S 3029APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY ot-1> 5 1 9 S
CITY OF CUPERTINO BUILDING - EILECI'RICAL
BUILDING DIVISION APPLICNFIONIPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT MEN' 1'WICAI lON
1'1312 f1'I No rk ^ /�
029 L M
V V
BUILDING ADURISS:
67���
�a L� 4117-4
SANITARY No.
APPLICATION SUBMITTAL DA'I
v /s/Ig
OWNER'S NAME: "flue":
/ ` ,/ / /)„e/'e
ON 6- Z_,2
CONIRACIOR'S NAME: LICNO.
NIC CONI ROLA
❑ g7
ARCHI'I'ECI/IiNGINEER: NO:
ADDRESS:
PHONE.'ACuoNE:
H1111,IJING I'ERMI'1' INFO
�)N'1I':
� �t y_)q�
❑ Consultant FecY Pail by Applicant (Initial)
PLUMB
NLD(' f:Ll❑-iC'I'[;MI'
ham/ L^Y/ CI
WC
n pp
=UIF
aUU
F W
LICENSED IDCGNTRAC'Td,, E owtur,RI Clot
I heresy, auhnt, mm I ata hcen.ed arch pct+vi.im+. of cnapm, 9 (cannmendng
with SK111,a]IXNI)++fUivisinn3ofthe Busintes and Prolhssions Cssle. and my license is
Lictsm,Class fall tome Jelled.
4°°nm U°°` Lm.x
Contractor
QTY ELECTRIC PERMIT PEE
AOR DESCRIPTION
R )F
JSFDWI. ❑KITCfiEN REh1ODE1.
❑ADDITION ❑PLUMBING RE -PIPIT
❑ MULTI UNITC1 STRUCTURAL
h1ODIFICATION
❑IhTER1OR ❑CHIMNfiY REPAIR
IMPROVIiMIiN! SWIMMING POOLS
I'ERMI'I ISSUANCE
AITTIANCES -RFSI DENTIAL
m6a
p., ❑ wDam
OZy Z
�Q
ANATI(N
ARCHITECTS DECLARATION
I understand my plain mall h used m public morJx
I\
UI"IX)200 AMPS
F -=FG
LittnscJ l'rolcvsi,wl
3111-IBIX1nMpg
C
y p W U
X y
ala ".y
pF�pQ
�ap0
d 6
f=�
p.
Law
OWNER -BUILDER DIiC1.AHATION
I hereby ffmi that 1 am exempt Iron, the Comirmor'x License Law for the
followin, ma ... u.(Sty, 17031,5, Bueincva and It I..it CO 1, Any ntyor county
whirl, myuires 11 permit m nansatcl, alter, ioruese, Jemu1'uh, or repel, any'busters
ju or to itssoranco, also4 theit,plairdI Tto te .,Tirrd:tt nen
Iha h If I t p (it the Cbravos,I (Chase,9
(ut curing, Ih Section 7(NN))ofDV.1t i fthe l3ui¢esu 1Prot c.. on:Cde)or
Ihal he a exempt thercfnnn and the basis for the alleged exempton. Any violation of
Section 70.115 by any applicant for a permit subjects the applicant to a civil psnahy of
not more than fie, hundred J.H. (4500),
(] Las owner of the prnpcny. or my employees wilt wagca as their sole u+mpensntion.
will do the work. and theaum is not intended or altered forule(See. 7044. Business
.am
and Professions Calc:'The Contractor's License Law dam sol apply m an oxer nl
property who builds or improves Iheterru and who docs such work nimself ar through
his own employees, provided that such imp ovemenrt am sol intended or offered for
sale.IL nnx'oau the building orimprovemenl is sold wahinuse ycan+fcanplcuvn, the
owner -builder will havens burden of proving that he did not build ar improve fur par-
❑ HATII REMODIi1JREPAIR [IDEMOLITION
❑ OTHIiR
aVIiR IINN)AMPS
SIGNS ELIiCfRICAl.
SPLCI AL CI RCU IOM ISC.
II?MP M1:1'I It OR 1101 ST.
COMMERCIAL:
❑NI?W BLDG/AUDI'll(1N [_1 DEMOLITION
❑TENAM1T E3 FOOD SERVICE
IMPROVEMENT
❑QTHEN
I'oWIiR DIivICILS
SWIMMINGPOGLELFCfRIG sii
UII"Il.l!1'S-SWI'1'CHFS-FIFTUHFS
NIiW RESIDEN PIAL. ELEC R SQ F
SQ.lel'. FLOOR AREA 5/SQ. IT.
•%
TI11 N..
pine of sale.).
❑ I.:u owner aline pcnpeny, am esebri-11, oodnaling with licensed contractors It,
l�J)
�2 /
,auqamII iso,ol(S 70,14,B ssanll ' he Comet L
sal 1 : t a,l,l IPnP 1y It,, build, ,, i ,th ,nand
QTY '.0 R I FEE
y�
wl„ n,Imu. Iar:ach pro Iwith a contractor(s) Iscowdpnr n me Contractor
Liacnsc law.
I em exmnpt under See , B& P C far Isis reason
PERMIT I' NCI:
I,UAI'By
I. 31 s
( hq CONSTRUCT IM
.
