S 3098 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITV OF CUPERTINO IIIIIhDINf,.ELECTRICAL Piet]I*No 3098
BUII,DING DIVISION APPLII.KPION/PERMIT 1'INGPLUMING.MF:CIIA MECHANICAL `v
BUILDING I'ROJECI'IDI!N'1'It'le\'P[ON
BUILDING ADDRESS. SANITARY — AP PLICATION SUIIMITTAL DATE
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OWN'R:SNAA1 � I'110N1i CO.T ACT0t)NA e: p - I.IC No NIC CONTRULM
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ARCITHICT/ENGINEER: LIC NO: AU)RIS': !~FI_* awL ❑
CONTACT
PHONE: rFl BUILDING PER INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ 01, ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby eirmt the,I nor fie...ell ander Pm.isinnx of Chapter 9(commenem, JOB DESCRIPTION
"Z Xaa [,jau,`Cl:us If Iol'UivisiunBofthe Business and Pmawwions Rda,and my licenm is El SFD RESIDENTIAL:
`a' PERMIT ISSUANCE
H a ".,,,,)ccand rlbwc ^7Z11b9 ❑MDWL ❑KITCI{IiN REMODEL
C F Ltc.a / APPLIANCES-RESIDENTIAL ❑ADDITION ❑PILA1tlING RE PIPE
FZW p Contractor 1/s����/La 106' OMGLTI.UNf1' ❑STRUCI'URAh
ARCIHTECI'S DECLARATION PANELS
Fm'Z I understand my plana shall MusD as public recad> MODIFICATIONOZYQ UP TO 20()AMPS C1 INTERIOR ❑CHIMNEY REPAIR
rN�W Licensed Professional 201-1000AMPS IMPROVEMENTSWIMMING POLIS
z,7- OWNER-BUILDER DECLARATION OVER IMOAMPS L3BATH RHMODELiREPAIR EIDEMOLITION
CK=a I hereby affirm that 1 am exempt front the Comment"License Low for the ❑01TIER
Il a O following rason.(Section 91131.5.Busineo'and Prafcsvions Code:Any oily nr manly SIGNS ElrCTRICAI,
which reclaims u permit nt comma[blue,imp,me,demolish one driven,any oni Q�
paidt ,'.. lwer'lifinc,the.ppficuld,f h varaild,file di,ignadatinceirem SPECIALCIRCUII'/MISC,
Nythat lie is licensed p :t u tile provisions(if rule Contractor's License L (Capterl COMMERCIAL:
p (carefu og with Section 7000)of1)vsou3at'the Business and professions Can)or 'ILMP MIST ER OR POLE.INS'I'.
a a e that he is exempt tMrefrom and the basis for the alleged memption.Any violation of O NEW BI.DG/ADDITION ❑DEMOLITION
Seel 90)1.5 byany tritium,for a permit subjece,the applicant Ili a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
rn not mor a than live hundred dollars 0651010). IMPROVEMENT
=QD1.as nwnerof the property.or my employees with wages as their sole compensation. SWIMMING POOL IiLIi IC
F. will Jo the work,and the structure is not intended or offered forsale(Sce.AVW.Business ❑OTHER
W w t,ad I'rot,,sx s Cnde!The Contractor's Liana:Low dnun not apply to un"wall of OUTLIi'S-SWI 5-I IXTURCS
L property who builds or improves tMmon,and Is ho does well work hial Cor though
his own employees.Provided that such improvements an not intended or offered for NEW BitS1UENI' I :CI' SQ PIl SQ.IT(LOON AREA Sal EI'.
sale.If,however,the building or imponcmem is sold within one yen of completion,the
own
m-builder will Intoe the hmdev oI'proving that ha did sol build or improve for pur-
pnm n(wlcJ. / OTA -
I,es owner of the property,um exdunivdy omm�ning witM1 IicemeJ atmmnon ht
msec,the prMcet(Sas 11144,Business and Pmfe,sions Cade:)rile Corr emr's Li.
