S 3114 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RICAL 1lfi fITND, 3114
BUILDING DIVISION APPLICATIONMERMrr PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
kBUILDING ADD "SS ���� Azlq / / SANITARY NO. APP/LIGATION SU HM9AI.[)ATF.
/^ 91[)All.NF. AMG / 1' O�1 C(INTRA R A .: IC NO: 7 N/C C/OONN-TROcL4 o
ARC I'fECI'll!NGINf?I?R: .IC O: Al]DRI?Sg:
❑ IO � O
CONTACT; PHONE: BUILDING PERMIT INFO
e-S �� ^
1:1 Consultant Fees Paid by Applicant(Initial) PL�ct J F.0,-- I'LU❑MB MECII
c'`J � G. iL� Ifs IrJ�
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hemby atmn atm I.m ueen.ed under novi,intt.archapa,v sam.m.dng JOB DESCRIPI'ION
won with Sxli.n]Btp)ofDivi.cion 3.f the Budne..a and Pmfexxiunnewe,and mylicenxe ix /'� RESIDENTIAL:
won p PERMIT ISSUANCE 0
Fes' in full force and eRu Q/� ❑SFDWI. ❑KITCHEN REMODIiI.
�UU Liccnse Chs Lick—(;}.' APPLIANCES-RESIDENT'I Al. ❑ADDITION ❑PLUMBING RE-PIPE
Hzw Dmc Cnmrmlur
m<= ❑MUIXI-UNIT ❑STRUCTURAL
5y ARCHIT IiCTS III[CLARATION PANELS
zpyz l rndcoutnd my plans,hullMusW as public records MODIFICATION
Oz- M UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
244 W Licensed Pneelsional 211-IIXXIAMPS IMPROVEMENT C]SWIMMING POOLS
�s1 _J OWNER-BUl1.DER DECLARA'I']ON OVER HCOAMI'S ❑BAI'II RFMODF.I/RI?PAIR ❑DFMOIJ PION
C Q 1 hemby alBnn m I am cxempr Tmm the Canmmtors License Law for the
7p5 a U following moron.(Seen,,.7031.5,Nueinea and Procelous Code:Any city or county SIGNS ELECTRICAL OTHER
RX a W ye which requires u permit to eongnml,uric.,inpnnce'denwhsh,or rgmir arty,fracture
F ��J prior to its issuance,also requires the applicant for such Permit to file a signedxtatnnent SPECIAL CIRCU I'I/MISC.
�y that he is licensed pursuant tomeprovisions ofthe Contractors License l.aw(Chapterl)
D (commencing with Section 70m)of Division 3 of the Business and Professions Cxle)or TEMP.METER OR POLE INS'I'. COMMERCIAL'
c.µo y that he is uxentpt Ihmcfroa,and the basis for Ibc allegr'd exemption.Any violation of ❑NEW HI.DGIADDI'I'ION ❑DF,MOLTI'ION
Scnion]IUL.E by any applicant lbrapemtit suhjenslhc applicanunucivil penalty oPOWER UFVIC:S ENAN'1 ❑FOOD SERVICE
�X� nor mum than fore hundred dollars($500). r IMPROVEMENT`
❑l,as owner of the pmpcny,or my employees with wages as lheir,nle cnmpenxmioq SWIMMINGPOC)LELECTRIC
$a' will do the wink,md the,(...fair is sol imendod or offered resale(See 70,14.Bu,mr,s C1 OTHER
and Professions Coda The Crur acmr's Li,cow Law doses not apply to an owner of _SWITCHES I'IX'fI1R1iS
a 3 property who builds or improves themoo,and who does such work himself nr through
—70
his own nnployces,provided that such improvements arc not intended or offered far NEW RESIDENTIAL ELECTR SQ ITT
rule.if how-T,the bei Im nr imp rnvanen(ie,reld within one ycarol ianldethm,the SQ.FT.FLOOR AREA E/SQ.FT.
