Carrier: I they No.: GAS-LA..YS' E 1
CHRTIFICATE Op EXEMP'T'ION FROM WORKERS' GREASI%INDUSTRL WA TERCEPTOR
COMPIiNSATIONiNSURANGE BUILDING DIVISION Ii
O'Buk stion need nn,he completed if, pemrit is lorone hundred dnllnm( :TRAP to
nrlcss) PhANCIIF.CK PEE 'Z-7 e
I camly that in the performance ofic,work for which this)..mitis issued,l shall SHWER-SANIT IEA.201I'L
no,employ any person in any manner on as to become%objecrto the Worker,'Coupon- ENERGY FEE -2�
O Z sation laws of California.(late WATER HEATER W/VENT/ELEC'1'R GRADING FEE
z O Applicant
try NOTICE TO APPLICANT:If,after making IN,Cenuradc of fsxemPlem,you should WATER SYST'ENVIREATING SOILS PER
F" hecome subject Ir the Workers Compenmtion provisions of the labor Code,you mast
{a forthwith comply with such provisions or this peomit shall be deemed revoked. WATER SERVICE
Q
CONS"1'RI1C1'ION LENDING AGENCY NEW RESIDENTIAL.PLM1B. SQ.IT. PAID
U O l hereby affirm thamem iso constmclion lending agency for the performance of Date Receipt)
Is. F. the work for which this permit in isauoil(Sec.3091,Civ.C.)
O U Lcndcrs Name TOTAL:
larder's Address TOTAL:
y 1 certify that I have read this application and state met the above information is UILDING FETE S 3
L
iN corrcm.I agree to comply with all city and county radmznees and state laws relating to QTY, MECHANICAL PERMIT FEF. SEISMIC FEE '
U z building conswclion,and hereby amhoriee representatives ofthis city to enterupm the
abovcmeo red prnpeny for inspection purpoaea' PERMIT ISSUANCEELI?CI'RIC FIiE Q
^ s q
(We)agree,o xave,indendify and keep harmless'he City of Cupertino against < 9
liabilities,judgmenls,costs and expenses which may in any way nomeagaind said C'% AUTER OR ADD TO MECIL PLUMBING FEE
in consequence of the greeting of this pemtn. n
APPLICANT UNDERS'I'AN 'AND WILT.COMPLY WITH ALL NON-POINT AIR HANDLING UNIFITO 10,00CFMMECHANICAL IiI?
H r Q
I&I2 &
AIRHANDIJNGUNI'T(OVER 10.000CFM) CONSTRUCIONTAX
gwmmnfApphcICT
ULAan Contactor Das EXHAUST HOOD OVIDUCT) HOUSING MITIGATION PEE
HA%ARDOUS NATHRIAfS DISCLOSURE
Will theappllcual or haurehuibungoccupargine urhandleh:rzmdime,needal HEATING UNITQ'0100.0u)BTO)
as defined by the Cuperhnu Municipal Coca,Chapter 9.12,and the Health and Safety
Code.Section 25532(T)? H17NIING UNIT(UVI?R 100,000 B'i'U)
E-]Yea 0 N VENTILATION FAN(SINGLE RESIDI PAID
Data Recei
Will the applicant or future building occupant us estupmem or devices which BOILER LOOP OR 1 W,mxl RTU)
emm
it hardoua ant
ircomaminas as deli be the Bay Ana Air Quality Management
Dismct? BOILER-COMP(OVER 100,10 RTU)
El Y. [:1 To
I have read the huardons materials requirements under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE IJATE
fomia Health&Safety CMe,Stations 25505,25533 and 25534.1 understand tlml if the NEW RESIDENTIAL MSCI I, SQ.IT.
building ions no,currently have.tccum,tbut it is my responsibility To Tandy the occupant
of the resperentmns which must Is,met prior to issuance of a Certificate of Occupancy.
Owner of mil o l,al agent Late I I Tyl'A 1.. ISSUED BY:
OFFICE — -