S 3190 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BOB LDING-ELECT RICA 1. PC:y\],)TT No
BUILDING DIVISION APPLICNFION/PERNIIT PLUMBING-MECHANICAL V 3190
BUILDING PROJECT IDENI'IF'ICATION
BUILDING ADDRESS: SANI'T'ARY NO, APPLICATION SUBMI'['[A[.DATE
%D,291, Deh 1,58h kjAeycross
OWNER'SNAME, PHONE, COM1TRACTORS N,MLi: LIC NO:
NEC CONTROLX
e fr
. ARCHII ECIATINGUE: LICNO'. ADI)q[ mer e ❑
CONTACT': NIONI:-I 33 ryryUU BUILDING PERMIT INFO
Z ❑ Consultant Fees Paid by Applicant(Initial) BI DG RI,ECI UM 13 MliCll
LICENSED CONTRACTOR'S DECLARATION Q'Fy ELECTRIC PERMIT' FEE
1 match,fifmt that T am licensed ander bmvi,im ar chapter 9(cummendng JOB DESCRIPTION
pMZ with Senion](NNDoI Divinien Sof acllusinec,and Puifen.innn Cale,and mY license in RESIDENTIAL:
at 0 0 PERMIT ISSUANCE
hw2 nfullforccandcnc' � C3� ❑SII)Wh ❑KITCHEN I REMODEL
a Zp.V I.ccnnr CWv Lic.N AI'PLIANCI35-It ESIOEN'flAl. ❑ADDITION' ❑PLUMBING RE PIPH
N 6'6 Ida a Culllraclor
ARCH[I ECPS DIiCLARATION ❑MUI:IT-UNIT ❑STRUCTURAL.
Fpm PANELS AfOD11ICA'1'ION
Z O'erZ ]and...l:ntd my planx.holl herssd as publicnal
OZ'a't� UPT0200AMPS ❑IN'I PRIOR El CHIMNEY REPAIR
Licensed NTfezinvl 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATA REMODELIREPAIR ❑DEMOLITION
C C Q 1 hereby tlinu tam I an,asempl Inn..the Contractor's License Law for me
k 3 G U filtrating ram.($taction 90115.Ilnaincsx and 1'el—ions Cad, Any city or aha E,y SIGNS IiLHGI'RICAL C OIILER -
m�0e hicla require, I f S I I ale.,
proor ar or, I. 4 'he'ppli t lor suchM n t!Ic a signedsttement SPECIAL Cl RCUI"17MISC.
that he licensed ptt the provisions fthe Contractors License L (Chapter9
CSM (commencing with Section7") 1Dicki Jof the Business dl da,ionsCMeI act TEMP.MITEk OR POLE rvST COMMERCIAL,:
a a c M that he is exettyn themfrnm and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
=m Section 7031.5 by any ap,licam for.,bermil w ipra the applicant on civil per I,of POWER I)]:ICBS TITANT El FOOD SERVICE
not Tare rano Hoc handled dollar%($500)
I'ROVEMENT
El 1, I it,bbnY Y ory — 'g d 4,Ralf m, SWIMMIN('1'OOI,ELECT
and h k' de a t t' I J J R does
"I (Sea9fW4,H s IEIRC
W 3 w prU progeny
who hat Ut.. The Comraet eo L and
w does such
work IY hit naw of OU IhI?IS-SWITCHES CIX'fURl:S �]/
property who naiad,or Provided
that
thereon,and wan nt, wch wnrk,deed or of through
his own owevertt,,building that arch ambos%old w am not intended or effort for NEW RESIDENTIAL ELECIR SQ Fi.
talc lL noxxvar,the building orimpmvunem is cold within one Year of companion.the SV.FT.FLOOR AREA $/SQ.IT
er-milder will have the burden of proving that he did not build or improve for par.
Eldxta,locos eof m.pmpurty,u xJhoivdy our-ling with liccnanl conmmaex ut TOTAh.
nran acs teat(Sec.9014,Busanew+ uiand Pfe, m m
Code:) Contractor Li
s .
