S 3313 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 1'li GN
BUILDING DIVISION APPLICATION/PERMPfPLUMBING-MKCHANICAL � 3313
BUILDING PROJECT[DRN'TIMcAI'ION
BUILDING ADDRESS: SANITARY NU. APPLICATION SU13M1II'TIAL 11X11
1017q5 liths ore S cv r ino CA. 9So1
OWNIiRSN ME: n PHONE: CONTRALTO :SNAML; LIC No.
Rtv V SGISC'r 40 N/c coNTROI,a
AIICHI1 TC17PNGINEPW LIC NO ADDRESS: ❑
CON INC P. YHONIi: IID ILDINO PFRMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BE DO pi PLUMB ME :u
LICENSED CONTRACTOR'S DECLARATION QTY GLCCTRIC PFRMIT ITECrrJf YrJ�/ I^J'/ Yr/J•
I hereby alarm that 1 am ficetsed under provisions of chapter v(commenting ` JON DESCRIPTION
wd'Z
Wpm witM1 Semian]IXNB of Division3of the Business nnJ l'mfessiom CWc.nnJ mylice,sc is PERMIT ISSUANCIi e!O RESIDFNTIAL:
J � I
ag Lioe a ClassnJ effect. ❑SFDWL WiCITGHEN kF:hlUlllil.
<UU License flaxs hic.a APPLIANCES-RBSIDIINTIAI. ❑ADDITION C1 PLUMBING RI PIT
F z w Dxtu Contracmr
wQa - ❑MllhFl-UNIT' ❑STRUCFURAI.
b.DN ARCIII'Flif l'S UECI,ARAHON PANELS MODIIICATI(lN
ZOZ." I unJurvlard III,dull shall he uscdas puhlic recants Oil 10 200 AMPS
F,RIOR ❑CHIMNEY R FI'AIR
Ir xAt: Licensed PouirWnnal 201-10M)AMPS IMPROVI?MI?NT C]SWIMMING POOLS
�; OWNER-BUILDIIR DIiCLARAGON OVER ItXN)Ahf'S QJTM'fH REMODIRJRI:PAIR El DEMOLITION
C sc I hereby affirm Nat I ten exempt from the Comoemr's Licence Law Lot
ad 3W U following rcason.(Section 703L5.Business and Prnflo
essns Cafe:Any city or county SIGNS li EC ICAL ❑OTHER
W a H which ethics a permit m commo.dker,improvedemolish,or repair any 11meum
Ff='Oq priorto its iswznce.also requires the applicant for such Permit o file a signed snmtnem SPECIA
Er�}� that he is licensed pursuant m the provniomnf the CoonataT License law(Cbnpmr9
1�+1�7 G0 (commencing with Section 7007 Division 3 of the Business and Profession.Cradle)Or TF,MP.MEFIRO it ST. COMMERCIAL:
A.d C That he is carried therefrom and the basis for the alleged exemption.Any vidmion or ❑NF,W BLDG/ADDITION ❑DEMOLITION
Wont Section 7U315b - perinil subjects theaplicantro a civil penalty mf P(IWF.R DEVICES
y any apPllcam torn p TENANT ❑FOOD SERVICI'.
11.... not vurethen five hundred Jcllan($500). IMPROVIiMIiNI'
tj QOI,as ownerIt'The propeny.nrmyutnpluyeex with wages as their lot.contpe,wdom, SWIMMING POOL L?I,L'CI'RIC
C t- villdol6c ork,and thosm¢ntre isnot intmulcdoruB'cmd fnrsalc(See.70f{Ihdiness ❑OTHER
�r� trail Prolcesinm Code']be Con ou,na's Laer,,c Law docs sol apply t,,nn nwnrr n Ol]TLISIS-SW I'I'Clllis-PIX'NRI?S Q
property who aurid,m Improves Thereon,:mit who docs such work himself or,hrough
hk own employees,povided that such improvcmcnl.s am not intended or ode d for NEW RESIDEN'1'[A].HLTC_rR SG PI'.
late If.howaxr.the buildingor improvement is sold within sac year ofcouldelinn,'he SQ, R(R)N ARBA &SQ�IrI'.
