S 3221APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT'IDENTIFICATION
PEL IT NO. 3221
�J`
BUILDING ADDRESS:
/05-p05g'I M/UeV kV67. &t&er//UO, CA g5501V
SANITARY NO.
APPLICATION SUBMITTAL DATE
p
GMI /�ry '1
( T
NF-
C NTRACTOB'S NAMIf Z46NO
/N'XI //Tf�IT[/y.
N/C
❑
CONTROL#
ARCHI'ITCT/ENGINEER: LIC NO:
O& � ,L1N(_AI
pp R„S:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ® ❑
QTY. ELECT PERMIT FEE
LICENSHD CONTRACTOR'SI ANATION
1 hereby of nnn tum 1 ain licensed ander pravlo is ofchopter 9 (commencing
JOB DESCRIPTION
PERMIT ISSUANCE
.an Section 70(Youf Division 3oftue Bustworind' ur Code, audmylicen.w: is
in full tome and efect (}�W
IZOE)
RESIDENTIAL:
❑SPDWL ❑
APPLIANCES—RCSIOGNTIAL
License �l..S�Liep I
_
Date ARCHITECTS DECLARA'T'ION
I unders land my plans shall her used as public records
PLUMBIKITCHENREMODFI.
❑AUDITION ❑PLUMBING RI -PIPE;
❑MULTLUN[T Ll STRUCTURAL
MODIFICATION
PANELS
UP TO 2M AMPS
C1 INTERIOR C1 CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
Licensed Professional
201-IfX)1)AMPS
OWNP,R-BUILDER DECLARATION
I hereby affirm ma I um cxcmpt from the Contractor's License Law for the
billowing reason ISecoon 70315, Business and Professions Conic Any city or county
Whish requires a permit m ..... true. aloe. Improve, deaudish...... ir any structure(�/
El BATH REMODEL/Riil'Alk (] DEMOLITION
❑ OTHER dd
�A��
OVER IINNI AMT'S '.
SIGNS ELECTRICAL
SPECIAL CIRCUTDMISC.
.'"lam
6&L"ki
prior to its issuance, also requim, theit,licanl forsuch pmorto, filen signedstmoni
that be is licensed panus. to the provisions of the Contmmors License Law IChupmr 9
(commencing with Section R(XX))of Division 3ofthe Business mrd Pmfessians Cade)ur
mat he is exempt IhWmfr,. and the basis far the alleged esempticam Any violation of
TEMP. METIER OR POLE INST
COMMERCIAL:
❑NEW BLDGIADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than five hundred dollars ($500).
etion,
Or, wnerof lire propeny, or my employees with wages as their sole armpnm
E] 1. nn
will do the work, and the structure is not lmended inuffemd f n ade (See 9044, Business
POWER DEVICES
(]TENANT ❑ FOOD SERVICE
IMPROVEMENT
'
❑ O'THFR
SWIMMINGPOOLELF.CTRIC
OUTLETS—SWITCHES—FIXTURES
,
and Professions Code: [he Cnnuacmrs License Low does ,or apply to an owner of
NEW RESIDPN'TIAL 1?LECTR SQ FT.
ptriroperty who builds or improves Thereon, and who does such work himself or Ilimugh
u .mprovemenm use not intended or offered dor
.,use. employees, provided hal such t
sale. If. however, the building or improvement is sold within imci ofeomplelimu he
SQ.FT.ILOOR AREA
S/SQ. PT.
owner tauildn will have the burden of proving that he did not build or improve for puts
pose of sale.).
❑ 1, as owner of the property. am exclusively contracting with licensed Ceramics to
TOTAL:
construct the project (Sea. 7144, Business and Professions Code) The Contractors I.E.
roue L.O. does not apply mnnownerof popery who builds or improves rhereantud
QTY. PLUMBING PERMIT FEE
who...neve¢ far such pmjems with u vomrnemrls)licensed pursuant to the Conmuor'a
PERMIT ISSUANCH'
License Lew.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Date
ALTER — TRAIN & VENT —WATER RA)
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
BACK FLAW PROTECT. DEVICE
I have and will maintain a Commence ofConsenuo self -insert for Workers Cooper.
