S 3099APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
RUILDNG. FLECI'RICAL I PHRMI'FNO.
CITY OF CUPERTINO S 3099
BUILDING DIVISION APPLICATION%PERMIT ,,,,,r .r'w�Rurv(Ir.r T1rnTl,wlcnf.
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OFFICE
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CONTAC . PHONE:
lr�❑Consultant
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Fees Paid b)' Applicant (Initial)
BUILDING PERMIT INFO
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LICENSED CONTRACI ORIS DECLARATION
I hereby affirm Thal 1 am licensed under pmvi.ions of Chapter 9 (commencing
with $cation ](NXpof Divi:Jy^ Jof The Rusincsr R esw Q dory tic msc is
in roll lima and eRect. rn
LiomTac Cln..v cid Ii,a
Onm '� 7 Cnnvucw
A CHITECTS DIiC ,ARA'IIUN
I unJenunJ my plum xhall be used m puM1lic records
QTY ELECTRIC PHRM IT Hili
JOB DIiSCRIPTTON
RESIDENTIAL:
CSFI O KITCHEN REMODFIh
Ulll'IION ❑PLUh1HING RE -1'11`1:
❑MUh9'I-UNIT ❑STkUCICATIO
CUIMMOT)IyCATION
❑INTI?RIOR ❑CIfIMNIiY REPAIR
IMI'ROVF.MI?NT SWIMMING POOLS
C]FA'1'II RI?M0DFIJRIiPA1R ODEMOLITION
❑O'1'll
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7
1117RMIT ISSUANCE
APPLIANCES-RIiSNEN'I'IAI,
PANELS
UI"IO 2IXIAMCS
eProfa..innul
Lie... ed
OWNI?R-BUILDER DITCLARNHON
I hereby ffn II II' ell The C 'ents, Liven- Law for The
µall.. b ': (Section ]1005 H:rocs JI f.. s Code: Any .tyst county
which 4 pe n c o t t Ir n p den I sl p , mature
prion I .. 1. y the ppl'c tf hpsmmnt fl 6 df t teen
Thai he I' dp t 'hep he Contractile, < 1 (Chapter)
fwnvm Ti Tgw,h Ssu m7(XX).f D\.... T3stlbe :" :n II t�Nnm Cale)
that he is exempt Nemfrvm and the buds Ibr The alleged evnnpdn T. Any violation of
Section 7031.5 by any applicant for a permit subjects The applicant) a civil penalty of
201-I0f1(IAMPS
OVER I001AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
/V CIL A 2
'PIMP METER OR POLE IN$'1'.
COMMERCIAL:
❑ NEW IiLUG/ADDI'1'I(lN ❑ DI3MOLITION
❑'I'HNANT E] FOOD SERVICE,
1'OWF;RDEVICI-1
SD
L.,
Wm
not mare Than five hundred dollars ($501).
C1,as owner ofthe propso,,or mYemployee with wages astheirmle compen.aiun.
will do the work. and thevuucmmls not intended or offered forale(See. 7044. Rasmus,
send Pna'csuion, Cock "The Cunnanors Larloc Law docs not aPPly Tu un owner nl
propery who Imi1Tk or Inlps ves thereon, and wha docs such work himself or Ihrnugh
his own employees, provided that such improvement% arc not intended mothered for
ule.lf. hnwevee the MTilding or improvement is sold within nneywr of completion. the
owner -builder will have the burden of proving That he did not builder improve for pur-
IMPROVEMENT
El OTHER
SWIMMING PHOL ELECTRIC
b
'I OGTLITT$- SWI 'TCfIF,S-FIX 'I'URb.
00,
NEW iNTIAI. [L[C')'R V rl'.
SQ. FT FLO(IH AREA
&SQPI'.
'I'OTA :
pownDlde.L
n I, as owner of lie pinpwsy, am cx.lunivd. ......Our, with Iiren,cd cvmn'eters nT
,....True, the pojccT (See 91H4. Rosiness and I`m1"csslu.. Cof,) the Cenuucmry Li-
ceme Law daes nwapply m an owner of ptnpcny who builds or improves 0erton,and
who contracts for such projects with a communist licensed poroma0 the Contractors
7�Q
QTY, PLU NG P171ZMIT FEE
�0
License law.
0 1 am exempt under Sec. . H & P C for this mason
PERMIT ISSUANC
AT:[ER- )RAIN&VENT 'T -WATER EA)
BACK FLOW I'R(TfECT. DEVICE
VALIIAlION
D p 0
CJ s�i
Owner Date
WORKI3H:S COMPENSATION DECLARATION
I have 1 hemby affirm under Finallyn of perjury one of the folhming declarations:
and will maintain a Certificate mCument to self insure for Workers Cori
% DRAINS- FLOOR, ROOF. AREA, CONE, 3
STORIE.
