S 3131 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF,RTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT 1'INGPRUMS NJECTID NIIFIC S 3131
14UILRING(BOJ f:OT IDI!N"I'IPICAI'IUN
BUILDING ADDRESS: SANITARYNO. API'LI "ION MITI M1II'ITAh U6 CE
J/ C n/ L G a of 1 - /2 �
(OWNERM S PHONE asao y£k CONTRACTORS NAME: LIC NO:
/C �-p =N�/CCUNIROI.'ARCIIII putI.NGINF;ER: LIC NO'. ADD ESS: /V C /4 I�JG
CON'I'ACII PHONE: V BUILDING PF.RMI'IINFU
K�rO l J gD ❑ ConsultantFecsPaldAyAppllcunl(Initial) HCLCr PLUMB MECrw O ❑ I
LICENSED CONTRACTORS DECLARATION
QTY FLECTRIC PF.RMI'P FEE
1 hereby affirm that I am licensed under provisions of chapter 9 m"i'meneimg JOB DESCRIPTION
O 4'Z with Sation]INN))of Division Sof the Business enJ l`ntfe.,dom%Cede.and my license is RESIDENTIAL:
LL:O 1'IikMl'f ISSUANCE
F h,O in full Come and eRcet. / ❑SrUWL ❑KITCHEN REMODEL
QVU Licenw Class Lic,p— x6 �
APPLIANCES-RFSIDHN1[Al. []ADDITION El PLUMBING RE-11111E
F Z m
wF,OQ6to Dam - rcr_
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TS -
❑
1ANIMUCI'1-UNT ❑ UC/ -Mr-��ARCHITECCUECLARAl1W i1MODIP[CAl'[ON
N Z I undemanJ my plans mull be records
as public recos
OZ=� UP T021XtAMPS ❑INTERIOR ❑CHIMM HIiPNR
Li'su'vd of„in ml 201-1NN0AMPS IMI'ROVIiMHN'C SWIMMING POOLS
C C Q I hereby apinn flat I:un caentpl front the Coolomlork l,' oVl?R 11NX1 AMPS ❑NAI'll k13MOD131JREPAIR IJP?MOL1'UON
OWNERTUILDER DI3CLARAI ION
,c Law lin the
Iullowin,re;s.... (See, t71315,I{u.inca,mall'm(romon,Code:An, ilyorommy SIGNSIII.IffiR1GAL ❑OTHER
1x13 LL vFi which mumm,a permit to consume,,alter,imprner,de.nabkh,or Rpm,any amcmR
u" on
prion l ': I: 9 the ,li, 11 hp lI flsignedstac
nen SPEC IA L ClCI RCUI'IMISC.
f y than licensed p a m p . Dh Cam.,
for
1 Ea (cnapnr9 COMMERCIAL,
�a00 (conesu ng with Section 900B)ofD vino Jot the Hasmew Li Profe'' nCWe)a II.MP.METER OR POLE(NST.
d 6 o Y that he is exunpt therefrom and the hlsis for the alleged ae asumst.Any violation of ❑NEW BLDG/ADDITION [IDEMOLITION
Section 703I.S by any applicant for a permit subjects the applicant to a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not morm than fisc hundred dollars S50(d). IMPROVEMENT
=O ElLaaowneraf the progeny.,my employee,with wages as theirsnle comNti,ainn, SWIMMING POOL ELECTRIC
will it,,the wark.m,dmcamR a w
mut mendedandfered fur sale lSec]BYt.Bu,ines ❑OTIIIiH
L 3 m and Profic,ninns GJe:The Contractor's License Law does not apply re an ow nc,of OUTLFI S-SWITCHES-FIX"TURES
prnpuny who boIId%or improves thereon and who docs such work himself or through
his it,.emp e,rs,,provided that such Intpmven ema arc hat intended or offered for NEW RESIDEN'DAL ELECTR SQ IT.
.ade.11;huwevur,lhu building ar imprnvemem is sold Wilton nmeycarofeumpleliun,the Net
FI*FLOOR AREA SISQII'.
c,1uofDT w111 have the bnMen n1'pm ing 1ha he dul non huild or improve fns par
p en1'.sale.). v 'IOIAI.:
I,us nwner of the properly,am exeluxivcly Cmnmm1ing with licensed contractors e.
