S 3276 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO fill]1.DINO-F.LFIC'I'RICA L PlitIT NO,
BUILDING DIVISION APPLICATIONMERMIT PLOMH1N'G-MECnnN1CAL 3276
l`7
BUILDING PROJECT IDEN'TIF'ICATION
HUILDINi ADDRESS: SANITARY NO. APPLICATION SUBMITI'ALDATE
2 D /o z---?
A
' NEIi$NAM1 PH!
DN1i: CO RAC 1) 5 NAAII',: LIC 40:
�ARCIIITECMSNGINCER: WiL'CNj: 1 NIC CONTROL#
AU RESS ❑ -
CON'PACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ULDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. 'ELIIC'1RICPL'RMPP; FEE
I hereby nllknt dmf I nm renrwd under rmvownx of Gunner 9(ennnneneiny ]OB DESCRIPTION
QZZ with Secular 9000)ofDlvjsion 3 effort Ousinessanl Promsions Code,andnry lkcow is RESIDENTIAL:
ul0 PF.RMI'T ISSUANCIi� ❑SFDWI ❑KITCHEN REMODEL.
F1_ in full litrce unA eHc
�UU .air ic.M APPLIANCES-RESIDI.NTIAL ❑ADUI'f1ON ❑PLUMBING RETIPE
waw nam Contmnor
ARCHITECTS DELL A'1'ION ❑MUI:fl-UNIT -1 STRUCTURAL
z O res Z 1 understand my plans shall he used as pa m records PANELS MODIFICATION
024p UP'10200 AMPS [I INTERIOR Ak'TITMNF:Y REPAIR
F W Licensed Pretentious) 201-1000AMPS INIPROoTMEN'r E)SWIMMING POOLS
w C Q I hereby aflirn OWNER amexemp BUILDER
he Connmors License Law home OVER IM)ANA`S ❑IIATH REMODEUREPAIR ❑DEb10LUION
aU following reason.(Section 9031.5.Business and Professions Crick:Any city m county SIGNS ELECTRICAL ❑OTHER
which rtgaims a permit to konstrucL vlfer,improve,demolish,o,repair any, lureto
priurmilslsvuance,alsurequim,the applicant for such permino rile a signed statement SPECIAL CIRCUIT/h115C,
� Pt firm he in licanwJ pursuunuothe provision.of the Cnmmmor's lJconsfsnwlChopter9
� ca that heenc xcon,s therefrom
of,Istusof rOn al a ed sand n..Any
Profession,Collor)On TEMP.MC'I'i?li OR fK)LE INSI'. COMMERCIAL;
LL Qtr tv' that he is 31.5 hf fhercfmli applicant
the haus far the alleged l,fica ion.Any viear inn of ❑ EW HLDGIADDITION ❑FOOD LITION
SERVICE Secdnn903LSve Ivry heddnmrs(S Permit nuhjeefs the applinnmm�civil lwnalfy of POWER DEVICES TENANT' [I FOOD SIiRYIGIi
z not1,tsov un livchundralty,or my employees
IMI'ROVY.MIiN'I' .
�pd ❑ Ido the work,and Pmpcny, rmyemntendedwith ofemod for ihe(Sec.compcnshelsetion, SWIMMING POOL ELECTRIC
F' O
will do the work and the xtntmuro is not imendednm0'nmJ for sola 15ce.90N4,Huslness ❑O'flll?R
L 3 m and Professions Code:The Contractor's License Law does not apply m;In owncr of OIITIUTS-SWITCHES-FIX'T'URES
property who builds or Improves thercfm,and who docs such work himself or through
his awn etnpinyces,prnv)ded tbm such,improvements arc not Imended cr offcmd for NEW RESIDENTIAL ELECT'R SQ FT.
sale.If,however,the building or imprevemem is sold within one year(it completion,the SQ,IT,FLOOR AREA k/SQ.ITb
mer-builder will have the burden of proving that he did not build to improve for poo
ptw of sale.).