TYPE CONSTRUCI ION
Notion, as provided for by Seen mT TRIP of The Lobo Code, for the pcibrounce of the
work lin whichlv..... i, lxu¢J.
0 1 have and will maintain Workers Compensation Insurance. as required by Sccdnn
T/IXlolthe lalan Cade, fur The pefrom ... ecafthe work Rnwhich This permit is issued.
My Workers Compensation Insurance camerand Policy number art:
Carden Policy No.:
(ICC.G UI'
.DING DIVISION
MIN
367-ol
IliliS _
% FIXTURES - PER'IRAP
GAS - EA. SYSTpM-I INC.4 OU'I LETS
GAS - EA. SYSTEM -OVER 4(EA)
CF,RI'IFICATF. OF EX EM I'r10N FROM WORKERS'
CUM PBNSAII ON I NSU RANCI?
GHEASIJINUUS'TRL W
PLANCI{IiC I O
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CThis.amien nreJ nm M1e comploullf Chep ail is foe ere lmadred dollar, 1$ IINII
orI )
IoyanyThar inthe nperformance of the wed for which This flueWosissucdl,hall.-
not enTpiny:mY pent;^�Ly�1'manncrm be uhlea hT the WorkeN Compen-
L,tws of Calif , A)
-r
GREASE. TH
$T:WLR-$ I
WATER MTA
Y -STORM IiA. 2IX11'T.
N � �
C/ Q
FNEH Y iF 7
OR C {E
AfTiun
NOTICE you uhmulJ
N ,tum, %1 j ct to ICANOthe Work IL utterpernatg n p erolream of Labor Code.
fwamm suhjeat m the worker. Cempc.his pmWsinal (if e de Tabor Gde, You must
forthwith comply with >uch provisi...... his permit shall he Jcemed rcvaked.
CONSTRUCTION LENDING AGENCY
I hereby alfifor That Ihere'm u amamclion lending agency Ibr Thu perlbrmunte of
the work lin which This permit is issuoil (Ser. 31197, Civ. C.)
lender's Name
Lender's Address
WATER SYS'I /TREATING
SUfLti P s
WATER SEH CF
PAID
Dam ReceiplY
NEW RLSIDIi 'I
CT 1
It ILDINGFEE
IT
1 certify that I have read This application and state that the above information in
,mete. I agreemcoreply with all city undcounty ordlnancesand state lawvmla,ingto
bmitingeo"an'ton,I.... h..rhy authndxa is.... o,ivsof thirdly bear, apmT The
QTY. MECHANICAL PERMIT FEF
SEISMIC IEE Q
above-mentinned propcny for inspection Impales
(We) agree, to save, indemnify and face harmless the City of Cuperm again
liabilities.judgments. costs and expenses which may in anyway acceptagainst said City
PERMIT ISSUANCE
AUEER OR ADD TO MECH.
ELECTRIC h'
PLU 1.' O
in enm'cgnenea of the staining of this permit.
APPLICANT UNDERSq'ANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNTI'(TO IIIINNICFMI
MEL IA IC LI:JIF
SOURCE LA'1'ION.'
AIR HANDLING UNIT (OVER IIfINNf CFM)
CO S'R "IION 'IAX
Squaw.. of A,pliciam/Cormem, Date
HAZARDOUS MATE IS DISCLOSURE
Will the applicant or lumre buildingsncupant store or handle Incrmlous amani.l
uv defined by the Cupertino Municipal Calc, Chapter 212, and the Heath unit Sufay
Cade, Stan T 255321.1!
❑Yes
EXHAUST UTTOD(W/DUC)
HOUSI GMITIGATION FEE
HEATINGON[ "1'(1'0100,010 IfrU)
HEATING ON[ I (OVER 11110010I1'TO)
PAID
Date Receipt e
VENTILATION PAN (SINGLE RESID)
ItO1LER-COMP (3HPOR 100,000BIT)
11 Will the applicant or turure building occupant use equipment or devices which
Ili, ha' ndaus air .mea ninan,n as defined by the BUY NcaAir Quality Management
"r( 1.: f
BOILER- QOMIt(OVER I(X),INX) BI UI
I: isuic,l
VcsIT
Al R CONIII'I'IONER/
ISSl1ANCE DATE
I have read circ hamJnus materials mryurnamu under Chapter 6 95 of he Cul.-
foram Health & Safety Cade, Sections 25505, 25533 and 25534. 1 undentand,hat it he
NEW RESIDENT IAL MFCIL SQ. Fr.
bullding does not �tjrrently have. tenant, then a is mY r.....nibillly m nrli,y 0e, uaupvm
OFFICE