S 3180 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
Cll'Y OF CUPERTINO BUILDING-ELECTRICAL I NO
AOI11LnWG DIVISION APPLICATION/P4RMIT PING PROJECYICHANIFICCAL k� 318O
.ate" BUILDING BIN -M II DANIFICA'1'IU]'
BUILDING ADURESS. /n ^ ,!:-�j IP/ ^ SANIIARV NO. AI'PLICA'lION 5UI1MIT1'ALDATE
G14
OWNERT NAME. `PI/OMI:— CONTRALTO 'SN 41 �O LIC NO:
C:7 NIC C(INl'ROLp
RCIIITI!Cf/ENG I!1!R: LIC N(1: ADDRESS: 7 ❑
CONI'ACI': PHONE: BUILDING PERMIT INFO
O 4�,,, ,/�2 ❑ Consultant Fees Paid by Applicant RIJ)Cr Isu PIUn� MECII /
LICENSED CONTRACTORS DE CL RATION-[��J QTY ELF,CFRIC PERMIT' FEE IJ
1 herehy atti mat tum recnscd lander Prnvisimta of ClIaplcr 9 avnmtucoeing JOII DIiSCRIP'I'ION
woZ Ih Scc.....I p(BM1 Ilusinms unJ'nstucions Codas uln amucis PERMITISSUANCE? RF.SIIJENTIAI:
CW nfull Ibree land clfcct. 7 `S�� - ❑SVDWI, I'fCHEN REMODFI,
QUU hiccnm Chis LI.'.k G+ AI'I'LIANCES-RLSIDEN'1'IAI. ❑ADDITION [_1 PLUMBING RIP,PIPE
'e+Z 61 p:lle CnnlNclur
tnQy ❑MUI;I'IU:VIT ❑STRUCTURAL
ARCHIF O y ar-hall N,use DECNfic re IDN PANELS MODIFICATION
I nmy pl:ms shall be used es public reamis
UPI"0IN)AMPS
❑INTERIOR [I CHIMNEY REPAIR
(=4F-w Licensed Profecsiamal 20140N)AMPS IMPROVEMENT E]SWIMMING POOLS
KC, 1 hereby a0inn bunt 1 a ncumlmtEfnsmEme C nmtD'IOQ License Law franc OVER 1000 AMPS ❑BATH REMODIiIJklil'AIR DEMOLITION
Q
yKj3=U fallowing a nson(Section 7031.5.Business and Professions Cafe:Any city lar nmmy SIGNS ELECTRICAL
❑OTIIER
to which rcauire,a Perms eu O namcL alter.improve.Jemnlish,lar rep:nr any stmcome rJ -
I�u'OQ prierto iv,ia,uance.also re4uim,the applicant for such permit nm file a signed amfenenr SPECIAL CIRCUIT/MISC. _ ANT/L
that he is licensed pursuant to the provisions of the Contractor's License Law lChapmr9 COMMERCIAL
1+100 Uommencitg wire Section....no,Uivixion3 of me tlusinasanJ hofe.wions Gtlel lar TEMP.METER OR POLE INST.
a a e¢ mat he i.v cmtnpt mCrefmm and me basis for me alleged exemption.Any violation of ❑NIiW BLUGIADDIT'ION ❑DEMOLITION
ti w Section 7131.5 by any applicant for a Permit subjects the applicant m a civil lcnalry of POWER DEVICES ❑TENANT ❑FOOD SERVICE
= nor more man Eve hundred dollar,($500). IMPROVEMENT'
2S0 D I.as owner of the prapeny,or illy employees with wages us their lade canpatsmion, SWIMMING POOL ELECTRIC
F will Jr.the work,and lire xuuaum is not intended or offered for safe(Sec. ❑OTHER
30o and Protea....,Code:'I'he Cantmmor'v License Law docs not apply m un owner ofKIIERMUISSUANCE
S-Il X'TIIRRS
pro,try slum builds or int111sel thcram,and who dna,,.III work blinnelf lir throngL
bis w m,Ih,,e,,pr vided that such ropmvumcnts are nor In cod,d or olln'ed Iia POP,— SQ P
sale lf,hnwcva,tbc Fnilmlingoriinprovemcnl is sold within ane you nfcnniplmian,the SQ.III'.FLUOR ANIIA VSQJ4.
owner will have thcbuNen ofprn Proving that he did not build or improve tin pu
powolslale.) v rTAI
❑ h as owner of Elm insist am exclusively contracting with licensed Infractor,m
onstrun rhe project(Sec.7(W.Ravines and Professiom,title:)'1hu Contractors Li-
>cl.uw dues not apply nu an owner of property who build,or improves them..,andING PERMIT FEE
who aammfs for such projects with a commen,O)licensed pursuant it)the Contmetoes
License I.nw.
