S 3159 APPLICANTTO-FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECT ItICAI, PE I'I No
HOILDING DIVISION APPLICATION/PERMIT PLUMBING-MliCIIANIC'AL 3159
It BUILDING PROJECT IDEN"I IFICA'ITON
BUHUDINGAUDRFSS: SANITARYNO. APPLICATION SUBMITTAL GATT
OWNER' / :5Y Z, I'IIONIi: GGNTRAGTGRk'i NAME LIC NO:
/ S O/t NIC CON'I'ROLit
�ARCIII'fEC'IIINGINIiI!R'. LIC NO: ADDRFSS: ❑
CorrrnC'f: PHONE: BUILDING PERMIT INFO ' _•,I '
S �` O O ❑ Consultant Fees Paid by Applicant(Initial) HLD _ ELECT PLIJM�1 MECFI
LICENSED CONTRACTORS DCCIARAS ION QTY I - �ELEC'I RACYERIVITs. {/ ,- FEIi Ir{TaI/ LTJ GLS I_Tv
Ihumbyarfimnl rl r :d d 1 - fChpl 9(0nme eS JOB DESCRIPTION
Meekd,ticet�,ndaom'D n3enneseta e„i din nR,' :( ylicense is
FSB infullfarce and effect PERMIT ISMJANCI!
1URESIDE TIAL,
F. ❑SFDWI. ❑KI'I'CHEN REMODEL
U License Class Lie, ,,i� ��..
vFi4W DateContract AI'PLInNCES-RESIDEN'EIAL MAUI)ITION El PLUMBING RP.-EIEC•
ARCHITEC'1-S DECLARATION ❑MUITI-UNIT L1 STRUCTURAL
zO z I understand my plans shall be used as puhlic records PANELS MODIFICATION
O IL 4-C UP'10280AMPS - ❑IN'flik101t ❑CIIIMNGV REPAIR
h Itw Licensed Professional 201-IIIBf1AMPS ECI FRIVIiM13N'I'
<y� OWNER-BUILDER DECLARATION ❑SWIMMING P0OIS
C a I leamhy.111.n.that I nn,exempt from the Contnt,or's License law for the OVER If fm AMPS ❑BAfH REMODEUREPARt ❑DEMOLITION
L O 6 U frillo� wing serum.(Se,irn]831.5,Rasion...and Pmfe.,,,in a,Code.Any city or eat u, SIGNS ELECTRICAL ❑OI'l1E
4130 N which rulmov,a penni[m emsWe,,cher,improve demolish,nr repair any smmhim /n
jog prinr to,it......mac.nb..near..a,the appllcanl lorwueh pcnnitm l ila a aicard smtenrent SIICIAL CIRCUIT'/MISC.
} that he is licunceJ punnantmlhe provisionsof rhe Contnamrs Licence Law(CLePlm9
W aq0 (commencing with Sedinn)fNMOnf DivisinnlnOhe Rosiness and lhofessions COJe)ar IEMP.METER OR POCH INST. CCDIF_RI1V.'
thin he is use memfmm and me h:ais for the alleged exemption.Any vielmiue of ❑NI!W BI.DG/ADDI'I[ON ❑DIMOLI I ION -
��w
Section 7031.5 byanyn,dienl for a penni,.uhjeclsdue nppheranle.civil penalty of POWER DBVICIiS ❑THNANI ❑FOOD SERVICE
not more than live hundred Jnllan($500).q IMPROVEMENT
❑ I,nowrnPmpenga
snufthaermycnp,loys with wage ns theirnule comPulsation, SWIMMING POOL ELECTRIC
F wdldo the werk,andlhesou,unelsno„ntended ors,ffeard farxalc(Sec.IIW,Bmsincow ❑0'1'1{1?k
43$ and Professions Code:The Contractors License Use does not apply u)an owner of OUTLET:S-SWITCI IES-FIX"roll
.......ly who Naim,u i,npnse,thee,n,sed who dna,Xtch wn,h him...It or though
his awn employees.Provided rise[such ineptrvememsare nor intended or NIimA fur NEW RESIDENTIAL ELIiC'!'R SQ IT.
sale.If.however.the building at improvement is sold within o
nne yvunde'n,Ple,inn,Ibe Q.IT.FLOOR AREA S/SQ.lel'.
