S 3856 Permit APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUII•DING UI VISION APPLICATION/PF.RMIT 1'LUMRINC-fsIF,CHANICAL S 3856
+;,BUILDINGPROJECTII)ENI'TFICATION pl'i 11.01;!,
BUILDINGADDRHSS: SANITARY NO, APPLICATION SUBMITTAL(ATI?
r o Ste' h,F4� -044 6a' b3 LIT-
OWNER'S HONE: CONTRACTOR'S NAME: LIC NO:
NIC CONI'HOLa
ARCHITF;C''/F. .R: LICNO'. ADDRESS: ❑
CONTACTf. PHONE: •It}�„!;;.ii-'BUILDING PERMIT INFO,`
6 /Q ❑ Consultant Fees Paid by Applicant(Initial) D LE PL E
ICENSCD ONTRACTORS DICT\ ATION '' L + II t +IN+
QTY , ELECT121C PER MPI;, tf .1•PEE;J+ '
p l hereby,R int m o l a,t I used under p f Chapter 9(commen g i s + t t + +'1 ( ../ -.IL ,r., J DESCRIPTION
LJOz' hSrstlnG(XX))of Di m3ofmollusnesam Pr s a nyacc
F O w full force and effetl PERMIT ISSUANCE
'” �•5 f
L [I KITCHEN RHMODEI.
QzW License Cl s L,CN APPLIANCES-RISIDENTIAL ]TION ❑PLUMBING RE-PIPE
yG 4 nam Comrc r
E•]y ARCHIIECPS DE 1 PANELS
I-UNIT•'• ❑STRUCTURAL
zOyz [tin cost a my plans shall W used as public records ` MODIFICATION
Oz"0 UPTO200AMI'S RIOR 9CHIMNHYREPAIR
�4�WLicensedProms,innn 201-IWOAMI'S OVHMENT E]SWIMMIN OOOWNER-BUILDER DECLARATIONOVER IpOUnMPS �j DEIl12EPA1R DDGM64tTI•N
C Q 1 hereby affirm that 1 am exempt from the Comme,or's License Law,for the (
kO L U following mason(Section 703 L5.Business and Professions Code:Any city or county SIGNS ELECTRICAL t
lel 40¢ which requires a permit m construct,alter,mmpmve,demolish,or repair any structure t•���
prion 't 9 thef hpermit t flsignedstatement SPECIAL CIRCUIT/MISC. - �'✓
pr ,hath 'I Ip n m P of the Coal t L I (Chapter9
00 (wan .g 1hS f 11NNp ID 'ro l f,l ❑ : e.su dP I t:C do)or IP.MP.METHR OR I.OLE(NST. COMMERCIAL:
d a p,fY, mat he is exempt henchman and he hai s for me alleged exemption Any violation of - ❑NEW BLDG IATION ❑DF LITTON
Scamin 7031.5 by any applicant for a permat subjects the applicant to a civil penalty of POWER DEVICES
tL m [:1 TENANT
V ❑FO SERVICE.
~=Om mom than five hundred dollars(SYRO. IMPROVEMENT
�Lasownerofthe Praperm,or my<mploye<s with wagesastheirvele csnnpensamme. SWIMMING POOL ELECTRIC
6F will rathe work,andlhes.ucome knob mendedmoBcrud forsele(Seo.Jf141,Business ❑OTHER
611 ee and Pmfessions Code:'the Cnmraemes License Low docs not apply to an owner of OUTLETS-SW ITCHES-FIXTURIiS
L property who milds or improve mown,and who does such work hlmxell',,through
his own employees,provided,hat.such improvements arc not intended or offered for NEW RESIDFN'I'IAL ELECTR SQ FI'.
sale.If,however. he building or improvement is sold within one year of completion,the SQ.FT,FLOOR AREA .USQ.FT.
