S 3163 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO fit)I ar..ELECTRICAL PFIT No
BUILDING DIVISION APPLICATION/PERMIT PLUM 1fIN1;.MKCIIANICAL 3163
BUILDINC PROJECT IDRN"1'fFicsrioN'
IOU I LIIING ADDRESS: SAN I'TARY NO. APPLICATION SUBMITTAL DA]T
1`63e5
P LO VISTA � - -99
y OWNPNI' P1111N1?' C< T ACIOR'S'NAM�� L� ��(C�NO: --3 NIC CI1N'TROLM
ARC]II'1'IiCTIILNGINISILN: LIC NO: alz- S.FF✓✓�_1lAA\\_ —, `� ✓-, ✓'\ �1S Z/ ❑
CONTACT: PHONE:
(�� 7 �1 -1 BUILDING PERMIT INFO
�/'Tr.{f� ?aq F� �i I 10615 ❑ Consultant Fees Paid by Applicant(Initial) BLDG EhI!C' PLIIMN MECH
LLCLNSED CONI'RACIOR'S UECLARA I'ION QTY. ELECTRIC PERMIT FEE
JOB DIsSCRIP'I'ION
I hereby affirm Thal]..I licensed under pmvinionz of Chapter 9(commencing
❑d'Z with Section 7gxqufDivi%ion3nftha Iusinessand l4nfessimsfeadi nd.,her..,, RESIDENTIAL:
y]p❑ PERMIT ISSUANCIi (�
CSF in full t'mon and efts". OSFOWL O KITCHEN REMODEL
a_u license Class Lie. APPLIANCES—RP_SIDEN'I'IAL ❑ADDITION O PLUMBING R17 PIPIT
F Z W Dam Contnam
tnaL ARCHI'I ECTS DFCLARA'I'[ON ❑MUI.TI-UNIT' ❑STRUCTURAL
F H Z 1 undersand my plans shall M used as public records PANELS MODIFICATIONOZ UPT01tNIAMPS CINTERIOR [I CHIMNEY REPAIR
FaF'6l I:mensml Pmfcsxinml 2111-IgN)AMP$ BAT IIREMDF OSWIMMING
rpONPOOLS
���,
OWNER-BUIhDEH UEChARA'I'ION OVER BNX)AMPS OBA'TII REMOUIiUR1iPAIR ODEMOI,1'TIGN
z W a 1 herenr mlirm mat 1 am exempt B,rrT me camnm,r;License Law far me
W 3 LL F" 11111 g (Section 703 1.5.1f -nee d professorate,C nI Any ity)r county SIGNS ELEC'DOCAL C OTHIiR
y which 4 permit I construct, Iter, p J tlixl I' ,%mewrc _
C'art
Puritans lotaince.alloomparasIh pylicam ficirstachsoundt flecougualstalmorat SPECIAL CIRCUI'LIMISC. �� I V r-U�
That be is licensed Punuanraa the pnrviaomnf the Coommou's Liceme law(Cbapmr9 ��
Yat aC0 lcamnencing whit Section 700mol'Diskiw.lnfthc ltu%inn%and Pmm,oi,m Codclnr 'I'EMIR MRI'ER OR POLE INST. COMMERCIAL:
e,c.e tY Ihm he is exempt tharefinnor and me nasi.Lin The allege)eseniptinn.Any violation m 0 NEW BLDGIADDI'I'ION 0 DEMOLTUON
X�mSeminn7031.5 by any applicant for a planar subjects the applicant to a civil penalty of MOWER DEVICES El TENANT ❑FOOD SERVICE
a1 marc unan live madred doll.«($5ua), IMPNOVF.MI?NT
7 01.as,wmmf the property.,tiny employers ITS wages.,lheiOudecampenwtinn, SWIMMING POOL,ELECTRIC
F.. will Jo the work,and The%racture isnot intended or offered for sale(Sec.701 Bmine%s El OTHER
L 3 and Tire...iu to Cudc'I he Conaall'a"license Lew Lot,not apply 1,va owner of OUTLETS-SWI'I CHES-FIXTURES
prepery who build%,,,in.......hereon,and who des,ouch work himself nr through
hi%town empbyam,provided that such improvements am nm intended or o@rt%I for jHASYS
ENTIAL ELEC!'R SV Irl'.
sale.IL Mwevcq lM1c building or lnTpmvmncnt i%vald within nneyemnfeomplctlon.the $Q.IT.IL,(bR AREA 3sSU.IT.
cohullder will have the burden of proving that he did ma build or Improve lin pur-
pmcof sumo (ITAL.
