S 3343 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILD INil-ELECTRICAL PERCH I'PNO
RUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL J 3343
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS � � SANITARY NO APPLICATION SUBMITTAL DAPI
�.0��76 L'
OR'S N fIONE: 'R )K" AME: .I:NO:
NIC COMfB(ILp
ARCHITECT/H C 1313R:LIC NO: A SS ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LD ELECT PLUMB MECH
LICENSED CONTRACT OR'S DECLARATION QTY ELECTRIC PERMI'P FEE:' El El
I hereby arfrm that 1 an feenled.oder pnwi,mn,.r Chapter 9«mm�encing JOB DESCRIPTION
�aZ whn Secb7n 70 id a' 3nrnelmones'. Profemimtn Qvirld my Ytcr,,v - R ). 1:
+I J O O I'ERMI'I'ISSUANCE
Hull llrtce d f ❑SFDWL -[I KITCHEN REMODEL
pa-Zpj Itce C Cor m APPLIANCES-RESIDENTIAL []ADDITION E3 PLUMBING RE-PIPIT
ARCIII'I'EC I ❑MUl:fl-UNIT' ❑S" UCTURAI.
Feta I'ANF.IS _ ODIFICATION
ZOra'z understand my plans shall be used as public reconly�/,/ q/�'/
OZ=Q //� (,//// Up1`02(X)AMPS ❑INTI?RIOR 1HMNEY REPAIR
G4-F.19 Licensal Professional 201-IIXIOAMPS IMPROVE MEN SWIMMING POOLS
dye, OWNER BUILDER DECLARATION OVER IIXXIAMI'S ❑BATH REMODEURI?P R ❑DEMOLITION
a 6 I hereby off'.0a 1 am exempt from the Chalmette',License Law for the
icS,O y U hillowin,naean (Seniors 7031.1.B.loess and Prol.xsi.ns Code.Any city orcowtY SIGNS ELECTRICAL ❑Of1{I?R
to 311 y¢ which requires a permit to construct,alter improve,demnl'uh,or repair any structure
Fp�O�J.J prior to its lssaance,also requires the applicant for such permino flea signed statement S PECIA L CIRCIJI'T/MISC.
2;!(y denheislieenscdponsuan III he pnrvNions of the Cnwmmnt'x hleemc Low l Chapmr 1) -
1+J,r00 (commencing with Section 7000)of Division 3 of the Business anJ Prnfassions CrNe)ar 'TEMP.MEI'ER OR POLE.INST. COMMERCIAL:
L ax'06 that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDIJ'ION ❑DEMOLITION
W^m Seedo..AHLS by any,,,Bann fin;I permit objects t he apphend Ion eivillwnnity of POWER DEVICES ❑TENANT ❑FOOD SERVICE
not more than live hundred dollars'($500).
IMPROVEMENT
< ai Lo,thew owner nfthe dDIw,In Ime ryempl,ymi with owages
hod for their sole 044,It aioq SWIMMING POOL ELECBIC
O aid do,the node [he Cma Lnho,nnded.n,l'f dsno[e(Scc.90.LLItunet oc ❑D7111:R
nal m andany%heb bonds
or imp Cestheme License Luoduesnmapply himself
net of Olfl'hH'I:S-SWI TCHES-PIXTIIRIiS
as pmpeny who builds or oiled than
thereon,and whn dues such work himself or through
his own empinyms,prolding that such intpmv,.1d w oro not intended or offered for NEW RHSIDENTIAL ELIeL:R SQ FC.
,steel!.htwever.lhe building or inyn7vemnem is s.IJ within me yeandbnmplesinn,the SQ.PI'.FLOOR AREA $ISO.FT.
owner-budder will have the bmJen of proving that he did not build or mpoi for pur-
sc afmlc).
E] 1,as owner of die property,am exclusively contracting will licensed c.ntnemrs t. A
ascan the project(Sec.$H4,9.xiness and Professions C,o,.I the Con..acsoi s Li-
nseLaw does nm.pplyman owner or pnrpeny whn builesm improvers shercon,onJ QTY. PLUMBING PERMIT FI?I?
