S 3373 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN0 BUILDING-ELECTRIC'AL 19!R lI NO. 3373
IIUII,DING DIVISION APPLICATIONIPERMIT rLUMBING-MECIIANICAL ``7
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANI'I'ARYNO. APPLICATION SUBMITTAL DATE
103'+S MA4?y AvE CvAETNo LA gSoi4- t34D Z22- 9
OWNER'S NAME. PHONE'' CONFRACIUR'.NAME: LIC NO:
• LW wASio-£w Stu CL�t� 14z-31� JAMS ER0,K\cAL- 6193II NIC CON,RGI.a
AHCUI'IISCTl1iNOIN[ER: LIC NO: Pt)1or\� 32gS StI JoGE [P gSISb ❑
CON'I'ACC: PHONE f L IO BUILDING PERMIT NFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MITCH
❑ F� ❑ ❑
LICENSED CONTRACDEUS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 ant licensed under provisions of Chapter 9(commencing J013DESCRIPTION
4100 vLon
Z with Swain7000)ofDi . 3 ofthe Business and Professions Cn le.and my licent,in RESIDFNTIAI'
PERMIT'ISSUANCE
C�E� in till force and ellbet. ❑SPDWI. ❑KI'TCHI!N RIiMOUEI.
auu License Class Lica APPLIANCES-RISIDF,NTIAL ❑ADDITION ❑PLUMBING RE-PINI:
f-Zty Date Contractor
m<T nRClIITF.CFS DIiCLANAI'IU.Y ❑MULTI-UNIT ❑STRUCTURAL
~yZ I andevendmyplan.allull be mad u. bl' UP TOS CHINIPICATIP
u R mads
i ON
ZOZNC r UPT021x1AMPs El INTERIOR �GHIAINEY REPAIR
F-4F41 Licensed Plnfs,innul 201-1000AMPS IMPROVHMENT E]SWIMMING POOLS
ZYE; OWNER-BUILDHR DECLARATIONOVIiR I(XNIAMI'S [D BATH R I:M0DFIJRFPAIR ❑DEMOL]'I'ION
yy C W 6 I hilelo affirm then I'allesInda lin.the Cn lion nr'.v License Law liar the
F 3� Gdlnwing tnoxon($eeimn 7031.5,Business and Protexaiom CodCod.:Any city or....nty SIGNS ELECTRICAL
WDOTED:
IC
y which r q . ennum comment.alto p e dimmulikh.or p structure tructure 2 1 ��
F4.OJ pile f t ':. assts my .th ppb ff chis in fl .g J.n ¢mem SPECIALCIRCUIT/MISC. .Q
,_$ } intoh f monedl thin pa.,kiamofffic Commml I lalrole I-ase Chapter
Wr1110
(connncnangwifb Sectlfnll)(X))ufD....into 3ofthc WatmsenJPnfur'nm Calep'r FEMKMI!TERORPOLEINS'L COMMERCIAI,
a o.e C tON
hat he is exempt therefrom and the basis for the alleged exemption.Any violmion of ❑NF:W BLDG/ADDITION ❑FOOD SIT VI
Section 7031.5 by any applicant for a Permit subjects the applicant a civil Penalty of POWER DEVICES ❑TENANT ❑FQGD SIT VICE
not more than live hundred dollars S50q. IMPROVEMENT
�zd p Lmnwnerolme property.or illy mnployces with wages as their side mmpensatlon, SWIMMING POOL ELECT RIC
OIIILR
w111doework, dou,neeme,is not Intended mounted for sale(See.IDM,omni,,
mun
Y c
-'N' TILS-FI%l'URES
13 m and Ikuleshie b CWe The Com Haste License Law,does net apply s if owner of OUTLETS S ITC
pigmy who builds or Lmproves'ne,It i and who Jeer such work himself or through
his own employees,pmviJnl that such intpnrvcmcnta are urn intended nr nticreJ los NEW RCSIDENTIAI,FIAT SV IT.
rudu.lf,hrwcvcr.nhu nuilJingrnimpnrvcnmm ismldwiihinn12I'd lanrpteT:i`lhu /iJA Irl'.II,OOHANHA 3150.PI'.
owner-builder will have the bnnkn of proving that fecal not tmild or implore for par- C.ly
ee.f eileJ. AL: O
�I 1,as owner of the property an:crehesivdY contracting with licensed contractors m s
4 trust the prnjecl(Sec.9(s44,Buamre.nu l Plotrssimry Cude:I ine -trour ll I I -
st,Unedoesnotapplytoanownerillproperty who an Ids or intpnnes thereon.and QTY. PLUMIIING PERMIT FEF.
wnu contracts for such projects with a commera s)licensed pursuant o the Contractor's
License Law. PERMIT ISSUANCE.