❑ I,us owner of me property,ten exdusivclY contracting with liccnvd wmnmon In
court r..I the To Two(Sou.71141 Busincs nnJ Noule...nm cone,'in.......emr'x Li�
cense Lawdeas not apply man owner of pmpcny who htild,or impmvex heaven.and QTY. PLUMBING PERMIT FEE
who canoe.for such prepal,with a co mrenr(s)looms,)pursuant arthe Contractors
Loretta Law. SUANCE
❑1 am exempt under Sec. .It&1'C for This mason
RAIN&VENT-WATIiR(EA) VALUATION
Qwnrr Ilam
_ WORKER'S COMP&NSATION DECLARATION RACKW 1'R(YIEC'I'.UIiVICI
I hereby allirm under porzlry of perjury,one of the following declandons:
(] IM1evc auJ will nminunnoCertiticnmd Cunsenlet;dbinxure for Worker,Con.pe,I- FLOOR,ROOP.AREA,CO ND. STORIES TYPI?C06STRl1GTION
satins as provided for by Notion 7710 of me labor Code,for the performance of the
work for which this permit is issued. —PER'I'RAP
❑I Iwve and will main one Winkel,Co u're i I hsumnce,a,required by Station
J]INlaf the Lmou Cod..for the Nuance r id me work rnr which his pe on"iso%wed. SYS IHM-11NC.4011'I'LETS OCC.GROUT' APN
My Worker's Compensation Insumnce carer it Policy number am:
Carrier: Pillory Na.: GAS—IIA.SYSTEM-OVER 4(EA)
CLRI'IFICATFCIl PENII'IIONFROMWORKEIeS' GREASHIINDUS'1'RL WAS HE IN I'ERCEVIOR
COMPENSAITON INSURANC17 VRG
UILDING DIVISION IFF%
(Thi-soll nneedmaheenmplcmol ifthe permit is brone humbroldollan($Igl) GREAS17TRAP
FEE
r la.)
Icenify that in the pcdnnwnce of the work lin which his pcmrit is issuN,lsmall $LWER—SANITARY—STORM ITA.HX1f4. it
mol employ an rata I `11th®,��rt the N',rkeri Co.,a-
O z %inion I,aw' dC.r' r t�1 1 I 1�'+•*+a WATER HEATER W/VEN'IMLECI'R
Q Applicant L —NOTICE TO APPLICANT:If,after ing This CCnhaleof Exemption,you should WATER SYSTEM/BEATING become xLbjma Io the Wmkef%Compensation mo,kinnsof he Li an Code,yuto musforthwith comply with such prasi,ionsor this perms shall be ifeemed revoked WATER SERVICE
z CONSIRUC7HON I.I!NDINGAGENCY NEW HhSIDENI'TAT PLMIf. SQ.FT.of te Re''sin#he work fr which this permit is Ill lSec.Jl19],Civ.C) TOTAL:lender';NmneU Lander,Addraw TOTN.:1 certify Thal 1 have read this application and%tate th I The abate infnmmtion is L
.F.% UI correct.I agree to comply with all city and county ordinances and slate law%relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z badhngcon%imehna.aml batch,nammirr repre%emmive%anhis city(()enter Th
enter upon o
mbozomenti,ned property for i.."atian Rurpows. I'ILRMII'ISSUANCE O
(We)agree no save,indemnify and keep harmless The City of Cupertino against ELECTRIC FE ( U
Iluhllilim.rydymcntacu.(land m'rseS which may in any wary vccrur against said City ALT ER OR ADD'IO MECIL PLUMPING PER
in nae9ucare of the Framing of this penow.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(D)10.(X0CPAt) MECHANICAL.Filo
SOURCE R17GI!LXI IONS,
AIR HANDLING UNIT I'(OVER ILIdNNI CFM) CONS'TRUC'T ION TAX
Signature of npphemil/Conm¢mn Dwe EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicantorfuture building excretion stare or handle hazvdour material HEATING ONE I'(To 100.000B'I'IT)
ns daEmJ by the Capetian,Mwticipal coda,Couse,9.12,and he Health and Safety IIEAI'IN<f UNIT'(OVER 100,000 1111J)
Calc,Section 255J2(aB
C3 Yet, ONo VGNH.ATION PAN(51 NGLF,RESID) PAID
Ume RttcipT N
Will the applicmd...future building mcupant use reeppmmnl or ocvlme which sIf01LER—COMI'(LII'OR HXoNX)BTU)
mit In7an us air contaminants a%defined by the Bay Arta Air Quality Management 'AI.
DlNrnp BOILER—COMP(OVER 1 W,W)O BTU)
ElYes C]No
I have mai the hazardous materials smiammenm under Chapter 695 tof the Cali AIR CONDITIONER ISSUANCE DATE
Brmia Health&Safety Coda%meaans 25505.25533 anti 25514.1 understand Led if the NEW It 1!SIDI IN I'IAl,MECU, SQ.FI�
building does nal commonly have.mount.that n is my regxmsibilitY m ramify the meupant
of he requirements which must va met prior to issuance of a Ceniticam of Occupancy.
(liner or amhnrimJ agora Oma 'TOTAL.: ISSUED BY: 7
OFFICE