S 3806 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICYFI0N/PERMIT PLUMBING-MECHANICAL S 3806
BUILDING PROJECT IDEM'IFICATION
y �f AI�)Rf:55: ��//�,/,uI`� /_ rJ1Y. ��y �Y SANITARY NO, APPLICATION SUBMITTAL DATI
*I.WACT.
R'S IS GE6 ofvTP[H�ONE: CO A sfe G0,V` NIC CONTROLSHII'ECUENGINEER', LIC NO: Alyyty 7S- �a�lssil /J//DzS ❑!J-0, PHONE: c�!!�'/(� `y(Y BUILDING PERMIT INFO
C /��a( �` �68�3�/ ❑ Consultant Fetes Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�jy( i^ �5- 2- C-]- L2-
LICENSHDCONTRACTOR ISDI:CLARSI'ION QTY. ELECTRIC PERMIT FEE
O=Z
I hereby mmrrthat 1 mm Iia•.sad under provisions of Coupon,9(cummmmcing JOB DESCRIP'T'ION
wadi Section 7OIDUd Division 3ofine Businessnnd Professions Cale.and dry,license is RESIDENTIAL:
IW-OO full fmce.od effect. PERMIT ISSUANCE SZi [J3(�WL ❑KITCHENREMODEI.
aUU act C- Lica APPLIANCES-RESIDENTIAL [I ADDITION [I PLUMBING RE-PIPE
N stas Datc Cnntmclnr
Fly ANCIII I'IiCrS UECI,AR 10 PANELS []MULTI-UNIT ❑STRUCTURAL.
Z p n Z 1 understand my plans shall he used a,public records MODIFICATION
OZ-O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
[FBF-4] Licensed Prlovamal 3014O10AMPS IMPROVEMENT E)SWIMMING POOLS
CYC; OWNER"BUILDER DECLARATION ssc�
(y C C Q 1 hcrcby affirm that 1 am exempt from the Contractor's License Law for the (IVT:R I(XX)AMPS ❑BATH RFiMO1)FHR1?PAIf�"�'DP.M0LTI7�N
X O G U fuIha ing,,rima(Suction 911.3I.S.Raminces unit Is I...am CUJc:Any city tit county SIGNS ELECTRICAL OOTHER
1+13 V-ha which respire.,a permit set cu..anim,alter,improve,demolish,nr repair nnY swclarc 1p _I--\�
IN
C)V1
prior mhs iswout—, leu reamrx,thcapplivent fn obla.ammo file uxiImcd,o intent SPECIAL CIRCUFUMISC. �I I
5 yEYn that he is licensed pursuant the provisions of the Contractor's License Law(Chapter 9 - e� ,I •I
tzog (commencing with Section 701 of Disision J ofthe Business and Professions Code)an TEMP.METER 0R P0LE INST. S '¢ I
a a o s that he is exempt merchant and the basis for the alleged exemption.Any violation of BL /ADD}TION LJ DIiMOLITION
..y Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penally of POWER DEVICES
TENANT FOOD SERVICE
nonore than live hundred dollars 65W). ❑
n
FZ6 Las owner of the rt.orm loess with wars as thcirmla,mri tion. SWIMMING POOL ELECTRIC IMPROVEMENT
property. Yemp Y 6 Penna E3 OTHER
(.. will dafhewons and the he rmare Comewhar,Livens Law do for Sala ply To an,come,
of
I�il�� and Professions Code The Conrrxtor's License Law Jces not apply m an owner n( OUTLIffS-SWITCHES-FlXTURGS
propos who builds or improves thereon,and who does such work himself or through
his own cntployees,provided that such improvemem.c um not intended or offewsl for NEW RESIDENTIAL ELECTR SQ FT.