ndrun me Pr Jce(Sec.7044,Busimn,.,,if 11,a1es.too,Code:)1'he Contractors Li-
eLaw does not apply manowner ofproperty who builds or improves thereon,and QTY. PLUNIEUNG PERMIT FEE
who contracts for such project with a connacmr(s)licensed pursuant to the Cnmrmmtr'I
Desnw Law. PFRMTI'ISSUANCE
lantesentptunder See. ,B&PCfimmi,m.wn
ALTER-DRAIN&VENT'-WATER(IIA) VALUATION
Owner Mute
WORKER'S COMPENSATION DECLARATION RACK ROW PROTECT.DEVICE
Ihereby affirm under penalty of perjury one of the following decimations
Iha�c..Jwillnaitnaim..Ccnificmenf Cnn.uemmsclf.in.vurefitr Workees ComKm DRAINS-FLOOR.ROOF,ARRA.COND' STORIES TY it CONSTRUCT ION
,;if..n,a,provided for by Section 3700 of the LUMo Cale,for the Ire,fi nner a of the
work for which Ink perm'..ix.,surd. IIXTUHIiS-PER TRAP
I Im,,a nJ will n onto Wnrke"Cnntpcm:niun Insurance,m required by Section •-
3700ofthe Lahn,Cude.for the perionanceol l lmwok for whishlhial'mnit is'mmcA. (1f 'A�SVS11'P.�1.�INC-d4LL'{}�TIs OCC GROUP APN
My Worker's C'nmpensation Inmmnce carrier and Policy n..n, /
carder: �bYaeT7= �iAA/1 roKcy No.: e: — c gFY n.sv"�:M-
11 RTIFICAT OF EXI3MiTIGN FROM WORKERS G w/.�FANDUS'fRL WAS'r131N'IP,RCIiPI
COMPHISSA'1'ION INSURANCE BUILDING DIVISION IT-ES
car less.)
IOd,Raed not M ion need c mplefed iNhe pamrit is f......hmalod Jolla, PfANC111iCK PEE
61011l ( ASE 2 _
leenifythat m meperfomtineenfthe week forwhichthislermi.....sved."'a11 ,13W'13H-SANITARY-S'IY>HM EA.2f X)
not employ any person in any manner m as to berome object me t lVnrker,i--,'- ENERGY PER
,� ,mi..n Law,of California Datc �^ IS A HIiATER WNE,T,,I.1iC1'H
ZO Applicant "I �� GRADING II i
y NOI'ICI?1O A 1PLICANT I nfmr.nakm,,thin Cen 1 1 of Exemption,you should WATER SYSTEMO`R SOILS Ilii:
? become wbject in the Warkda Compemutin r pro sin t,el the LaNn Code,you must
W lorm,,ah untply wilh,c,h mo,Won,or this permit shell be decmedrevoked, WA'i13R SERVICE
Q PAID
CONSTRUCTION 1.13NDINO AGENCY NI3W RIISIDENI'IAh PLM({. SV P('' Ute Reaapin
UO hereby offinn,Ind mem is a eon,walinn lending agvmcy tonne perfnrmunce nl'
{L. the work f..r whielt mi,permit s lxsaal Sec.3097,Civ.CJ
TOI'A h:
Olander',Name
L) Lende, AJJrts, 'TOTAL:
} 1 1 amity that 1 have read this application and stain Nat the aNw,infmom ion is BUI1. 1 113E
FN ComecL l agree 10 Comply wire all city and county ordinance and state laws slating to QTY. MECHANICAL PERMIT FEE SEISMIC t:,:
U sZ building mmtmdion.and hembyamhori erepteaenativoaRhis city to enmr....he
chose mentioned progeny for inslection purpows. PERMIT ISSUANCE �h
(We)ag.m save.indemnify and keep harmless me Gly of Cupertino against CPEE
ttl [LG
.. hmbddm,.jmhmem,.costs andexpemenwhich...y in any way accrue agmnm,dd City At;'ER OR ADD TO MECII. PLUMIU 'PEE
in consequence of the granting of this permit.
APPI,ICAN"T UNDERSTANDS AND WILI.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,100 CFM) MECHANICAI. +:13
SOCK$'II REGUI,ATI(INS.
AIR HANDLING UNIT(OVER 10,000CFM) CONS UUR C'CI)N' 'AX
Sig -imul ApplicamUsCmimemor Dam EXHAUST HOOD(W/DUCT) HOUSING MI'TIGAT'ION FEE
HAZARDOUS MATHRIAS DISCLOSURE
Will thcipplicaa or rums huildin,u,va,v Idom or bundle hirmob aacrial HENS ING UNIT TO 1000X1 III LU
;is defined by the Cupertino Municipal Code,Chapter 9.12.and the Health enJ Safety
HEATING UNIT(OV HR I00,00()III'U)
Code.Satin.25532(a)T
❑Yes -IQ No VENTILATION FAN(SINGLE RESID) PAID Dare RaeiptN
Will the applicant or future building occupant use equipment or devices which
emit hmaa, BOILER-COb1P IJHP OR 100.0)(V100.0)(V ITI'U)
ardnu,air comd...is Jdiii by the Bay Arta Air Quality Managermid TO
Dinner?
❑yet BOILER-COMP(OVER 100,000 011'11)
rt
I hove rc:ul he hamrdnu,mumrin6'regnismmiabwWcr Chapter 6,95 of the CuAlk CONDO LONER
li- D ISSUANCE DAJi
t'omla Health&Safety Code.Shinn,2551).5,25513 and 25534.1 underd.rd dont i1'lhe NEW RFSIDEN'HAL MECII. SQ.FI'.
LuilAing deux nut currently hnvc u asmnL mut it is my rcpmnihilily nr notify doe navpnm
nnhe rc mets whiub mull pd. mis,tyncuml'a Cenlficamoroee.paney.
Ow.mror u agcm ac 1 f ISSIIEDBY:
OFFICE