S 3080 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO PLUM NC-MECII NIAL I'EItyY1n'No. 0 O
BUILDING DIVISION APPLICA'1'IONIPERMIT PLUM PROJECT IOHnN1cn1. S
BUILDING PROJECT IDI?N'I'IRICAI'ION
BUILDING ADDHI//SS: SANITARY NO. API'LICAIION SIJIthl l'I/T�5ALDN"li
i OWNEOR'S 5 /D
v PH(INIi: CON'rRACIDR5 NAM11Ii: LIC NO'.
Mla ^
NIC CON
J
AItC1{I I'li T/ENG Iil!R: LIC NO ADDRESS: El\
nSLI
CONTACT: THONG: BUILDING P13RMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLOC, ELECT Pi*114 MLCH
LICIiNSED COKTRA OR:S ECLARATION QTY ELECTRIC PERMIT FEE JOE DESCRIPTION
I hereby affirm that I um licensed under provisions of Clear,9(cmm�mwm,9
'OZ with Sectioo 7000)of Divisb,n 3 of the ltuvine,,and P...I-ions Codc,u..dary l lcensc i, RESIDENTIAL:
H full force ural eRa'G'. �= ' I'IiRMI'1'ISSUANCIi
O C / . l �a � � E]'LL", ❑KI'fClll?N RY:MOUL+1.
QF�.UI` Llccnu Clav bice p /1J�� APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGRE-111111;
WQL Dau---4t- slen6 �—Contrednr ❑MUhI'6UNIT ❑STRUM URAL
ARCI I I PCI"S DECLARM ION PANELS
F hZ 1 andemm�d my Plans shall be sed as public rawrd.s MODIFICATION
UP'I'O100AMPS ❑RSTERIOR [I CHIMNEY REPAIR
CZ Licensed Pro(aslonal 201-10n)AMPS IMPROVEMENT (DSWIMMING FOOTS
6 .] (IWECLARATION
C C Q 1 M1erchY alien Thal 1 am exenNER-BUILDER Dmt four Inc Comraanr's License I.aw for the (IVI?k 1000AMPS C1 BSI 11 kEMODI!Vk1iPAllt DEMOLITION
a U following noon.(Section 71O 15.Business and Pr.fe,Mer,CNe:Any city wrrounT SIGNS ELECT"RICAI, ❑OTHIiH
a�31, whin requires a inanarldt t .improve,demolish, l y,tmem. 1��dA
.�.^0e/� Port t '1. 1 Ih alpl' If hpe ill IIhowledkora ncnt SPECIAL CIRCUIOMISC Se
y thath Ic dp t Ih p fn f t r',I I' (Chupter9
.14<0 frnmmencing with Seaunt 91X10)ofD� ,on31B If .' s and Frolicsome,Cnde)m T I:MR METIER OR POLE INS r. COMMERCIAL:
6H e C lbw he is cxamPr rherefnrm oral the Fossas!ur the alleged exnnption.Any viola;-a of NF, aFP LITTON
ticutinn 7031.5 by any nppllcum far ul'rnnit subjects the applicant mucrvil pewllY of POWER DI?MCPS TIEN ❑ ' SIiRVICIi
re than live hundred dollars($VXUEd Rod
FSa
an fl as owner of the o,orm toes,with woes as their sale eam tion, SWIMMINGPOOLEI.l-MR 01 I
E C the st Y Ynnp Y % ,Bus; 01"HIiH
p. will Jo Mc work. Mc,tmnure i,nrn imm�dNonlBc.d for vbc(Sec.911th,Business
Wm and P.fe,aions Code, ",Convnctor'n License law Joe not apply m un owner of (IUTLETS-SWITCIIILS-FI U - f)A
prnperty who build,or improves thereon,and will,Anes such work himself or lhamsh V ����
his own employee,.Provided that such improvements am not intended lir offered for NEW RESIDENTIAL ELEC R 'I'
sale.if.howasi the building or improvement is sold within one Year of completion,the SQ.lT IIAR)H ARIiA &sSQ.I'1'.
cr-hu ildcr will have the nurden of Proving fled he did not build or initiative for par- Y
pax.of,alc.l, 'r(yl'A1,
M 1,as worrier of the Nati, at exclusively contracting with Eccn,al-allocation,
mel.ct the project(See.9161).Business and Professions CNet)I re Comnaor'I Li-
ocivulawonesnotapplytnanownerofpropertywhobullo,or improves theuon.and QTY. PLUMBING PERMIT FEE
who cwnm¢N irr such projects with e.wnuvcmu,)Ii'eawd pursuant m the Cunnrmnr's
License Law. PERMIT ISSUANCE
❑1 am exempt ender see. .B&P C fur tai,.cora
ALDER-DRAIN d VI?NI-WATER(EA) VALUATION
Owner O
WOHKI!R'S COMPENSATION UECLAHA'I'IOION BACK PLOW PRO['li(:'IIDGVICI? I
I hereby affirm under Penally of Perjury line of the fid.c oog JMaraions:
0 I have and will mainain a Ccniicmc ofConscm to self-insomw Worksra Grmryn- ORAINS-ly,(IOR.HIR)Ir,AR ,COND. STORIES TYPE CONSTRUCTION
nation,us pmvlded for by timbal 3900of he Lntxn Cale,fur me perfmmanee of the
work for which this permit is v..rd.