sation, A provided for by Section 37M of the Luton Code, for the Performance of the
DRAINS— FLOOR, ROOT AREA, COND,
STOR&
TYPECONSTRUCHON
-
work for which this permit is issued
VjKhave and will ntuinmin Worker's Compensation Incemnco, vs required by Section
.337700ofthe Labor Code, the nee afire which this permit is is sue d,
FIXTURES — PIER TRAP
OCG GROUP
AP N
GAS — EA. SYSTEM-] INC. 40UTLIUS
'foot'yNrrour'1j
and Policy
Comer: (; L/�'/ /�✓U�`s ro Policy Nn..Ilew D I My
GAS — EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE
GRFASFIiNDUSTRL W'AS'I'E INTERCEPTORCOMPENSATION
BUILDING DIVISION FT -ES
(This sectionneednd be completed ifthe permit is forone hundred delta. ($1000
or loss.)
GREASETRAP
PLANCHF,CK FEE
I certify that in the performance ofthe work for which this permit is issued, Ishad
not etnploy any person in any manner w as o M1ec me lyres m me Wurkeri Cnmpea.
SEWER—SANITARY— STORM EA. NNI Irl'.
IiNERGY FEE
WATER HERI'I?R WNENT/ELECTR
GRADING FEE
union Laws of California. Date 7 -
Applictmt
NOTICE TGAPPLICANT, If. after making this Cadherta al F,sempron, you should
become subject to the Workers Compensation provision% of the labor Cade, you must
WATER SYS'I'I?M/THI?ATING
SOILS FEE
fnrhwiN comply with such pownh mor this permit shall be deemed reactor.
WATER SERVICE
CONS11'RUCf10N LENDING AGENCY
I herebyaffirmthauhere iso construction lendiagogency far the perfonnaream
NEW RESIDIBJTIAL PLMI3. SQ. FT.
PAID
D e Reailnp
the work for which this permit Is issued (Seo. 3097. Civ. C.)
Lender's Name
TOTAL:
TOT
Lenders Address
he information N
IIUILD1 G FF. EK
1 certify that I have read this application Unit erne unit abase
coram, l agree to comply with all city and county ordinances and shite laws relating in
building construction. and hereby authadm mposenmtives ofthis city to enter upon the
-
QTY. MECHANICAL PERMIT FEE
SEISMIlyrric
PERMIT ISSUANCE
ELECTRIC FEF.
above-memioned Property for inspection purpoms.
(We) agree m save, indemnify end keep harmless dm City of Cupenina against
ALTER OR ADD TO MECH.
PLUMBING FEE
Iisbiliti"' itgmems,s I no expenses which may in anyway accme against said City
in consequence of tl -gmnin .,isfaread.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT U - ER.' I S AN WILL OMPLY WITH ALL NON -POINT
SOURCE AT S.
AIRHANDLINO(TNI"1'(OVEiRIO,M(ICFM)
CONSTRUCTION TAX
4(�qw
Si um nfApplicu JFonwcol Oalc/
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST I COD (W/DUCT)
HOUSING MITIGATION TEP.
HEATING UNIT LTO IIir" B'ITh
'•Willmeapplicam urfmumlwildingrc<uponlmnm ohandlchamrdousntumnal
as defined by dre Cupenino Mu I s`V o Cei Chapter 9.12, and the He...h amd Salety
Cade, Section 25572(a19
HEATING UNIT (OVER 100,000 BTU)
❑Yes C] No
VENI'I LATION PAN (SINGLE RESID)
PAID
-
Date Rosetta
- - BOILER—COMP CHIP OR 100,000 BTT)
Will the applicant iofuture building by the it ,use A equipment of devices which
mit hazardous air enntnminnns ns fnW try the Iluy Arora Air Quality Management
Diurinl
❑ Yes No
T
BOILER — COMP (OV ER 100,000 BTU)
AIR CONDITIONER
I have mad me haeaNrgomentc under Clmpurr 6.95 ofthe Celt
ISSUANC r ATEfominIlealm&Safe
NEW RESIDENTIAL MECH. SQ. tellhuilding
dc, 33 and8534. 1 mukrsland mo if the
dcest t tly hasy mspnmihilitym nadfy the tKcurym
ofthemgohien muance of o C =fca of '•�t{�g�-(ryy,
ISSUED BY:
TOfAL:
Owner nr authnrizeJ agent D:Ge
OFFICE
APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING. ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT'IDENTIFICATION
PEL IT NO. 3221
�J`
BUILDING ADDRESS:
/05-p05g'I M/UeV kV67. &t&er//UO, CA g5501V
SANITARY NO.
