S 3293APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT, PEN ONLY
CITY OF CUPERTINO
BUILDING. RLECpRICAL
PLUMBING. MECHANICAL
PE I'I'ND.
3293
BUILDING DIVISION .
APPLICATION/PERMIT
BUILDING PROJF.CP IDF:NI'IFICATION
BUILDINGADDRESS.
4
SANITARY NO.
APPIJCAHON SUBMITTAL All
5 I L3F(01Tt__L040
r
OWNS STA.1 N'
rn
/ _� PH NE:
-I-e "�N{I1
CON'[NACI') :SN E: _„I.LICNO:.
.G>_f�'tW}}_yy
N/C
❑
/� 1C(INFRO7/L p/
'`"I 12'V
AI{CI'ITI I I;exNC�Ii^: 1? -..J e,A " I,, G)
10.
c/i'r ......- V`r ! �]iNw/'YD/ K',
I hereby affirm that 1 tun hexeseJ under provisions of Chapter 9 (commencing
OCZ, withSSection 700Bof DlvAinn 3afthe Enunciator] Professions Concand my license is
E� W G in lull force and effeel.
�UU Liccnsc Class IJn#
I. z W Dare Contract
ARCHITBC'PS DECLARATION
~,nZ I u demand in, Tdoe,roll be used as public records
OZ—O
P:4 L W Licensed Pmfesional
�.�N_a OWNER -BUILDER DECLARATION
ti C Q I thereby affirm thm I am exempt from the Commcarr's License I.aw for me
L
�a. V fallowing reason. (Section ]Oi 1.5. Business and protecsxlons 6da: Any city or essunty
F LL LLO h rmbn
which reforms a peil to nnuel, alter, imprm
eve, demolish, or repair any structure
nations i .... race, also1 Ih ppl , haunchpe ,all, to file .,iiinadmationeral
tlait he is licensedp the provisions ofth Contractor's Acenw, Law (Clmmr9
OW ��
(commencingwith S t 7000) ol l 3 man, litalint,,noulI f,. .Code) a,
d pal he is c.iiam mimhom o all am had, Far (]in alfe,d nwarplant. Any inflation of
Section 7031.5 by any applicant for a permil mlijems the applicant In a civil penally, of
iSGnal more than five hundred dollars ($51XB.
❑ I. as owner of the Property, nr my collisions with wages as lheirsolc compensation,
F., will Jo the work, and the wouclure is not intended or offered far sale ViceJBW, Business
and Professions Code: The Committees License leave dins not apply m an owner of
d 3 property who builds or improves thereon, and who does such work himself or though
his own employees, powided that such improvements are not itncaded nr oteted for
salt If, however. the huilding or impowcmetm is sold within ane year of emindetor, the
potenbuilder will have the harden of proving that he did not build nr improve for poo -
w ofxafe.).
1, in owner, of the property, out ui,lo,ivdy eonnacting will Iionnnd caalrumars to
n .Ire the protect (Sec. 71144, Bulinus and Profcseiom Calc:) The Counsi ofx fi-
xe low does not apply o nn owner of property who builds or immroves therwm, and
.it,, contmcta far such pojees with a nmwmags) licensed pursuant at the Coal... nfs
Liec w Imw
I am exempt under Sec. .BY 1' C for this reason
Ow Doc
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
Ilmvve unJ will maintainaCenif¢are afCanxem to
worpoll-insurelnrWnrkcr'xCnmpen-
woiokforr f ) provided far by Section 3]1111 of rhe LnM1or GWa, Inc rho pcdinmancc til the
which psis permil is ;,sunt.
❑ I of I and will atmmmn Worker's Con r ofthe w Insurance, h his Isen by Section
RANI tilthes Co Cute,fon thec,furane cemnofthework far whir are pcnnil is iveued.
My Wnrkcrs Compensmion Insurance center and Policy mm�M1er arc:
CERTIFICATE Olt IiXEMTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed it Ne permit is Rome hundreddollars (SIM)
or less.)
1 certify that in the performance of the work for which this permit is issued, l shell
not employ any ammo,, in any man.am,u men become subject m the Worker; Comma -
0 %. radon Lows of California. Data
Z APplir:an 1
/L.rn N0,11ICE'1'0 APPLICANT: 11, fact making this Certificum at H.cmptina, you should
benmm subject to the Worker. Contperomian pnom.ro of the Linen Code, gnu must
LkI fonhwith comply all each provisions or this permit sha111w dernmd revoked.
