S 3879APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION- APPLICATIONIPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
S 3879
BUILDINGAUDRCSS;
/0700 Fr'rQt1ZL0eaff DOE,
SANITARY NO.
APPLICATION SUBMITTAL DATE
3 g
OWNER'S NAME: f�PHONE:
CONS yC S2
CONTRACTOR'S NAM F.: rr LIC NO.
O G .S*SX
WC
❑
CONTROL#
`r RCHI'IECLIENGINHER: LICNO'.
ADDRESS:
CON ACI': PHONE:
❑ Conatthant Fm Peal by Applicant (Initial)
BU ILDING PERMIT INFO '
IILI>G ELE(1 PLUMB MECH
rLfJi r
LrQ-,/
LICENSED CONTRACTOR'S DECI-ARATION
I hereby mfr ef Ibl I ani lib boxrt nook, proo,od — m Chepler y 1«,mnKrcina
with Satim]000)a(Divieion 3nf ThC Busiress awl Profgxims Codc,ed myli,mxc is
in lull lame vnd effect. s— [�! B_Z i
U,asc (]o. Lk.T :Jb
Nuc ConTmnar
ARCHIELTS DECI.A ION
I uwIClsTurW my plans shall be used!u public rmxd.
QTY ELECTRIC PERMIT FEE
JOB D DESCRIPTTION
RFCIDFNTIAL
❑SFDWL KITCHEN REMODEL.
❑ADDUON ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
El INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING P(X11S
.8'�TH REAIODEIIREPAIR DEMOLITION
Of HER
.1 ISSUANCE
APPLIANCES - RESIDENTIAL
PANELS
UPT02U)AMS
licca 1Pmfcui«W
OWNER R emPr DECLARATION from the Commcmte Liceoae Law for dxc
I Mmby affirm bear I ani. -ran,
folluwfng ¢um. (Saxon ](131,5, Husiness and Pnde.asions Ctdc: Any city or county
which acclaim, a pmmdt In emxw,, ager, imlmse, demolish, oe repair my nrucmrc
prior To its i.croma, also myuirts the aPpliunt for such permit to BR a signad! uuemca
that ham licensed ponce m w the pmvisims of Ne Cnmraewr's Lieemxe Law IChapmo 9
(ewmrrncing with Seetion]00()of ly i6on]oflhe Busing. and Rotevsion.s Coda) or
Thu he is exempt Oertfmm ad the basis can Ik elkgd cxcmpion. Any vinlmim M
Section 7031-1 by any applicant for a Premia stabjaw the uppliemuo a civil pgulp'M
t oncrceIhm five hundred dopa, (5.5X0).
❑Luwmraf Ne prgeny,mmy employ, with w.gg ex 0rirsnle cnmpemmtion,
.W da The soak, and The abucmoc is Iwo inewkd w dlmd f,: apply to a4. Bvimas
ad I'rnfcuinns C«Ic: The Cmwntc's Live law Jtcs nd apply m m owner of
prgcny wfio builds or imprvvu Thmm,a, W who dex xuch wort himself ar Through
pe vi
his own employe., dmJ Barb art avcimPrmemews not inmadad m offered f«
wle.It, Mrwexx.r. the talking orimpmmantnl is Wd within ors..vofcamplhr. Nc
owmer-Wilder will have the harden of Proving thea he did wa budd « impmsv f« Pur-
pe�mf:> ).
0 I, v Imner nt the Pooped, am t,xclueivdy emuanina with llttvd anmmoa m
malrty the Proje n (Sec. 70W. Baxincs. end 1'mt,sinms Co_1 a Cunaacmr'a Li.
cane Lav des rocapply m an awmcf M propcny who builds be improvenMr,n, and
who coma.#. f, such Projects with a mown«(.) liemd peau,, In the Comaanelx
Lien#. law.
l con ombep aider Sa. ,B & 1' C Bu Thier Txvan
201-1BMAMPS
OVER IM) AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITNISC.
TEMP. METER OR EOIF INSf.
COMMERCIAL
❑ NEW I�G/AppI;TTou T1 nFMOLfITON
TEN
c ❑ F<X Ell
'M'R 1ENT I'JI
❑ OTH
POWER DEVICES
SWIMMINGPIIOLELECI'RIC
0UTLETS-SWDCHI3-FlXTURF5 o
NEW RGSIDENIIAI. I:I,ECTR SQ FT.
FT FLOOR AREA v
By
L
A D
1
QTY. PLUMBING PERMIT FEE
PERMIT ISSUANCE (J
ALTER - DRAIN & VENT -WATER (EA)
Owner Date
WORKERS COMPEN,SAI'[ON DECLARATION
Ilembyalr ander peaalty ofprju
cry orcofthe foll.wing �larminn¢
I east, "will msimuin.Carfi eMCmemuoal6in.um fm Wmtrls Coop,-
. tim, u pnxv Fkd far by Section 3]1X1 of de Tabor Cade. [or Oe perfomuna M dTe
wnwbicM1 thix pemtit is i.swed.