APPLICATION SUBMITTAL DATE
p
GMI /�ry '1
( T
NF-
C NTRACTOB'S NAMIf Z46NO
/N'XI //Tf�IT[/y.
N/C
❑
CONTROL#
ARCHI'ITCT/ENGINEER: LIC NO:
O& � ,L1N(_AI
pp R„S:
CONTACT: PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ® ❑
QTY. ELECT PERMIT FEE
LICENSHD CONTRACTOR'SI ANATION
1 hereby of nnn tum 1 ain licensed ander pravlo is ofchopter 9 (commencing
JOB DESCRIPTION
PERMIT ISSUANCE
.an Section 70(Youf Division 3oftue Bustworind' ur Code, audmylicen.w: is
in full tome and efect (}�W
IZOE)
RESIDENTIAL:
❑SPDWL ❑
APPLIANCES—RCSIOGNTIAL
License �l..S�Liep I
_
Date ARCHITECTS DECLARA'T'ION
I unders land my plans shall her used as public records
PLUMBIKITCHENREMODFI.
❑AUDITION ❑PLUMBING RI -PIPE;
❑MULTLUN[T Ll STRUCTURAL
MODIFICATION
PANELS
UP TO 2M AMPS
C1 INTERIOR C1 CHIMNEY REPAIR
IMPROVEMENT C]SWIMMING POOLS
Licensed Professional
201-IfX)1)AMPS
OWNP,R-BUILDER DECLARATION
I hereby affirm ma I um cxcmpt from the Contractor's License Law for the
billowing reason ISecoon 70315, Business and Professions Conic Any city or county
Whish requires a permit m ..... true. aloe. Improve, deaudish...... ir any structure(�/
El BATH REMODEL/Riil'Alk (] DEMOLITION
❑ OTHER dd
�A��
OVER IINNI AMT'S '.
SIGNS ELECTRICAL
SPECIAL CIRCUTDMISC.
.'"lam
6&L"ki
prior to its issuance, also requim, theit,licanl forsuch pmorto, filen signedstmoni
that be is licensed panus. to the provisions of the Contmmors License Law IChupmr 9
(commencing with Section R(XX))of Division 3ofthe Business mrd Pmfessians Cade)ur
mat he is exempt IhWmfr,. and the basis far the alleged esempticam Any violation of
TEMP. METIER OR POLE INST
COMMERCIAL:
❑NEW BLDGIADDITION ❑ DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of
not more than five hundred dollars ($500).
etion,
Or, wnerof lire propeny, or my employees with wages as their sole armpnm
E] 1. nn
will do the work, and the structure is not lmended inuffemd f n ade (See 9044, Business
POWER DEVICES
(]TENANT ❑ FOOD SERVICE
IMPROVEMENT
'
❑ O'THFR
SWIMMINGPOOLELF.CTRIC
OUTLETS—SWITCHES—FIXTURES
,
and Professions Code: [he Cnnuacmrs License Low does ,or apply to an owner of
NEW RESIDPN'TIAL 1?LECTR SQ FT.
ptriroperty who builds or improves Thereon, and who does such work himself or Ilimugh
u .mprovemenm use not intended or offered dor
.,use. employees, provided hal such t
sale. If. however, the building or improvement is sold within imci ofeomplelimu he
SQ.FT.ILOOR AREA
S/SQ. PT.
owner tauildn will have the burden of proving that he did not build or improve for puts
pose of sale.).
❑ 1, as owner of the property. am exclusively contracting with licensed Ceramics to
TOTAL:
construct the project (Sea. 7144, Business and Professions Code) The Contractors I.E.
roue L.O. does not apply mnnownerof popery who builds or improves rhereantud
QTY. PLUMBING PERMIT FEE
who...neve¢ far such pmjems with u vomrnemrls)licensed pursuant to the Conmuor'a
PERMIT ISSUANCH'
License Lew.