A
CON
hSTdLENDINGAGENCY
U l herebyrhi thelte, is.comelending sency
home peRnrmance of
L2 + the work foe whichhis pemtl is issued (Sca. TO],
Civ. C)
0 V I.crdc ,Add
� 1 �ndcr's Address
I certify Thal 1 M1 ova read lh ill and Ilion and dine Ihul the ubnve vel elmulinn Is
ta/1
..... v 1 cone m l many with all city;emd county ntain� ecce and crumb hmwe r'chnin6 e
Z hui Wingcnnaauction. and hereby mbon E representatives mrve nr Dari city to emrr apmm nm
uhnvc (We) ogre 1. errysave for inspection keep lea
(We)agreecall, Indemnifyand keep may
City 'if Cnpcninaud City
in
of
costsung expenses which may in any way attme ugainn said City
Aconsequence of Ne granting of permit.
APPLICANT IINOERSTANfISiND WILL COMPLY WITH ALL NON -POINT
HAZARDOUS MA'PRRIAI 4 DISCLOSURE
Will the applicant or Julian building nu:upvm store urhondr huc:ndnus rnumrivl
ax defined by he Cupertino Munie'mal Colo, Crime, 9.12, and Ira Health and Safdy
Core, S25532m)? 0 EA
Will the applicant or fmure building occupant use equipment or devices which
emit hmafdnus air cminam... I, as deli tied by the Bay Arca Air Quality M.... marim
Disaicfl
❑Yee ,
I have read the hazoduns nwturiul, ,,,are ... en. under Chuptcr 6o5 of the Cali-
fbrnlu flcullh & SetnC:aa, L55115, 25533 and25534.1 axdcmtund dna If Ile
ngdues 34.1lndenlalhuon i mr �nwl friar In ix,;Lff a Cyril -oft mnlOwner `,��` l/ !'/(/jZ=Data
❑ Consultant Fees Paid by Applicant (Initial)
IT'Y I71.ECTRIC PERMIT
PERMIT ISSUANCE 3.7
APPLIANCES - RESIDENTIAL
PANELS
UITO 200AMPS
201-1000AMPS
OVER 1000AMPS
IIihI I'. Mlil'f?I 'I
1'UWlia DIw ICIiS
SWIMMING POOL E
(TUI LEST -S W ITCF
NEW RFSIDIIAL
PLUMBING PERMIT
PERMIT ISSUANCE
ACIER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECL DEVICE
ORAI NS - FLOOR, ROOF, ARI?A, COND.
FI X'I'U R IS- I'HR TRAP
GAS -IiA. SYSTEM -1 INC. 4 011'11.171'5
GAS -EA. SYSTEM -OV 1 E-)
GREAS1IINDUSTRL WA ITN I'hR
GREASF.TRAP
WATER 11 HNI14R WIVEN'(/1
WATER SYSTEMGKITiM III
WATER SERVICE
SQ FIT
NE
W RESIDENTIAL PLMR. SQ. IT.
TOTAL
QTY. MECHANICAL PERMIT ''77
�PERM1t1'f ISSUANCE J \ISSUANCE J s
�) 1 F..CH.
AIR HANDLING UNIT CTO 10,060 CI'M)
AIR I IANDLING UNIT (OVER 10,000 CPM)
FXIIAUSIHOOD (W/DUCT)
I IHA'I'ING UNIT (10 U)0.Qa0 BTUI
I I HATING UNIT (OVER IIX aph bf-C)
VINI II.AI'ION FAN (SINGI.R RfiSID)
BOILHR -COMP OFF OR [00.010 BTU)
BORAX - COMP (OVER 100,1X13 If TO)
AIR CONDITIONER
NEW
SQ, Em
BLDG
1_7
D�IGG E EECII PLUMB MELD
E3 T ❑ Li§'
FEE JOB DFSCRIPI'ION
RESIDENTIAL
CSPDWL C KITCHEN REMODEI.
ElADDITION El PLUMBING RE -PIPE
❑ MULTI -UNIT C STRUCTURAL
MODIFICATION
RIOR ❑CHIMNEY REPAIR
IMPROVEMENT ElSWIMMING POOIS
C BATH RF.MODEL(RF.PAIR ❑DEMOLITION
C OTHER
R
NFLU
DITION CJBMOLIfIONHNA ❑ FOOD SERVICE
ROVEMENT
10 ❑OFHER 2
J
SQ, FT. FLOOR AREA E/SQ. FT.
FFE
VALUATION
/0 00
1t, STORRIIESy IYPBCONSTRUCI' N
OCC. GROUT' AIN
31wa1u r
BUILDING DIVISION_ I_TiLS_ Q__
.ANCHF.CK FEE 2- ( s"
13ROY PEG
ADING ITE
In S ITE.
PAID
Omar wipl a
SalTOTAL:
BUILDING F .
FEE SHISMIC':F.
(^� r / 0
S L
IT
I.ECTRI ZO
O PLUMBI "F
MF.CIIANICALP.E o
CONSTRUCIH TAX
I IOUSING MITI TION FRE,
PAID
Date Reecipt a
TOTAL:
2 -
ISSUANCE [TAPE