who canna,,lin's'umh pr.ju'ta will)a eminn9tr(n)IiwnseJ purament..the Convnetor'a
License Law. PERMIT ISSUANCE
❑1 oro exempt under Sec. ,B&P C for this reason
Owner Don N:CER-GRAIN&VENT-WA'Il3R(HA) VALUATION
WORKFR'S COMPENSATION DECLARATION BACK FLOW PROITCT.DEVICE
I hereby aff rat under penally of perjury one of the following dmtarmimI,
❑Ihovc and will maimainnCenilicme of Cnnsem mself-Torose lin Winare,Campea- DRAINS-FLOOR.ROOF,AREA,CONED,
1.117 ,as provided for by Section 3'700 of the Labor Code,far the performance of the STORIF '1'YPIi CONS'1'RUCI'ION
it con dirt which this permit Is isanal, Fix'IDRES-PC;R'I'RAP
L have and will maintain Worker's Compensation Insurance,as required ltdo
fifth IaMn Cei fa the rtmancenf the wnrk f i 1Yl [� eC ee. GAS-ITA.SYSTEM.I INC.4 OUTLITS OCC GROUP MIN
We K f,r�nln. At c dPolic7J-
m GAS-EA.SYSTI?M,OVER4(EA)
Coni1. Ilcy FROM
CERTIFICA FI17NS TION INN PROM WORKERS'
COMfIiNSATION INSUIXANCF. GRF.ASIIINDUS1l21.WAS IF,IM'Ii12CF.PTOR
IIIJI DIV ISIO_N FIi1:F _
IT his senion neeJnntbecfi..plemJ it lotion,h
flat permit is lot.nundred doll...(SIM) GREASE TRAP m less) PLANCIIE PIiE
I cenlfy that in the performance of the work for which this annit is issued,l shall SEWER-SANI'T'ARY-S'I ORM I3A.200 FI'. 1
oat employ any prion in any manner so ns to becmne subject to the Worker.'Comped- iN .
moon Laws of California.Date WATER]HEATER W/VENTIELEM R
Q Applicant GRADINGY9,
'Z q NOTICI?'IVO AI'PI.ICAN'n If,afier making Ihis C'enilicate of Exemption,yon should WATER SYS'TEM/IBEATING
F > Iecome vubjecr u)the Worker's Compenmlion provisions of the Labor Code,you must SOILS PER
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
aQ
7 z CONSTRUCTION LENDING AGENCY NEW RLCIDEN'1'IA1.PLMB. SQ ET, PAID
I herebyaffirm that them is a constnetion leash for the formance of Date Receiptr
. .C.) Y Icor
the wink for which Chic pemmit is issued(Sec.9119].Civ.C)
u"Ulender's Name TOTAL:
L) Lender's Address TOTAL
I :
certify mol I have red this upplieniun and none mot the above offer nwtinn is 01111.DINO FIil3
Ffn nconecr.l agree m comply with all city and county ordinances ane state low,refusing 10 QTY. MECHANICAL PERMIT FEE
)z buiningaaswnion.and hereby nnthodze rcpresenmtives of This city In enteruM'n the SEISMIC FEE
above-mentioned property Tot iaspecft n pnq,nses.
(We)agree n mvw indemnify and keep hanMas me Qty Ica th....gain,, PI?RMIT ISSUANCE ELECTRIC PEE
liabilities,judgmems,eoessand expenses which may ins�sW��¢/cry S1 `ECBY ALTER OR ADD TO MECH.
onscyncnce of the gmnlin6 of lh' 1d1, /// / PLUMBING FHI3
AI'PLIC TUNDERSTAND NO ILL COMPLY I({ I. O POINT AIR HANDLING UNIT(TO 10,IXp CFM)
SOU ERF MECHANICAL PTF.
AIR HANDLING UNIT(OVHR 1).000CFM) CO NS'I RUM ION'I'AIX
core 7fAppi unmet Dale EXHAUST 14MD(WMUC) HOUSING MITIGATION PEE.
HAZAItI S MATERIALS DISCLOSURE
Will the applicant fir future building n.cupant store or handle limitations material I]HATING UNIT(1'0 100,000 BTU)
as defined by she Cupeninn Munici al Cane,Chap1 9.12,and she Hcalm and Safety
Cad.,Saction 25SC(a):' HEATINC UNIT(OVHR Ig1,OM R'fU)
E3 Yes PAID
VIiNT11.R1'ION FAN(SINGLI?RESID) Dam Receiptr
Will the applicant fir marc h;iddag ueeupmt sue egnlpnmen m devices which BOILER f311P OR IINI,OW li'fll)
anis humrdooxnir cnntam ass; IclineJ by the Bay Area Air Quality Managancnl IUFA
DiariclY
El Y11 BOILER-COMP(OVER 100,1X10 BTU)
o
I have mail the eaJous AI R CON DI'1'ION ER
requimrunnss under Chapter A95 of me Cali- ISSUANCE DAT
Toni, s t Sufm otle, Minns 25. 5,25533 and 853,.1 understand mat if the NEW RESIDENTIAL MECH. SQ.IT
M1uil- Ines mnLlha ilia mytcspoust hiliry to )ayt ecetyvm
Is nms
nen ch . broona
ecs oissuve.fa Yi to of V
O wroo,ouloall,141,ra is I Due,I TOTAL: ISSUED IIY
OFFICE