l sen exempt under Sec. .13 A,P C for this reason
ALTT
ER Tk(BA) VALUAION
- .L
O YDate
( ORKER:SCONIPENSATION DECLARATION BACK FLOW PROTIiCT.DEVICE
1 hereby affirm under penalty of cont,one ofthe fallowing Jeclarmiom:
ih:tvu and wilLnuimain aCurtllicmcol'C�n.cnrmsell-imfafnr Werke-Conlpen- DRAINS-FLOOR.HOOF,AREA,GOND' STORIES '1'Yft!CONS'fRUCI'ION
NaOor:,us pruvidel for by Section 3900 of the"but Code,far he performance of the
irk for which thin Nadir is maned. FIXTURES-PER'FRAP
E3 1 have and will maintain Workers Compensation Insurance.as required by lection
,,00flhclanor Cndc,lortheitcrmore ceofine work let which this perm,i s issued CAS-I!A.$YSTEiM-I�WCfJ'OIJ?LETS� DCC OHUIII' APN
My Worker's Cil 1paeation Insnranw earlier uad Pok,oumficr are: s
Cartier: Policy Na: GAS-1!A.SYST1iM OVER41EA1/� +
CE IFlCATE OF F%I1.IPFION FROM WORKERS' J
COMPENSATION INSURANCE GRI!ASIaNDUSlRIINI"STC:INITI,�I!H((CEYTOR BUILDING DIVISION ITIiS
ITho,eelin treed nil neom IOM it hepeout is li,rmnch:n:Neddollars(SIINO GREASHTRAP Ulli
it nr kn*1 fr" 2 2 A I I'LANCIIIiCK PEE
I certify that intoe performance ofthe work forwhich this t s issued. shall 1U11 Peen' iidl SEWER-SANITARY-STORM PA. FI'.
not employ any person in any manner Nn as m become subject to the Workers'Cnmpm ENERGY FEE
Z cation Laws id California,Date WAFER HHATER N4WENT/ELEC'IR
GRADING I9?C
Z Applicant -
NOI'ICE TO APPLICANT.If.after making this Ceniticate of Esetnptinn,You should
O'ATF.R SYSTEM/1'REA'I'ING' -- — SUILS Flit!
F' hcatme sobject to the Workers Compensation pressures of the Labor Cade,you must
limhwim comply with such previsions or finis permit shall of defined rcvokcd. WATER SERVICE f
Wy Q PAID
CONS"I RucTION LENDING AGENCY NEW RESIDENTIAI.1'LA1R. SG IT. D Receipt g
U O I hereby alrw t .d,m,is a....auction[coding agenry far the reformana of
FL F the work far which this permit:s issued(Sec.JINI,Civ.C.7
TU'IAh
C) Lenders Name TOTAL:
r COSI Lenders Address HUILDIN( P
0. 1 cendy that 1 have read this applicaninn and state that me above Inhsmmtion n
,F. fn atml l agrecm comply with.11 city and coumyoNinanccs and one laws alining m QTY. MECHANICAL PERMIT FEE SEISMIC ITT
J Z hoilding condmctinn,and hereby authuri'm rcprewnadvr_s of mix citymrn¢r upon me
ab—c-i tenfiuned property for inspection purposes. PERMIT'ISSUANCE MTAX
'00
I We)agree ut save,indemnify and keep harmless the City of Cupenino against
Iiahilinies.judgments.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
fonaquNI ofinegranting Sobis I)WII.
API'LICAN'1'11N1OliHS'I'ANDS ANU\VELI.COMPLY WI'IA ALi,NON-POINT AIR HANDLING UNI'1'(CO 10,111111 GFMI eli
S(llll CE REGl11.A1'IONS. GGo
�Z'ZZ_Ip AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCT ION TA%
. ,name,of icam/Comner�ms Dart EXHAUST I I(OOD(W/DUCT) GA'IION PEE!
I IAZA IH)OUS MAI'ITRIALS DI SCLOSURI!
W ilthe applicam or fnare buildingnere,ant.anrc or handle bmartluus mmcrial HEATING UNIT(To I(X.(XX)B'IU)
as defined by the Copious)Municipal Code,Chapter 9.12,and the Health and Safety,
Cade.Section 25532(a)? HEATI NO UNIT DOVER 100.001 BTU)
❑Yes Fl No VENT I LAfION FAN ISI NGLE RES I U) PAID
Doe Rfceipfp
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(31111 OR 100.000 BTU) fn
calif trvuNous air contaminants as defined by the Bay Arca Air Quality Management
Distort's BOILER-COMP IOVER W.0on if I'U)
E]Yes No
I have readtne boznJesus materials nyuircment,under Chapter 6.95of the Cali- AIR CONDITIONER ISSUANCE DATE
It dfi ,des,&Safety GJe.Somans 255115,25533 n",25531.1 undemmnd mat if NI!W IiliSlOIiNTIAh MI?CII. SQ.11
ofthe re dee �nts which
Lave the e%preah issuance aouibilitycatcof thmannY. 2-
of
ohne reyutremantN wmfn moa the,n,et pdono issuance nracmuicne nr oecuraney.
(Owner or ammori ted agent Oaf 'FUTAL: ISSUED BY:
OFFICE