❑ rn
L as owner of the prnl &am exclusively contracting will,licensed contnumrs In TOTAL:
construct the pmjecf(Sec.700.Business and Profession.Cde:)'Bac Commctnrs Li-
wave, ace dotesnrn apply in an owner of property who build,,,,supreme,therenn,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commucions)licensed promises it)the Commences
License Law, PERMIT ISSUANCE
❑ Iaat exempt under Sec. ,It&I'C lin,his reins,,a
ALTER-DRAIN&VIiN'1=P'NfRN.{hpL-, - VALUATION
Ow
wa Dam
WORKHR'SCOMPENSATIOND1iC1.Al<AI'ION BACK FLOW PROTECT, CE {,� /- O O
I hemhy oflirnt unJr,Penalty of perjury one nl'the following dwlurvtions: as
I hawand will tnuintnin uCenifinem of Comonncuel-homc on WurkmMCompcn- DRAINS-FLOOR.IHX iA.CONDS I o�loo TYPE CONSTRUCTION
suJnu,as provided I'or by Seen 3900.1 he[,shot Code,fur the pnnnntnce e1 fire
work In,which this arrntif is,,mcd. FIXTURES-PER THAI
❑ I haw and will maintain Worker's CourPer ction Insurance,as inquired by Section
3901 offhe Lollar Coda,for the performance of the work iia whichthis permit is issued. GAS-F.A.SYS I HM-1 '.a OUTIA11'S OCC GROUP APN
My Worker's Conourre ion Insurance carrier and Policy number am:
Carrier. Policy No.: GAS-EA.SYS"ICM-(V (IiA)
CERI'IFICATEOFMEMPTION FROM WORKERS' GRF.ASFJINDUSTRI.WAS
COMPENSATION INSURANCE I1U11.DING DIV ISION FHIS
(His sectionnced nut be rompleted iOPermit he peit is fora relundreddollamr($1M) GREASETRAP
or IeSs.) i'1.ANCIIECK PIiE
I cenily that in the performance efthe work for whichmis pemtif is issued,I>hA SEWER-SANITARY-S'I'ORM HA.201 FT.
nm employ, r isninany manners astoCsubjectto the Workers'Cont HN1iRGY FEE
O z satin,,laws ulilncrior 1). WATER HEATER WNENI'IELECTR GRADING Igili
z Appli'an
r. N NOTIC11 0 AI' 1 A f,a cr making this Cenifcam of Ibernnion,you should WATER SYSTEh1/IREAI INC 50145 PEIi
become subject oto Worker's Compenwflon provisions of the laher Code,you roust
so
nmwith cuntply with such provisions or this permit shall he deemed revnkal, WATER SERVICE
Q �
UO CONSTRUCTION LENDING
ending NCY NEW ItIiSIDHNTIAI.I'LMIi, SQ.fT. I'AIU I'ulcvl Receipt#
I hurehyallatoelfthi Ihorohne Isaam(Set.i3( lending ngcncy Ibrlltc Perlin'nmmv til
!-s the work for which this pemtit is Issue)(Sec.31N],Civ,CJ
U Lender's Name TOTAL:
{U Lender's Address '1'(yfAL: BUILDING I:
I cenily that 1 have read his app]
icaion and Stam thin the above Innsnnntion is
i-
aVi ahrect,l agate too comply with ail city and county ordinances and stale laws rcl:nin610 QTY. MECHANICAL.PERMIT FE-E t^
C.) z building construction,and hereby authadze representatives of this city to enter upon the SEISMIC FEE J
above-memioned pmpeny for inspection purposes. PERNUTISSUANCIi
(We)agree m save,indemnify and keep harmless the City of Cupertino against 13LECfRIC Fli'
Iiabilifies,judgmenta costs and expenses which may in any way nec,ue against suit[City ALTER OR ADD TO MECIL
PLUMBING hili
in conseynce of the granting ld this permit.
uc
APPLICANT UNUERSTAN)S WH .COMPLY WITH ALL NON-POINT AIR HANDLING UNIT('1'O Hk00 CFM)
BOUNCE REGAL TION' MIiC11ANICAI.ITE
/ 2iC Sin AIR HANDLING UNIT(OVER 111,0011 CFM) CONSTRUCHONTAX
Siomomoral A,endlCCfmtrvnrSrTt ]Tata 1 EXHAUS"1'HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Thoapplicant nr notion,buildingoccupunfstareor anile hnznrdammmurlal HFATING UNI T('1'010t.00ITU)
a's d0lord 1, for Cupeninu Municipal Code,Chapter 9.12,and the Iudfh and ruler,
Code Selloff 25592(u)'I �� IIEA'1'INC,UNI'I'(OVER 11X1,11001{1'U) - -
❑Yea d/JNs t PAID
VEN'1I[,At ION FA N IS INGI,17 R ESI Df Umc Receipfp
Will Thu applicant,,,future building occupant use equipment(it devices which
emit hazadotionir nmfaminants av defined by the Hay Area Air Quality Munagemem BOILER-COMP(311POR 11X1,(NNI li'1'U) ` T A.
Dimdeet
❑Yes BOLLEN-COMI`(OVF.R IW,(10I111'fU)
1 have read the huz:Wnmmt
rtendm
s yuirtmenar utak(Chapter/.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safey Coi Sections 25505,25533 ma12553J.1 unskrsund thin if the NEW RESIDENTIAL NIFO. SQ.
but ldin Jfcnnmcto odyhave afenanLthat itismymamrsibilitytonotify the neeupanf
of cquimoment which t prix smunrufa Cenrem�f/apo cy.
11
ag a TOTAL: 155UEU BY:
OFFICE