❑ 1 am exempt under Sec. , B & P C for this reason
Owner Date
ALTER — TRAIN & VENT —WATER RA)
VALUATION
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
BACK FLAW PROTECT. DEVICE
I have and will maintain a Commence ofConsenuo self -insert for Workers Cooper.
sation, A provided for by Section 37M of the Luton Code, for the Performance of the
DRAINS— FLOOR, ROOT AREA, COND,
STOR&
TYPECONSTRUCHON
-
work for which this permit is issued
VjKhave and will ntuinmin Worker's Compensation Incemnco, vs required by Section
.337700ofthe Labor Code, the nee afire which this permit is is sue d,
FIXTURES — PIER TRAP
OCG GROUP
AP N
GAS — EA. SYSTEM-] INC. 40UTLIUS
'foot'yNrrour'1j
and Policy
Comer: (; L/�'/ /�✓U�`s ro Policy Nn..Ilew D I My
GAS — EA. SYSTEM -OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
INSURANCE
GRFASFIiNDUSTRL W'AS'I'E INTERCEPTORCOMPENSATION
BUILDING DIVISION FT -ES
(This sectionneednd be completed ifthe permit is forone hundred delta. ($1000
or loss.)
GREASETRAP
PLANCHF,CK FEE
I certify that in the performance ofthe work for which this permit is issued, Ishad
not etnploy any person in any manner w as o M1ec me lyres m me Wurkeri Cnmpea.
SEWER—SANITARY— STORM EA. NNI Irl'.
IiNERGY FEE
WATER HERI'I?R WNENT/ELECTR
GRADING FEE
union Laws of California. Date 7 -
Applictmt
NOTICE TGAPPLICANT, If. after making this Cadherta al F,sempron, you should
become subject to the Workers Compensation provision% of the labor Cade, you must
WATER SYS'I'I?M/THI?ATING
SOILS FEE
fnrhwiN comply with such pownh mor this permit shall be deemed reactor.
WATER SERVICE
CONS11'RUCf10N LENDING AGENCY
I herebyaffirmthauhere iso construction lendiagogency far the perfonnaream
NEW RESIDIBJTIAL PLMI3. SQ. FT.
PAID
D e Reailnp
the work for which this permit Is issued (Seo. 3097. Civ. C.)
Lender's Name
TOTAL:
TOT
Lenders Address
he information N
IIUILD1 G FF. EK
1 certify that I have read this application Unit erne unit abase
coram, l agree to comply with all city and county ordinances and shite laws relating in
building construction. and hereby authadm mposenmtives ofthis city to enter upon the
-
QTY. MECHANICAL PERMIT FEE
SEISMIlyrric
PERMIT ISSUANCE
ELECTRIC FEF.
above-memioned Property for inspection purpoms.
(We) agree m save, indemnify end keep harmless dm City of Cupenina against
ALTER OR ADD TO MECH.
PLUMBING FEE
Iisbiliti"' itgmems,s I no expenses which may in anyway accme against said City
in consequence of tl -gmnin .,isfaread.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT U - ER.' I S AN WILL OMPLY WITH ALL NON -POINT
SOURCE AT S.
AIRHANDLINO(TNI"1'(OVEiRIO,M(ICFM)
CONSTRUCTION TAX
4(�qw
Si um nfApplicu JFonwcol Oalc/
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST I COD (W/DUCT)
HOUSING MITIGATION TEP.
HEATING UNIT LTO IIir" B'ITh
'•Willmeapplicam urfmumlwildingrc<uponlmnm ohandlchamrdousntumnal
as defined by dre Cupenino Mu I s`V o Cei Chapter 9.12, and the He...h amd Salety
Cade, Section 25572(a19
HEATING UNIT (OVER 100,000 BTU)
❑Yes C] No
VENI'I LATION PAN (SINGLE RESID)
PAID
-
Date Rosetta
- - BOILER—COMP CHIP OR 100,000 BTT)
Will the applicant iofuture building by the it ,use A equipment of devices which
mit hazardous air enntnminnns ns fnW try the Iluy Arora Air Quality Management
Diurinl
❑ Yes No
T
BOILER — COMP (OV ER 100,000 BTU)
AIR CONDITIONER
I have mad me haeaNrgomentc under Clmpurr 6.95 ofthe Celt
ISSUANC r ATEfominIlealm&Safe
NEW RESIDENTIAL MECH. SQ. tellhuilding
dc, 33 and8534. 1 mukrsland mo if the
dcest t tly hasy mspnmihilitym nadfy the tKcurym
ofthemgohien muance of o C =fca of '•�t{�g�-(ryy,
ISSUED BY:
TOfAL:
Owner nr authnrizeJ agent D:Ge
OFFICE