site,If.howcvcrnha buildineor imprnvchima is,,,d withinonc year of comtpelion.the ^ SQ.PI'.FLOOR AREA SISQ,FT,
tier-builder will have the burden of pricing that he did not build or improve for put-
peZ (J� �(
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so of,ila.) / /�
Fl 1,as owner of the property,am exclusively contracting with licensed contractors to
construct The project(Sec.70,34,Business and I'mfesnlons Cel The Contractor's Li. /Y 2
cause Law Jres not apply to an owner(if progeny m
who builds or improves arcor.and QTY. PLUMBING PERMIT FEE
wlmeohnows fir such projects wins acorn..I sl licensed pti....un In,Commemrx
Liccmw I.aw. PERMIT ISS ANCE
❑I am exempt under Sec. B oft P C for this reason
ALTER-DR IN ENT-WATER(EA) VALUATION
Owner Date
WORKIik'S COMPENSATION DECLARATION HACK RO (lT1=DEVICE (.1 O O
I hereby Wllrm under penalty ofperjury nue offfollowing declarations / D
40 I have and will maintain a C'ertllicateof Con,col m Self-imme for Worker s Compcn- DRAINS-FLOOR, ill'. EA, ND' STORIILS 'I'YPECONSTRUCI'ION
,alio.,as provided for by Section 37W of the Lots Care,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
Cl 1 have and%ill maintain Worker's Compensation Insurance,as required by Section
3700mhe labor Code forboperformanccofthe work for which thispermit is issued. GAS-EA.SYSTEM-11 Y Of ETS OCC.GROUP APN
My Werke' lair tram rearricrandl'olicy num t•rt GAS-EA.SYSTP,M"UVI?KJ(,
Carrier: ! _IYdlcy No, GAS
✓���: TIF CATS p ISATIONION FROM OR(kiRS GREASMNDUSTRI.WASTE INTER EITOR
COMPENSATION ON INSURANCE BUILDING DIVISION IBES
(Ihix>tttinn nudnot be atmplerN iOhe ptmit is(Drone M1undred dollar($1(1(1)
or Icss) GREASETRAP S
PW(CHECK hF.E
Iccoil'yominflut rfnfmunceofd,� kforty ' thixpennirinismcd.lsholl SEWER-SANITARY-STORM EA.2O0 IT.
not employ unypetron In unY inimnerro a,la filo ccuo the Workers'Cnnyen. ENERGY FE
Z ration Laws Of C31im ni..Date WATER HEATER W/VIiNT/ELECfR
O O Applicant -( n s GRADE
Z
NOTICE TO APPLICANT:If,nfer making Ill Certificate of Exemption,you should WATER SYSTEWfREATING
F ; become subject to e Woderx Compnsaion provhio,of the Labor Code,you must SOI E
m
forthwith comply with suchprovision,.,,his permit shall he deemed testified. WAT12R SERVICE
Q
CONSTRUCTION LENDING AGENCY NIiW NIi51UEN1'IAh I'LM13. SQ.PT. .AID
U O Ihceby ulRrm That mere lsuamamcdnn lending agcncY for ec
he performance of Dam kciplM
P To work far which this permit is issued ISce.3097.Co,C.)
Lender's Name OT,
O LfD
� lenders AJJreu 0
0s I ccrNy thus 1 have rand this application and state that the above information is
BUILDING FEE
h um,ca.I bgrsc m comply wish all city and curly ordimmo:cc and taws laws rcluting m QTY. MECHANICAL PERMIT FEE
U Z bconstruction.lding construction.and hereby authorize representatives of this city to enter upon the SEISMI 0
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
rase,
(We)agree b indemnify and keep harmless me City of Cupertino against I ELT IC .E
Iiabilitio,juJgmems.costs and expense�which may inany way ocerue against said City ALTER OR ADD TO MECTU
tmcyucncc IMgramimgo(1yiCp)fmif. PLUMRI' FEF,
APPLICANT 1NDE-f TANI _ ff��WILL C(IMPLY WITH AI.I,NON-POINT qIR IIANDLINGUNI'f(TOIU,UIN)CPM)
SOURCEI TI NS MIiC N L
AIR HANDLING UNIT(OVER TO."CFM) CO TR ION TAX
Signmurcof App aM(tntrraoroat EXHAUST HOOD(W/DUC) HOUSI'k MITIGATION FEE
RDOUS MATERIALS DISCLOSUI.0
Will the applicant or loom,building uectrylul smrcnrhundle hurardous nturnal BEAT ING UNIT(101O1,(5O BTU)
as defined by The Cupertino Municipal Code.Chapter 9.12,and the Health unit Safety
Cala,Sfnlion 25532od! 1117ATING UNIT(0VER I0,00n BTU)
❑Vias VENTILATION FAN(SINGLE REMIT) PAID Dam Receipts
Will the applicant or fume building occupant use eyvipmem or device.,which
it hm.urdmu air conmminana its defined by The Bay Area Air Quality Management ROILL'R-COME'(31111 OR 100,000 It PH Y'AI
I
artist'! ��� ��� BOILER-COME'(OVER 10(i 0'TU)
E]Yex XNo
I have mad me hirowl materials eyuiremem,under Chapter 6.95 of the Culi. AIR CONDITIONER ISSUANCE DATE
forma Health h Safety Ca 'Minns 255 SD end 2555,1 understand That if the NEW RESIDENTIAL ATHOL SQ.ET.
huiWing doa,nnt current un ort spry mspon,thhity b aunty a he aacu wn ��
of the rcyuirencents chic 1h natponoissunce ilicate off an
Owner orauthon gam ate T T f ISSUED BY:
OFFICE