S 3170 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HIIILDING-RLI?C'TRICA L PEgI I NO. 3170
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MITCHANICAIT `\1
BUILDING PROJECT IDEA 19FICA'1'[ON
BUILDING ADDRESS: SAN]I'ARY NO. AI'1'LICATION SUBMITTAL ONE 17
okee
O NI R'S NAME: PHONE: NTRACI IR'
S 0 NStE; hIC NO'.
--�y- NIC CONfROLx
A (:1 PE(.TI1iNG LI' Y ADI) SS'. T ❑
CONTACT: PHONE BUILDING PERMITINTO
e ❑ Consultant Fee.Paid by Applicant(Initial) BLDG ELECT PLh1M{1y MECH
,06 00 ❑ ❑ CJ ❑
LICENSED C 'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby union Ibat I ant licensed under provisions of Chapter 9(commmmentg JOB DESCRIPTION
UCO wish SeeIio.7000)of D....lon Sof c11-inexs Tend Profusions Codd.md my llccnsOr' RESIDENTIAL:
W p PERMIT ISSUANCE
Fly full force undo ❑51'DWI, ❑KI'ICIIEN RHMODEI.
aUV Liccauc '�. .ic.p APPLIANCES-RE IDENTIA1. ADDITION ❑PLUMPING RIiPII'IT
HF Ql iy Dom Glr ❑SIKUCTURAh ARCH]'I'ITC'I"S DECIAN Y ❑MUIT[-UNIT
PANELS
MODIFICATION
ZOZ_Z understand myplam,hull hemoold,puhhemeoNs UP 10 200 AMPS
❑INTERIOR C1 CHIMNEY REPAIR
F yl-W Liccmcd precxsinual 201-1100AMPS IMPROVEMENT 0SWIMMING POOLS
OWNCR-1 here, ffmt mm I am leummti GnmElhe DECLARATION
License
Luw for the OVER BEER AMPS ❑BATH REMODF:IJR6PAIR DEMOLITION
a ya
K 01 U fallowing reason.(Section 7131 I.S.Burnes and Professions G.Im:Any city or county SIGNS ELECTRICAL ❑(OTHER
4:3 U.y which acquires a Permit In co n.Imct,alter,improve,demolish,or repair any.wchire
FNON.a.I pro ( t :. al,nio,modlarappliwarnf h Pertail I,,IdO.sian,11%loatioriat SPLCIALCIRCUIT/MISC.
uMLL]]y
the,l fp a d r. ffl c t I L (Cheaper 9 ) COMMERCIAL
WE50C (co ang wall Section 70W)of 11 simon 3aIbc B .'ato,ond P,oI :..on,Code) I LIMIR MLFER OR HLDG/ADDITION El Il1iMOLITION
POLEST
thin hu is tts"a t Ocartmn n d alto Ntsis for(he t Ilegc'J env a,n m.Any rout nn of IN ` 1 ClNIiW
'Ma') Seclion]031.5 by any applueanl for a irerntif subjects the applicant et a civil penally of POWER DEVICES gr1 ITNANT C]FOOD SERVICE
re faun Five hundred dollar S500)
IMI'ROVEMERT
=0 D I.matwmo,d thep v,ar,or my employees an wages us meinoleunmpensation. SWIMMING POOL ELECTRIC
F-ee will to the work.and the xrruaum I%net intended of offered for sake(See7044.Business []OTHER
ad 3 m aaJ'I'mressions Code:The Clatharmra Licenw law does no'apply to Tea owner of OUILBIS-SWITCHES-FI%" RP_S
property who builds or improv.,Ihcmm,and who does such work himsdf or(hvmgh
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELI' SQ FT
sale.IL hnweven the building or improvement is.snM within one year of completion,the SQ.II'.FLOORAREA S/SQ.FI'.
erhuilder will have the honlen of proving that he did tent huilJ or improve for par-
pNe of xalc.) W '1'OPAO
❑ I,as o son r ter the property,u n leloosely eonmacting void,licensed.....a cion m
m..to,,the pnajcct(Sce.7(34.It ux ss Tend Professi nu lona) 'he Coonallor,ra 's 1 i-
sc law does not apply seanownend property who buddxar int provus fhermn and QTY. PLUMBING PERMIT FEE:
who com(rects in....h projects vs4h a,snlrsdnotx)licensed parsuanl to the Contractor's
License law. ,B.G P C holds mason PERMIT'ISSUANCE
3J 7_5715-
C] I am ea sept under Sec.