cense law docs not apply it)an owner of pmpeny who builds or inym+ves thereon.and QTY. PLUMBING E 71' FEF,
who contracts for such projects with.contmcmrts)licensed pursuant o the Contractor s
license I'll.. PERMIT ISSUANCE
�l oat exempt under See, .B&P C for this rrnsnn
ALTER-DRAIN k VENT-WATER(EA) VAI,UAIION
Owner Dine
WORKER COMI'1!NSA'Il(1N DEChARAPION RACK Il.(lW PR(YI'I?CT.DEVICE
�flhertby afrma under penalty of perjury onenf the Lllm,f dmluer',Cc:
�I as owi.jI...by Section
370K)ofConwnu.Colt-insarefor Worker's Comp cm UR,VNti-I1WR.ROOF AREA.COND. STDR{� PE CONSTRUCTION
!"0, tido.as pmvmed lar by ,i..illHl of he land,em1e,ma me pcdartnttncc ser me
�1t r which this prima n issued, 19X'i'URES-I'Elt'I ItA1'
�f have and will maintain Wnrkds Cnmpenraion Immranre,as required by Section FF Inno
J]BI)othe Labor Code,for the peramnanec of the work for which this remains issued. GAS-I:A.SYSTI;M-IINCAO1Jl'LETS Y 1 OCCGROUP MIN•.+ + I
Ell' QQI cn:inion '1'ol cY NaNr r , O/ GAS-RA.SY51'GM-OVEIR 4(EA) §
CIiR IFICA'TE OPIi%fiS11RION FROM WONKIiRS' GREASMNDUSTRL WASTE INE RCE C
COMPENSA'HON INSURANCE JILDING DIVISION IBES
flTis w0lonneednnt Secom"Ic'edd Ieprount iNonreebnndrWAullnts($FX) GREASE TRAP
or lcssJ I'LANCHIiCK Itifi
I cenify,ut'mthe perfaranal ofthe Is k for which his Perini,I,i...cd,[,hall SEWER-SANITARY-S IORM Els.200 IN.
not employ:my pmxo.many man all as to become soared m the Workctp'C...t Ebl PER
2 an..laws of Cuba iA.Dale WATER HEATER WN17N'UELECI'R GRADING ITC
I z 0 Applicant
NICE OCl?FOAPPLICAN'1:It,ahcr,raking this Certificate(If Usivalption,you should WATER SYSTEVirrREATING
F r becomr object m the Workers Com f the Li l i Rule, ',a'I'll" SO]US PEE
j penwnvt email hal o
PG � forthwith comply with such pmviaintn.obis pcnnit shullMdttmcJ revnkN. WAIIiR SERVICE
❑ 0
CONS'i'RUCHONLENDINGAGP,NCY NEW BESIDE Date PLMI3. SUIT. PAID
^" Dom Rad to
U 0 I Mreby vlfmas,at
Timor
is sued(Sec.30lending agency Entire peramnanee of
U. F the work for which thin Pcmtit is inwcJ(Sec.3(19].Civ.C.7 'TOTAL:
O U Leader's Nmnc 'I1)'I'A L: /
r W Lcndcr s Address BUILDING Ell,
d 1 certify that I have th this application and star that the above information retain,is
U Z aarrem.lagree
mar Cot a r,oil,add with all airy and countyamiordinances;nd nate laws rdaing to Q'I'Y. MF.CIIANICAI.PERMIT Flifi SEISMIC 19i1i
U z building convwmidn.and Mrchy oulharire rgtrescnmtivcs Col this city to coma, on the
above mentioned property for inspection purposes. PERMIT'ISSUANCE ELECTRIC PER
(We)agrcc m save,indemnify and keep hamJess the City of Cupertino against
habil ltim,judgments,costs and rs,cr,cs which liay'm Any way accnm against said City ACI'ER OR A DIT TO Il I, PLUMBING IIiE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(`010.000 CFMI MECHANICAL Illi
SOURCE t-J2!_fiULgl�0, S �O
NUT
AIR HANDLING UNI'1'(GVHR It1,111NI CPMI CONS'1'HIIC'fION'I X
Signaturu�picall//Coontradmr am EXHAUST HOOD(WNUC) HOUSING MITIGA'I'If plili
HAZARDOUS MAI ERIALS DISCLOSIIit:
Will the applicant or future(wilding occupant store or hall lc hec nines material IIF,AI'ING UNIT TO I(X)L(XX)B'lJ)
as defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,00E 13'1'U)
Code Section 25532(a)'I t,,r�
❑Yes VEVI ELATION PAN(SINGLE RES ID) PAID
Uaro Rcmipt p
I WJI the.PPI¢^nl ,,furore building occupant use equipment or devices which BOB ER-COME'(311P OR I000RI BTUI
area hamrdom air nmmnducal ns doral by the Ray Arca Air Quality Mann
age eW '1'f
Donald?
_/ BOILER-COMI'(OVER IBL(100 BTU)
1-1 yes V N.
Alit CONDITIONER ISSUANCE DA'I E,1 have vtJ the hanudou.materials mqu:aemcnts node,Chapter(�95 of the CallAIR
Health&Safety Code.Sections 25503,''55]]=125511.1 understand that if the NEW RESIDENTIAL SUCH. SQ.FT. �ell-
� /3 /Y
building does Icum:ml,It,, um thud ax my resrymdhllitymnou y the punt C x-% o
same rtquirenmms.nicht t r wane nlaCcnilic/y)g /{,lac/y[yC/yyy+� -
/• /O/ U TOTAL
Osturoruuh uada t )mc ISSUEDBY:
gen
OFFICE