sense Low doe.not apply to an owner of property who brgtm or mnpmves thereon.and QTY. PLUMBING PERMIT FEE
whit contras¢for such projects with a courewha fs)licensed puouam to the Contractor's
Germse Law. - PERMIT ISSUANCE 3
C] I am exempt under See .H A,PC for this mason
4 ,6
ALTER-DRAIN ds VEIVI-WAI HR(EA) VALIDATION
Owncr D:ne
A WORKER S COMPIINSAI ION DECLARNIION BACKPLOWI'RIYIFCI INEVICh
T herchy attinn under penalty of perjury one of the following delmaeams:
❑ [have and will ntuimainaCerificacol'Co..sent mself-inwra tin Workers Compcn- DRAINS-FLOOR,ROOF.ARHA.GOND' STORE 'IYPL'CONSIRUCTION
,mien,as presidia]for by Section TAXI of the factor Cask,for the poAbrmnmee of the
work for which his permit is issued. FIXTURES-PER TRAP r
❑1 have and will aviation W'orker's Compensation Insurance,as required by Section
3700ofthe lata...Code.for he perfnnnonee"Ohe so kfor which vis scoot&rowcal. GAS-EA.SYS HIM-]INC.4 OVILEfS e AI'N
My Workc yp nx:yima l jorcc airier mtU Pe icy ya�ry{'to 9S
Corrie ttLYY Vh I-ohcySo.: D .tea GAS-HA.SYS'I'HM-OVITR4EPA)
CERTIFICATE OPIi%EMlot'[ON FROM WORKERS' GREASIJINDl15TRL WASTE INfEHCEMOR
COMPIiNS/A ION INSURANCE HUILUING DIV 'ION PEGS
This region need not be completed if the permit is for one hundred dollars CS1001
By
,or Tcsc.) GREASEI'RAP -
Iccmilyaat in the pvrfirrmancenffic vork for which this Permit is i.wed.[.,hall SEWER-SANITARY-STORM E.A.21X1 FI.
or reado,gnu lar, :my m niter m ae m becone subject ta me Worker,'Coro,., ENERGY FY.E
t nn in a
z vatinn Lawn of Ctibonin.D.I. WATER IIEAI'IiR W/VI!N'I'/IiI.FCI'R
z O Apnfaram GRADING IEE
y NOTICE TO APPLICANT.If,vOtaromking this Cenificatc..fl?xcmptian.you ohm Id WATER SYSTEMil PUNTING
h" > bxomc nrnjcet In the Worker Conal,,wmon provisions of the labrt Cele.You.,all SOBS HE
Iimnwia comply with such proysiomar this pannit shall he deemed revoked WATER SERVICE
a0
Uz CONSTRUCTIONLENDING1NGAGENCY NEW RISIDILN'fIA1,PLMN. SQ.17. PAID Date.
hereby uR mit mm mom in n..of Noc.30 landing agency bathe 1Trlornrmaenf aeibl N
U O 'he
-e wnrk for which dein lhnnil an in,ucd IScc.Jo99,civ.G)
�" F" L:wara Name TOTAL:
V Lender,Address TOL'
f}" y T candy that 1 have read this application rand state that the above information is BUILDING IE'
pp correct.I agree to comply with all cityand county ordinance%and state laws relatingm QTY_ MECHANICAL PFRh1IT FEE
V Z building croserelion,and holistic mode tui repreaenulives of this city men¢.upon be SEISMIC FE.
above-mentioned pmpeny for inspection parlsv, PERMIT ISSUANCE
(We)agram to save,indemnify ant keep harmless the City of Cup.ninn against I ELECTRIC FEE
Iiubluics,loJgmcn yva of anA upcnmx which may in any way neemeagninntxald City ALT ER OR ADDTO MIeCI I.
in emrcyacn)))t I Mgr ring al this b"mit. I'Ll1MHINC li
SOURfA / '(UEONSNDS,Y WILL COMPLY WII'fI ALL NO N-POINT' AIR HANDLING UNIT(TO IILgNICI'M)
(� MECIIANICA PEE
//� NR HANDLING UNIT(OVER 10,(X10 CFA1) CONS'FRUCT10NTAX
Signamm ApplicaTmCont tar (/l� Date EXHAUST HOOD HOUSING MITIGATION Hill
IIAZAI )USM, hS DISCLOSURE
Will the appliemt nr Rome lar t in, opantnml'e nr hwtdlcbvuNnus anumriul HEATING UNI'I'('IU IfN1.INN1IfIl1)
as defined by the Co,wein..Mmawipul Coto.Chapter 9.12 E life 1leala and Salary
Cold,Station 25533(a)? HEATING UNIT(OVER 100,O)h IfU)
C3 Yes LJ No VENT ILA'T[ON FANS INGLE.RE.SI Of PAID
e X511 the applicant or future blildin•occupant use equipment or devices which Dam ReceipIn
t p
pp 6 pan Area
Qu BORER-COMP(311P OR 100,000 BTU)
mit havarJous air amtammanu un]dined M1Y the Buy Arca Air Quality Management TAI- (
Di...icl!
C]Y, E]No BOILER-COMI'(0VP.R❑XI,I11N1 11 FU)
AIR CONDI'I HINER
1 have real�y1aacm ISe.inic
nn,nw¢ri"repro, easorder Chome-6.95of me Cali- ISSUANCE DATE
fomiu Heullh h 5y'llety n ' 5115,255]3 and 255]4. unJenrmJ tam it he NEW RGSIDIiNT1AL MECII. SQ.FI'. p
nuildm d. /tar tiveR2 .anti Ry resrymsmility to notify me cecupamn( a 'chs n e of a Cartificme o (kc ,nay. r
O rL/odagent T 11 TOI'AI,: ISSUED BY�
OFFICE