Fr luxe test will madman Worl Conyen.etiun Insvmae, as repaired by Sion
37Wot the labor Cale. for the perbr.a of We wmt f« which mik permit n romml.
C rrAc Cpngxcn nlnjUn/yrnuP.1, madPA,Nmy"lF%'�'1 W -9.P
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This action nvcd am he complmd ifthc perm , is I'ororc hod led dollen (51 findBULLI
a,,)
1 anify that, in IN, ptarm aeofthe vert fer which thin permit is o,md.I dWI
n« employ any pcwon in any mummer yx uJJn hecy}�lra�t, ubjand
o e W«tert' Contpen-ENERGY
�Da 6'� S 1, 9
vtim Laws M I ff e
Appliranl 1��.� s
VALUATION
�/
r 0
BACK FLOW PROIECE DEVICE
DRAINS-IB.00R. ROOr.. ARRA, GOND.bT
IES
OCC. ROUP
TY CONSTRUCTION
l
/ /11
v
APN
IIDCIURFS-PER TRAP D
In
GAS - EA. SYSTEM -I INC.4 OUTLETS
GAS-EA.SYSTM OVER41EA)
GREASU(NDUSTRL WASTE INfERCEPPOR
WIG DIVISION HES
GRExSETRAP
PLANCHECK FEF.
SEWER -SANITARY - 5IDRh1 EA. 300 Fr.
EFF,
WATER HEATER WPNT/ELE=
N
GRADING HENnTCE
TO PI.ICAMP.If, a icr mating this Ccnifruc of Exemmiom, ym shmld
became whjccT m The Worker. Compo..,.. pmvisim, of fm Labor Cole. yea mot
forthwith comply with ....h pmvnitms or the pewilshstl be dmmmcd revuted.
CONSTRUCTION LENDING AGENCY
I hereby aRrn Thea Thele is.commaCtie. leMing agercy far The'm.m.aoce.f
the wool 1M which chi, pewit ix o,sucd (Se. 309]. Ci, C.)
1<rder'x Nae
WATER SYSTENME.A IN'G
WATER SERVICE
SOILS; FEE
It
PAID
a RadPrM
NEW RESIDENTIAL PI.MB, SQ. ET.
TOTAL:
m
Larder',Ad]rens
1 cgufy dlaT 1 have read Ni. application and stem that Ik #hove information is
conal Tepee to comply with ell city aM Coumy oNiowees end Suet#.. alning la
hooddingeonumnlnn. and berchy author— representatives ofthis city Income upon tkSEISMIC
ahoy'-mcmvred poopeny fm impatim "on"
(wt,) ,gra m sive, iodrnmify and kap harndga the City MCupmino eRninst
Iiahilio�,judgnem.costs ard expnlsea which may in my way acam against yid City
in mcyucrccof na:grmtingofthix lacrmo
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT'
SOUR EGUTATONS, q
/
TOTAL'
BUILDING
QTY.. MECHANICAL PERMIT FEE
�E
PERMIT ISSUANCE e
ELECTRIC P
V�
ALTER OR ADD TO MUCH. Z0
12
PLUMBING FEE -
AIR HANDLING UNIT (TO 110.000 CPM)
MECFIANICALFEE
AIR HANDLING UNR(OVER 10.00) CFM)
CONSTRUCTION TAX
Sigma nfAPralicmJC«uremi Da¢
HAV RDOUS MATERIAIS DISCLOSURE
Wllthcepplicam«Balm huildingtecapan,sturem hmgpc hvam]we rwured
as, defied by the Cupenim Mwicipal Cde, Chapter 9.12, east the Health and Safety
Coda, Smite 25534.1"
❑Yes F] No
Will the applicant m forme landing n Mnl ase equipment «devixg which
nit hummus art contamination u dmfrcd by Is, Bay Ar® Air Quality Menagemem
1J15 0Ye ElNo
1 have rtud ale hwuJuus mmaiaH ryTrinnents Tudc Eloper 6.95 of the Call-
forma Hghh & Smny Cdc. Sc,ims 25503, 25533 unJ 255.H.1 udo-xwv] dwt if the
building does m cwrenly bevc a Rated, that it is myr ,osibility to unify the occupant
Male nmuwha an prwrmissvnc cfaCamfi fOmymay.
/fes— 6 -—SFS
EXHAUST HOOD(W/DUCq
HOUSING MRIGATON FEE
HEATING UNIT ITO 100.000 BTU)
HUTTING UNIT (OVER 100,00(1 BTU)
PAID --
Dutc Receipt
VENT] I.AIION PA N IS INGLE RISID)
BOILER -COMP (311P OR 100,000 BTU)
BOILER- COMP (OVER I(M." BTU)
AIR CONDITIONER
ISSUANCE DATE
f ,-x
ei r /y
!
ISSUED HP.
NEW RESIDENTIAL MECH. SQ. FT
fArayeRr aamesn'd ogcm DaTc
T AL ♦
OFFICE