er-builder will have the bandana of proving that he did not build or improve for per-
pweofmle.). a � /l
❑ 1-as owner of the property,tun exclusively contracting with licensed protractors to TOTAL •V
,oration(hit pr gcat(Se VM4 11 d Predictions Cola)The Cm a...or,L t t , , t-+ _
e Lnw dws rot aPplyt rp penY h b'IL ter improves therein arta QTY.'„','t A.,f+ PL BINC PCRMI"f 41 zii-i, :TEEM G
hocontransfnrsuch projens with acnnvenorls)I ce rased......ntmme Cinnamons it + +' t. UG�
Limemelsw PERMRI U 'CE - /-
❑IamexemptunderSm, ,B&PCmrmismason
Owner Date ALTER-DRAIN&V; -WATL VAL TKTN
WORKERS COMI-17NSATION DECLARATION BACK FLOW F-G C T DEVI -\/
I hereby affirm under,malty of perjury nuc of the following Bederstions a
«�l have and will maintain a Cenilicam of Comenno self-insom for Worker's Compen- DRAINS-FLOOR,ROOF AREA.GOND. STORIES TYPE CONSTRUCTION
sari..,as provided for by Section 31W of me Labor Code,for the performance of the
work for which,his Permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3100 of the lamnr Code.for Nrf rmunceaDhe�RANIE
r is issued. GAS-EA.SYSIEM-IINC.4OM.ETS
My Worker Ion OCC.GROt1P APN
�'�'�P ns.�t
Carrier: �- fR�FC TEOFH GAS-BA.SVS'THM-OVER4(HA)
13RTIFlCwTE OP 1iXF.MI'TIONCOMPENSATION INS GREASFIINDUS'I RL WASTE INTERCEPTOR
if he sf ddalan(bl0p) BUILDING DIVISION FI?PS -
Gimisuc- i tied ryM�gyt�leyl�opepryy�f�ye hg� CREASE:TRA('
.ter less.) W�eN ty(-\K/''Ul�G(Ju, ILds Pl/e PfANCHECK FEG Gj
I ccnifyrhann perfnrumeaof th In h' h ,isiss"ed,[,hall SHWGR-SANITARY-STORM EA.2fp lrl'.
not employ anypenon in any ntnnner nu as m frec.nme suhjccl to the Worgcrd Comport. LIS BRGY FEE L}"�s 20
Zsedan Lowe of California,Date
0 WATER HEATER WIVGNT/ELGCTR
Z t' NOT(am GRADING FEF.
NOTICE q CE TO APPLICANT:If,rs ager making hie Cenons of of Esemplion,you should WATER SVST'IiM/IAGTING
a ; become subject In the Workers,a nes or this provisions of the .red Celoa you must SOILS FEE
[l7
forthwith comply with such Dmvixinm or permit shall be deemed revnkeJ. WATER SERVICE
O CONSTRUCTION LENDING AGIiNCY NEW RESIDEN I IAI.PLMB. SQ.FT. PAID
I hereby affirm that there is a construction lending agency for me p",fornnu etif Dole t.Receipt#
LL F•' the work for which this permit is issued(Sec.3091.Civ,CJ
O Lenders Name TOTAL:
>a W Lender's Address IOTA :
asI in ify that I have it thka,fict and state,hut the aboa,information' - - BUILDING FEE
h conetIr , ply 'tit a iO e county admmtceada, In t gt !QTY, MECHANICALFERMIT �'' 'FEE I
V7- building atm'onatd herehy+mhrrze representatives alibis cty,oc,c-.Ammo (r.f +Is, tS{!(+ SHISMICFE
above-mentioned property forinspection partieses' PERMIT ISSUANCE w'1'1 •. /O
(We)agree to sive,indemnify end keep harmless dm City of Cupenin.against ELECTRIC FE 2 14
Iinbiliries.judgments,costs and apeows which may in any way nomeagainxt said City ALIERORADDTOMECH.
in nuquenc of,he granting of his Permit. PLUMBING FE
APPLICANT r
NOR ANDS AND W LL COMPLY WITH AL.N N-POINT AIR HANDLING UNIT(TO IQmX)CFM) MECHANIC .FEE
SOURCE i CATIONS.
7 a AIR HANDLING UNI I'(OVER 10,0kin CFM) CONSTRUCPIO TAX 3
Signmur plicanUCommno Date EXHAUST HOOD(W/DUCp HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant stores handle hazardous material HEATING UNIT ITO 100,0010 BTL)
as defined by the Cupertino Man it tpal Code.Chapter 912,and the Health and Safety
CiA,Section 25532(")1 HEATING UNIT'(OVER IfluiW)B'1'UI
❑Yes
VENTILA)'ION PAN(SINGLE R FMD) PAID Will,M1e applicant or atone Wilding t use meat or devices which Date Rueipt N
pp gby then egmp BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air conmminants as defined by the Pay Arca Air Quality Management TOTAL:
District? I-/ BOILER-COMP(OVER I WBO0 HTU)
J E]Yes y�No
I hove we the hnzaN,o]u�s\ounnials ranoirentents tinder Chapter 6.95 of[tie Cali- AIR CONDITION(?It ISSUANCE
DATE /l/r
feria He afety Code.,adorn 25505,25533 and 23531.i undcrBy thin if me NEW RESIDENTIAL MECH.
boards m, scu dyh. Tion to it is53 sand 25534,1 o,ify ercupan,
ofine a n: hi m t n to issuance of.Cei 0.' f ncy.
Owner or uthorize on[ Data TOT LCSUHp BY:
OFFICE