ee-builder will have the burden of proving that he did not build or improve for yar-
n oI I I A f
I.us owner of the pmpeny,am exclusively contracting with licensed contractors In
n)met the project(Sec.71,14.Business and Pro esome Code:)The Conlot ceno,law does not apply to an owner of property who builds nr improves thereon,and QTY PLUMBING PERMIT FEE
who contests for such projects with a enmranorb)licensed Pursuant be Counalon s
Li<cnx Law. ' PIiRNII I'IS UANCH 3
I ton exempt under Scc. .B&P C for this ma
0111 n, ALFUR-DRAIN&VI!N'F-WAI[In(HA) 3 0 VALUA'r10N
mar D;oe
WORK. 'S COMPFNSAFION DI',CI,ARATION BACK PLOW PROFUCF.DEVICE �p
I hereby affirm under penalty of soja,one of The following elimination,
I have and will maintain a Cedifiadc of Consent to xdLimurc for Workce%G,mpcn- IIRAINS-FLOOR.ROOF.ARBA.COND. STORII!S TYPO CONS'FRDCTIOD
satinn,as provided for by Section 371X1 of the Labur Code,for the performance of the O
work for which(his permit is issued. FlXTUNI?S-I'IiR THAI'
O 1 have and will maintain Wader's Compensation Insurance.as quircd by Sectio
371N)ofthe lalsor GMe.forthePerformance ofdhessork fora hich this permit isiwed. GAS-EA. -11: if, UCC GNOUP AI'N
My Wurker'x Compewation lnsurancu currier and Policy numtterme:
Carrie: Policy No: GAS-EA.SYSTIiM.OVER 4(IIA) ,
CERTIIICATEOpp F NELIHON FROM WORKERS' R Y' rt1R"1'NI,WAS'I'I?INTERCGYI'OR
COMI'ENSAIION INSURANCE- BUILDING(DIVISION PEES _
('I'hixsmlinn nwJ nil M,cuntplcted it thnpemdl MRronchundaddollan(§Bb) IASF:'F Z
J
or taus.) Kll 113 C�
I wnilythul in the peformaneeofthe work for whi,b this Panna is issued,l nhull WEE-SANI'I' Y-S'1' N EA.^ 1
not co"I Y any paean in any nenncrso as to liemn,cenbjecun the Wallen'Cau,Rn, L' Z2_
OZ cation Laws of Califarra.Dae WA AIT WVIINT/EI.RCF I iliZO Applicant= NOTICII TO APPLICANTo If,Baer.oinking this Certificate of Exemption,you should WATER SYSTR liecame subject to the Wmkcfs Cnmpensmion provisions of the Labor G,le,you must LLI forhwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
ZCONSTRUCTION LANDING AGENCY N ' 'IAL TUNER. SQ.14.I herby Thomfledhere is a co...ITT uIT lending agency >um Nocw [enders NamcF(l"fU ],emdurs Address Ab r I atify tool 1 nose real this upplicnlinn and stem(hut tic above infurntudon ix Eli.F.: 0. c rea.lagree m cumPlY carte all dry ad county oNm:races ala slim Incas rd:niog n, QTY. MECHANICAL PFRMIT 17FE
U hulldingcorelractina.and hereby aulhonee representatives m dol city u,amen Mate the l3
moss oentioned pmtxny fir inspection purposes. PERMIT ISSUANCE! 3
(We)agree m save,indemnify and keep Theories,the City of Cupertino against ELECT .I'lili
liahilitics.judgments,costs and expenses which may in any wayaccmcagains,said City ALTER OR ADD TO MECH. D PLUMBING :E
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL.COMPLY WITH AL1,NON-POINT AIR HANDLING UNIT TO 10.000CFM) MECHANICAL 1113 tO
'OURCH REGULATIONS.
AIR HANDLING UNIT(LIVEN 110.000 CPM( CONS1'Rl1CfION TAXX
Signature of ApplearossUourectur Date , EXHAUSTHOOD(W/DUCT) r 0 HOUSING MI'I'IGA'FION FITH
HAZ RDOUS MST PRIALS DISCLOSURE
Wlllthenppliunlnr lumen hnlldiugoccupanl Hnrenf handle h:varAuun ntawdal HUNTING UNI'I'(10 I Ob(01x11f TO)
;is defined by The Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Crile,Section 25532(.)? �/1/�,' HEATING UNIT(OVER do.(NN,P-GH
E3 Yet �' , VENTILATION PAN(SINGLIi RESID) PAID
Doc Ncttipt a
Will the applicant nr fawrc hurtling r,ccupam uu equipment or Jevicw which BOILER-COMPQHPOR Ifla"BTU)
coil Weati us air conmmirmms m defined by the Bay Area Air Gould,Management
(Barret? / BOILER-COMP(OVIiR I(p,IX1U)
a BT
E3 Yes fJNr'
I have read the hemNnusntarerivlx p, armorial under Chaim,695of the CT AI R CONDI'I I(INRR ISSUANCI3 DATE
Tania health&Safety Cole,Sections 25505,25533 and 255311 interisland(he,If the NEW RPSIDIiN'I'IAL NUICIL SQ.ITT
nrt'dd'tngn«x mol cane„dr hawolconol dtm It rotor runonsinilirymnodty me oeaapam 2 111- 3
at Imumornocat,which mmIO la,mal priuou issue noce a to Cediticmcof(kelpw,cy.
Owncrnrmohmimclagcnt Dam rTAL: ISSUED BY:
OFFICE