I am exempt under Sec. .B&P C lin this reasons
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Omwr Dale is
WORKI!R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE / D
1 hereby affirm under penWry of Perjury one of the following Jeclautions:
�Ihavc and will mainminaCcnihcate of Consent self-in.mrc for Worker's Cntnpen- DRAINS-FLOOR.ROOIt AREA.CON¢ STORIES TYPE CONSTRUCTION
Ir lion,m provided lin by Section 3700 of the Labor Cede,for the perfornmacc of the O
work for which this permit is issued. FIXTURES-PER*1 RAP
I have:rod w,If mention Worker',Compensation Insurance,as myuireJ by Section
3700ot he Lab orCode.for me Nrforvanceof he work lin whichnis permit is',s rd. GAS-EA.SYS"TEM-1 NC.40U'UJII'S OCC,GROUP APN
My Workcr's ContPCnsurioalnsuroncecammund Pnlicynutnhrum. nVme nAl f1
Currier: Policy Nu: mr
CI!KI FICA'1Y,017 EXEMPTION19fOM WORKERS, 'rINPC I.WA '1ll 1 'HiRCEPTOR
COMPENSAITON INSURANC17 BUILDING DIVISION IBES
fllif sect.....neat sol he cunmpleted if rbc Permit i,LiroacI ndreddollam( CREASE'I RAP
nlc„) PLANCI{ EIi
I crony that in the rfotmance ofthe work for which this fiction is issued, Isl 41 ,f1. .1. s
Pe IY V.4 SPA -S ) HA.21X1]IT r`
not employ any person in any manner so as to become subject n)the Workers'Cot 4ENFRGYIOn.Z smion haxs ill Califoorm Date WATERHEATERW/Vii ❑P,!CIR O Applicant
res NOTICE'11)APPLICAN'It If,after makng his Cenlfieme of Exenmprion,you moylll WATER SYSTEM/TRBATING
? baorae wbjmpua rhe Wedno Coonea,this Provisions oftherued revoke,.
forthwith comply with suvh provisions or mi>perminhall be JcenacJ revoked.
kij
0. 0
=Z CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLMB. SQ.1'I'. Orae Receipt R
U C) I hereby affimrthat there is a construction lending agency for the performance of
he work bar wh!chthl,pc mut is issucd(Set.3007,Civ.C.) �, '1' Lf
F' Lender's Name O
V Lcndcr',AJdres, I f
>fI Cenify In.,1 have read this oppliwfinn and Irate hot he above infannatinn is
Ii DING PBI!
F to correct.1 agree vu camaply wih all dry and county nrlinance,and state lawl mluring to QTY. MECHANICAL 1'ERMI'P FEE SF.IS C PER / S
UZ hmdlningena,mnaian,..it herehy ambnd..c rcpmlemaJ.esnfmildty Pa enter upf he
.hrvo-uaOunoned Pro,vny lin a,D.1 on purpose, I'I!RMU ISSUANCE D ELECTRIC PEI! O
(Wel ngra ro slava,Indutunily and keep oI less the City of Ctgveninu again((
Iiialair,"luJgmm.t.,co."nnA cap,lase,which at In any way aceta,ngain.a nniA CiIY ALTER OR AUDIO MSCI{, PLUMBING FEE ^
in u¢yra:ncc ul the giuning of rhi,pons(.
APPLICANTUNDHRS'1'ANDS AND WILL COMPLY W1,11 ALL NON.POINT AIR HANDLING UNITI O 1110NICITA) MECIIANICAI.Id!li
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER❑I,IXNI CPM) % T CONSTRUCTION'I'AX
Signature of ApplicandCommemr Dure EXHAUST HOOD IW/DUCT) J v HOUSING MU IGAIION FHE
HAZARDOUS MATERIALS DISCLOSURE
Will he applicant or future holding occupant store or handle havallou,material HEATING UNIT(TO 100.000 If I'U)
as defin d]by the Cupertino Municipal Code.Chapar 9.12 and the Wallin land Safety
Gude,Section 2553200? HEATING UNIT(OVER 100.000 If IIF)
E]Yes ❑No VENTILATION FAN IS INGLE RESIDE PAN
Date Receipt
Will the applicant or future building occupant use equipment lar device,which BOILER-COMP CIHPOR X01.000 BID)
mit havardous air cnnwminums as defined by the Bay Area Air Quality hlunagmncnt T(" Li
,,,net? BOILER-COMP(OVER 100.000 BTU1
[:1 Yes 0 N
I! fn chvvrdou,maorid, life cm,anlcr Ch; lafs95ofthc C'.d. AIR CONDI"1'IONEN ISSUANCE DA/TI-3�
fn nhh fcty title,Saviam 25. 2553)and 25,534. unJc lana(tlnn if lire NEW RF.SIDENTIAI,MECII. SQ.171 Z C/ •-t
ulldln"a mntly have renu, 1lsmy rcs mxilobl,tnno ythelac tpart
ofineranirt oswhiahmu,rl enlE�utkOe pa '
Own, N.,cut U;t LPOU61ISSUEDBY: 177—c/^.,J
OFFICE