nen-huilde,will have the burden of proving that he did not build nr improve for-pur-
pireaf.rlc.). ,•�/ 3
1.as owner of the property,am exclusively contracting with licensed cont1actors to T L: O
construct(he pmjcel(See.](144,Business and Professions Coda) Ihe Contractor's
Li- 1
n,e Lawdoes am apply n,an owner of IT pen,who mild,m iumroves lh.mt..and QTY. PLUMBING PERMIT PFiF:
who contracts for such projects with v contructne(s)licensed pursuant to the Courtrai
License law. PERMIT ISSUANCE
\ -iI nn exe+Tn under See. �✓1- ,B&I-C for thi eramn -
'r/ /TAIA'1311-DRAIN&VENT'-WATER(l. VAWA'I'ION
Owner Date �i `^1
WORKER:SCOyor Perjuryon DECLARATION PACK FLOW PR(IIECT.DIiVICF. 000 V A �/1
I head will
ntain a CntuhyrfofCoyone of he Bmrwingdeedrs Co: NS v
❑o.,as..cid, (a,by Se tion 37M of the La l to Calf.an the
performance
of the
DRAINS-FLOUII,ROOM,AIi IiA.CIINII. y'I'OR18S IYPIi .ONS'DtUC'I'ION
no.,a provided for ri Section 3]00 of the Labor Code,for the performance of Ihe -
work fur which this permit is issued FlX'1'IIRE.S-PER TRAP
❑ 1 huvr and wi-maimnin WonkcLs arristtion work
11 avice,h required by Section
3]q)of the labor Code,for the peri'rnmnn<e of the work lir.which lhlx permit is issued. GAS-EA.SYS'1'EM-I INC.4OUT LE'I% (ICC GROUP APN
My Wmkers�mr�tf�n�ion Intrumn 'amid Policy number a : GAS-IiA.SYSI'IiM-OVf:R4([A)
Cartier: (C/aMrn�J'olicy No:
CEG IFICA17.70 EXE M ION FROM WORKERS' GItEASP/INUUS'TItL WASTE INTERCEPTOR COMPENSATION INSURANCE {IIILOING DIVISION IT I-S
(This secfinn nceJ nor be cnmpletulif the permit till)...rhrndreddollan(EIIXq GREASE TRAP
or lea.) i'1 'CH FEE ZO
Ioy any firm in lie any banner
for subjectch to the W rke,'Commerri ell SEWER-SANI'I'AItY-S'rORM L'A.2Xl FT.
not employ any person in any mmnncr so as to become xuhjccna the Wen*erx'Cntnpen- P 'RG Ylil3 l 2 "3.
(�
,Z soden Lars of Califomid Data WATER HEATER W/xiMLECTR
C) Applicant G FF.F,
IZ) NOTICE )APPLICANT 1;alter nelking dr,Certillcnm of Ev n tide ,you shoNd WATER SYSTEM/TREATING
Ft ; hecome,ubject to Ihe Worker's Compensation provisions of the LnMa Code,you mute Wit. FRE
Ghammed,comply with such provisions or this permit shall he defend revoked. WATIiR SERVICE
0
� z ded The RUCTION
cia, LENDING AGENCY NEW RF.SIDGN'I'IAL PLMIf, SQ ITT. P Date Reeclptk
V 0 I for which
Pe(iron issued Gunn len ding agency❑v lira perfnrtnunce nr
the work for which Ihis permit is issued 3097.Civ.CJ
Lenders Name ♦/ /is YEA
�a isndcr's Addre ��-• � TOTAL: IIIIILDI 'lettLl
I certify that Ian l have rung(his applictnlon and state that'he above informmimt 11
.E". fn correct.l agree to comply with all city and county oNinances and state laws relming it, QTY. MECHANICAL PERMIT FEE
L) � building construction,and hereby authorize representatives ofthis city to enter upon the ( SIi15M
ahovemeufirned pmpeny for inspection purposes. ^ r q
- PIBIMI'f ISSUANCI? IiIA?C IF,
agree nn save indennify and keep hamlet,lire Cory of Cupertino against (.�
liabilities,judgments.costs and expenses which may in anyway acemcagaust said City ALTER OR ADD TO MECH.
in consequence of the granting of this perent PLUM 1 GFBF. I V�
APPLICANT UNDERSTANDS AND WII,I.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(10 lypo ICFM)
MECH ICAL
SOURCE?RETGULAIONS. FFai
AIR DANDLING UNIT(OVER WAS)CFM) CONST CTION TAX
Signature or AppllcmtVContntmnr Darr EXHAUST HOOD(WIDUCI) IIOUSING`kHIIGAI'ION FEE
HAZARDOUS MAI ERIALS DISCLOSURE
Will Ihe applicant or future halding uecupanuto,or handle hazardous material 1IRA]'ING UNIT(TO Iorrhod B'ru)
ns definel by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Seutiun 255t2(n)? 1 HEMI NO UNIT(OVER 101000 PTU)
Q Yes ON. PAID -
VP.N'fILAT10N PAN(SING LE RES]D)
Date ReM
Will the appl ican or future building becupent use equipment or devices which
BOILER-COMP pHP OR 11X1,(100 B'rU)
.mi(hntimm,air oI) at tear,a,defsnW by the Bay Arm Air Qual ity Manugemenf O„ qN
I icaieT {/
I'
E)Yes ONo BAILEft-COM (OVER I00,00)1{TIJ)
AIR CONDITIONER
I huvc Safety
hazer.So nim,255 5,2S5mants under4.1mal b95 or CUB- S$UAN P DATE
Tonin f{evlth&SvfuD Cnde,Sections 25505,25533 vnA 25534.I undemnnd that if the NEW RESIDENTIAL MI?CII. SQ PT. I/i %L//p/1y
huilJings
no
curmntl I,that it is my respmsthility mnmifylM cecupam y
ofthe pI Iswht tl et rior nlimuacc..fn C cul f y.
Owner or authonze cal Ilam OTA L: ISSUED BY:
OFFICE