ALL ER-GRAIN a VENT-WATER(EA) VAI.UAI'[ON
Owner Dole
WORKERS COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE
I hereby alarm under wool,of poria,one or the following deduratione
❑ Ihlvemal will reantuan.CcnlfcatcofConanunmlr-Insult far Wnrkcr'x Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'I'YPECONSTRUCTION
e'alin i,a.provided fix by Section 37100 of the Labor Cade,for nbu performance of the
,oak Iia whichlhls,nai(is 1unl. FIX'1'URIIS-1'ER'IBAP
�H
have and will otain,ain Worker's CO pcnen.on hi'maneu,ao rnpalred by Section
.r.)of the Labor(;ode,fur the l'salouinCe offhe work for which dale permit is issued. GAS-ITA.SYS'I EM-I INC 4 OU'11.171 S OCC GKOUP APN
M1 Wbrlyr�Co>apc'y.rtnrelnu!pn' r!'c Pol ey No.Y (iAti-ITA.SYS TEM-OVER a(ITA)
CLRTIITCATf:O1'li%ME'M4,0,FROM W(IRKERS' GREASI%INDUSTRLWASTE INHTRCEPTOR
COMPENSATION INSURANCE U LDING %V SION FEES
pLLs section need nod M complc(eJ ifthe Permit is for one hundred dollars(SIM) GREASE TRAP
it,less) _ /1_L-AN(il1ECK FE'
I cenify that in the WrIonnounce atth work for hich this Po disisued,I shall SEWER SANITARY STORM EA 200 IT
nod PI y ,at r, Io yy Yl'YIUt th W k Cnmpcn ENERGY
Z xu I .111 /f Cl 7/\ WAIITO TEARR WIVEN1 IFLLCTR
z 0 Am l �M4 6 Tel .r
N U ICI I( .C N 1f II a k g Ills Certificate I I pt ,you should WATITR SYSTEM/FRF,A'1ING
SOILS IT:C
Isla nm subject in the Workers Contpcnstuiun pmv stuns of Omm],.NorUde you must
limhwi(h comply with such provisions or lhi.a pvratil shall he deemed revoked. WA'I ER SERVICE
a �
OZ
CONS1 RUM ION i.. ....LENDINGAGENCY NITRBIiS1UliNTIALPWIB. SQ.FT. a Receip(a
U O I for which
thi tb erah i is m ted(See.on lending agency fonhe per(onnarme of
F-' IM work for which this permit i.issued(Sec.309].Civ.C.)
0 Lender's Name TOTAL:
,r {U Lender's Address F(Yr X 0
P. 1 ccnaty tam 1 have rand this appdiandon and state mal Ibe above infomtmion is If 111LIlIN £Fi
.Fi
too, cns,r.lagm.:w comply Wim all eify ordemm,ordinaret,no dxtumlusvxrcmtingtn QTY. MECHANICAL PERMIT FL'E
U Z build nga nntnmtien'; I hereby dlotuaile Tcltreeentutivcxot'lJsul(y loearaul 0the SEISMIC
FEE
uhuve-awationed property for Inspection purposes, PITRMI'I'ISSUANCE EI.ECHOIC P'
(We)agree to save,indenntify and keep hamulus the Clay of Cu,arrom against
Iiahilitics,judgmenln,ttrsuanA expenses which may inonywayaccmc againsl said City ALI IIR OR ADDTO MECH. PLUMBING FE �^
in consequence of the granting of This permit.
APPIACANT)JNDERS'FANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.05 CFM) MECHANICAL PEE
SOLI .R ,UL• ONES. (Lac
AIR HANDLING UNIT(OVER 10.000CPM) CON."RUCTION TAX
Sa alurc aL ppina ontmctnr �((JJ Inc//CC EXHAUST ifOOD(W/DUCI) HOUSING MITIGA'1'I(IN PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the upphcunl or Whim buildingomupamelnacor hurdle h:vonlous material HEM INC,UNI T(TO 1(0),(0X)II'1V)
tee defined by the Cupertino Mmali d Code,Cholloal 9 12,and the I Ic;dm Tend Safety IIIiA'1'ING UNIT(OVER 101,100)[I 113)
Coda Seclion 25532(u)7
❑Yes CNo YEN'I I,A'1'ION FAN(SINGLE RES]D) PND
Uam Ncccipt x
Will the applicantrooccupant orfure building occupause ctliipntem tees r devicwhich BOILER-COMP(3HP OR 100,000111'U)
e
mil harurdnus air cnnmminents as defined by the Bay Area Air Quality Management 'I(
District? BOILER-COMP(OVER 100.1X011-111)
❑Yes 0 N
I have rend the haenrdaus nta(crluls requirements under Chapter 6,95 of the Cali- AIR CONDIT IONER ISSUANCE DATE
Toile Health A,Safety Code,Seutimns 25505,25533 and 25514.1 undemtund had if the NI:W RIISIDIiN'FIAL MECIL SQ.ET.
hnilJing tl9cµnot euncn(ly,'nvc:o wnunl ohne it Is my rc,ao,Ealify do noaly ahe oecupent /j
of rho re,,..cnturts whfrh ound he noel prior Tea iv,uar,c it CcNEc:nc oroeeupancy.
Owter ter authoriecJ agent Date 'FOl'Ah: ISSUED BY: O
OFFICE