AC113H-URA - ENT- L (li
_
BACK PLOW IR ) CE
Gone, Date
WORKER'S COMPENSATION DECLARATION
Ihavperjury ane of the fallowing Jeclarationc
1c hemhY uBiT under' penalty of
�(]anAwill mainmina Cenificac of Conwnlmulf-Insert for Workch Compen-
•tion, as provided for by threaten 3700 of the lalxt Cale, fm Ise perfomunce of the
,,it for x'hi,h,hi,, perm, islssuad.
DRAINS -FL R.ROOI'. AR .COND.
URI -PERT IIS
IIXTS
GAS - En. SYSTEM -I INC. I'LISI'.
I have and will maintain Worker's Compensation Insurance. as required by Section
3700of he Lelear Conde, for the perfnrmanceol'the work tar whicb this perms is issued.
(KC GIBIDµ- APN
GAS - ITA. SYS TEM-OVER 4 CA) Y---
My Worker's Compensation Insurance carrier and Policy number am:
Currier Policy No.:
-�'�-
GREASI%INUUS'1'Rh WASTE IN'IERCIi19Ult
CIIRD[FICATE 01: EXEMPT ION FROM WORKERS
COMPENSA1 ION INSURANCh
BUILDING UIVISI(1N FRITS
Gi ixsoction nwrinat be compleledd due,r I in faronc lunndrat Jnllau($1no
,it less)
I easily that in lhemiLrinunmof thcwerk forwhich l hi,crmil is issued, Ish:dl
not employ any pcwon in any nnunner so as m hccmne subject In the Workers'Cont
,/(��
GREASH IRAII WZ)
PLANCHECK PTI!
SIMER- SANITARY - STORM EA. 200 Fr. I /
ENERGY R11?
WAI ER IIEAI'12K W/VGNI/ELECI'R
GRADING hili
Z mlion Laws of Cithfnmia. Dae
Z O npplkam
NODCE'IO APPLICANT: If, after making• this C,i ificate of Escmpuon, You should
f•-' ? hemm objector me W'orkds Compensaion pmvislom of the laluo Cale. You muss
Wforthwith comply with .such provislo-t is permashall he deemed revoked.
a CONSTRUCTION LENDING AGENCY
rnce of
tmainn lending for the perfoma
U O Ihercbyaffim+the' there isa cnmagars,
W H the work for which this perms m issued (Sec. 3097, Ci, C.)
I.tnd ', Na
o
LLI heed 'ALJ s
� I ffY lhllhn 'dth: pplifdl 1.11 Ihal lh b itf 't
rto tun g I reply olocil la'Rod ly I' e.I I hr' gt+
UZ. bui6hnganuvucunn, unJhcrcbyaulhuriec repressnahvd ,Ithn�tyloenterupnthe
WN ITR SYSTI:Mn*REATING
SOILS PEserum.
WA'1'INS SERVICE
0a Receipt p
NEW RESIDENTIAL PLMB. SQ. FE;,PAID
'I'OTAh:
TGIAI`
/ O.
QTY. MHCI IANICAL PERMIT I.FE
I'IiRMI'IISSUANCE
AIT iib OR ADD TO MF,CH.
4BUILDINGI
g*7
abmrntenlionnl propcny for inqu,iown pur,mr,
1Wel ugme In saes, indemnily and keep harmless the City of Cuprnino again.ap
and expenses which may in any way accrue against said City
rI!�himilitievjodgmmiu,roses
p`-6;/to
cunm9ucaec of the granting of this permitAPPLICANT U NUERSTANDS AND WI LL COMPLY WI'I'If ALL NON -POINT
AI R DANDLING UNIT(TO 10,000 CFhf)
h1ECHAA.
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER IBM) CFM)
CONSTRUCTION'1'AX (7'
1 Signameof ApplicanUCumetimr Date
EXHAUST HOOD(WMUCD
HOUSING MITIGATION FEE
HAZARDOUS MAI 'ERIAI S DISCLOSURE
Will lheapplicanlo, future nuildingoxcupant semeor handle haornsh smaerial
as dctie,d by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Sccdon 25532(a)4
BEAT ING UNIT 00100.000131' U)
IIHADNG UNIT (OVER In)," BTU)
RAI 'ION PAN (SINGLE RESID)
El Yes ❑NuV17N'I'
PAID -
U:ne Ilce<IpIM
Will fit 'p"Imal or future hidingis 'qtP + J res wtid+
II N : ant I' Ilnedby( ItyArea A Q ht,Mnagmnutl
8(111 PR COMP'(3111'OR IIXI,IllX)N'I'UI
q
'IT)'PA.. 3
BUILER CONIP(OVER 100,00013'1 U)
s t
UI to
❑Y: Fl N,
AI R CONDI'11ONFR
ISSUANCE 'I`]ATE
"ame read the leemajorr, meserialf, mquircurems under Chapter 095 ofthe Cal
NEW RESIDENTIAL MECIL SU. Vf.
forma Iltvlth k Safety Code, Sections 25505, 25533 and 25534. 1 undcnla"J that if the
hulliingders not cutmntly have a meant. that it is my respnmihilay to ratify Inc occupant
of the requireasom which must be met prior m issuance of a Centipede of Occupancy.
T(1TA1.:
ISSUED BY: V