FIXTURES-PER"1'RAI'
1 have vad will maintain Wnrkers Cothpenrutilm Insumnce,-require)by Section
X)of�thle{laYm mi
Code,hnthe Performance of the work for which thin pert is issued. GAS-EA.SYSTEM-I INCA DOI'LEfS OCC.GRIIUP APN
My Wo
,MPI'1Oil Policy numlfer are'�.�CJ
Cnrricrl�C,CE I CCAIE IsSAT10NalNN IROM WPulacy No,, ORKERS' GAS-I?A tiYSTF.M OVI?R4Q?N
5UBOM GRIASF/INDUS'fRh WASTE IN'I I:RCEPIT)N BUILDING DIVISION IIiGti
frhiswcdonncul not heemnplcted ifrhe Permit is Barone hundred dalln6(51(X) CREASE'I RAP
lir less) . I'hANCIIECK FBI;
I crony that in he D:rforromwewfthe walk for which this Permit is;loud,I0a11 SEWER-SANITARY-STORM BA.200 PI'.
not employ any person in any manner w as to became subject to the Walken' mMn,Co ]ENERGY 1:171.1
Z ,ation Lawlor Califianne,Date WATER DEALER Much T/fiLEMR
GRADING FEE
Z
2 Applicant
�. y NOrICE'IO AI'PLICAN'C IL alter,ranking this Certificate of Exemption,yen should WATER SYSI H fpREMING SOILS I:E13
f" Menthe adem In the Workers Compensation provisions of the Labor Code.you must
forthwith comply with such provisinnsm this .it hall IN,deemed.,liked. WATER SERVICE
aQ
Z CONSI'HUCfION LENDING AGENCY NIiW RIiSIUIiNT1A1,1'LMB, sR "Il PAID
Ihereby'ammr thatthemisaconstrucm,n lendergagency fur the perfonnanceof nota Be upra
CUL . the work lbs which this pmol it ix i...ed(Sen.31X99,Gv.C.) TOTAL:
O I<tder's Name 'IOTA1;
rU Lcndm's Address BUILDING FE1?
6. 1 unify that I base read this op,lication a.I seae rho the cMrve infunnstiwn n
F. ln comet.lag.c to comply with all city and county ordinances and state law,renting to i9fig
ANICAL PERMIT I`E SEISMICITE its
U haddingum,vudion,and httehy and, file mprncnntives alibis city rat enter upmnhe
shove-mentioned pr,,,,Iy fm in,pc,'Iion purial ea. ISSUANCE 11 CrIKIC PEE J
(We)li to save,indemnify and keep harmless the City of Crisman isolator
lerbi'itic,judgmente,costs and expenses which may in anyway accmc against said CityO MECH. PLUMBING FEE =
in rnscyuerec of the granting of this"ril,
APPLICANT IINII1?k STANDS AND WILL COMPLY WITH At.[.NON-POINTUNIT(TO 0.000CEMI MECIIANICAI,I:IJiRCi REGULATIONS. CUNI'TrOVER I ld"i CFM) CONSTRUCT ION TAX
Signtu o1'AppornIA hancou Dat, 17%HAUS'I'HOOD(W/DUCT) HOUSING NU I GADON FHL!
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building r¢cupant,m.or handle harardur,mamrial HEATING UNIT LTO 1(X1.00011 FIB
;is defined by the Calandra Mmricil it Cede.Chapter 9.12,and the Health and Safe,, HEATING UNIT(OVER 1g1.fXq R'rU)
Cade,Section 25932(u)'f
E3 Ycs1 VENTH.NHON IANI SINGLE RESID) PAID
' Date Reshape x
Will the applicant lir rumre building acupant use equipment or deices which BOILER-COMP(ILII'OR 100.0 BTU)
coil hue:udous aI.......mincer,rte defined by Thu Buy Are,,Air Quality Managemem TOTAL:
District! BOI Lint-COM P(OV IiR 100JXXI BTU)
❑Yes
AIR CONDITIONER �^ ISSUANCE DA'I'li
1 h.rve rcaA Il,o h:vaNnu.,mumrials rcyuircnrcnle.",let Chapter 6,95 of the it thee V
lirmia Ilculth k Safety CNq Scdiwm 25511$,255)3 unA 2553).I unJc,'nomNEW I11151DiN'rl Al.MECII. SQ.Ff. �
J 11,11,it the
kk'�t� gdel.mcunnnly bm'cumnanl,thm it i.smv.......bilitym arlythcsvcupant
son ,which.. dlvout primo issuance of a Cenificao of Occupancy.
owner lir aamnn.d'gena Doe T(mnL. ISSUED fly.
OFFICE