,ahuildcr will have thebunlen of pnwing thud he did net huild or Memento far par-
pose of sale.),
❑1,as owner of be property.am exclusively connecting with licensed cnmmmnrs m TOTAL:
,nano.[th,:plica,(San 7(144,Brine..,sad prof.. er,Coden'mean,wemr-, ,(
cense law mxs not apply to un owner rf pmpeny who hnilds er itnprovex[hereon,ane QTY I PLUMBINGPPRMI'1' '"EFFI
who conttacrs for.mch pmjems with a cum ousrtsq licensed punonnmhc Commcmrs
License law. P1BRM15'ISSIJANCI:
1 an, i;empl under Sec. ,11 A P C inr,ho,realm,
' ACI'ER-DRAIN N VEMI'-WATER IEA)
Ow, rI -o S I VALUATION
WOH KERS COI. I SA ONII DECLARATION BACK FLOW P - ;
Ihereby affiren underPenalty ofperjury,one ofth following dl t
❑ 11' dl d' 'C If 't.,fC t[ "If umahaW ke,-:C pen- MAINS- 6C) ,ItOOP, EA,C 5'I'UlilE$ 'I'VPI3 CONS'I'kUC'I'ION
tl..n,as pn viJnd f rz M Sal nn 3'IfXI of the 1.,trot C.de,[anise perfnnnance of the
work for which this pamot is issued. TUR- -PFR TRAP
❑ 1 Imre and wilt nrainlain Work—Cumpenx'atin,Irvmnmce,Its required by Section n
391Wof the Lada Gula foOhe perf trounce of Incised limwhich this penni,Is issued. 5- '1'1 1-��J LE OCC GROUP APN
My W'orker's Compensation Insurance carrier and Policy number am:
Coition Policy No AS- 3A.SYS'I EM OVER 4 CA)
CE RTI FICAfI,'OF EXEMPTION FROM WORKERS'
COM PENSA I'ION INSURANCE ,R HASH%INDUST RL WASTE INTERCEPT(.)
This section nod not hu mmplcmJ if tine permit 1,or one hwNn.IdnlWn(S IIXI) �,�/ BUILDING DIVISION FEES
er less.) f"•"TSS''^""'` PLANCHECK IEE
I cenify that in the petlbmmnee afore work fm which this payout is issued,I shall SHWER-SANITA BY S'I'ORM EA.208 FL
no,employ any person'm any msumer as toss,,hecumn eub,,1,,dm Wmkcrx'Gm.pcn- ENERGY FEE
Z ,mien l.vwsef W/V
California,DateHEATERHEATERL'NT/IiLECTH
z 'Applicant s WRIER- GRADING FEE
% NUI ICE TO APPLICANT:Ilnfler mating(hi,Ccr[ili,:sec of Hsentsien,you of Id WAI TIR SYSTEM/I'BBATING
a ; beconm subject la he Worker's Crimp....firm Provisions of the Labor Code,you must SOILS FEE.
W forthwith comply with such provisions or this permit shall be deemedravoord. WATER SERVICE?
Q
7z CONS]RUCTION LENDING AGENCY NIiW RESIDEN'I'IALPLMIi. SQ.FT PAID
L)O Ihervshich the,mmere isaco (Sao.3nlending agency for the performance of ❑: Neceipsp
L4 H the work fur which Ihlx potation Is isatel f5cc.31191,Civ.Cd
O ULenders Nome '!ORAL:
G IulAcrs Address 'roTAL:
I cenify mv,I lu,ve.cud this a,larrtiu i oral stn,On the naive informal i Is - BUILDING FH e
h correct l agree to comply with all.nand county ordinances and state laws relaingm QTY MECHANICAL PERMIT FF.E�
V z building construction,and hereby minutia,reprcscmmivcs of this city to enter upon the SEISMI FEI
ah tent W....Puny to ....F.thnt.arrywe,
(We)agree no suvq indemnify and keep Imrmle,s the City e[Cupertino against PERMIT ISSUANCH ELECI Irl
Iiabili[ies,judgmems,costs and expenses which may in any wayaccme again,,said City AI:TER OR ADD A'O M[CII. PLl1b1BIN FIA:
in cisgo
,seencc of aha granting of(his permit. _
APPLICANT UNDERSTANDS AND HILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,018 CFM)
SOU^CE�EGULATIONS. � MF.Cf1A. CpL RE
II l AI It HANDLING G
I IN '(OVIIR I IUXID CPMI
� �c-xw� IpAaf oaf _19 -CCONST RUC' ONTAX
.yy.�rara o,Appl^uaont�Contrec—iu�TX CF.'07 EXHAUST 11001)(W/DUCE) HOUSING MITIGATION FEE
I IAZARI1r NS MATERIALS DISCLOSURE
Will thati,iicamor Pomrc huimingeceupamsmreorhandle huardousmvtenal HI!A'1'ING IINI'IYfO ING.00 BTI11
m defined by rhe Cupenino Municipal Cade,Chapter 9 12,and the Hea1,h and Safety
Gde,Sari..n 255320)! I IEAfINC UNIT(OVER I00.000It I'U)
❑Ya -❑Ne PAID
VENTILATION PAN(SINGLE RP_SIU) Da,a Retain#
Will rhe applicant or wer,nts as building y the B A ea Air Qu or devices which
emir hvzardous air contaminants as Jefincd by the Roy Arca Air Quality Mamgctnent NOILEk-COMP(JHP(3k IINI,BIN111'TU) O O
DutnctY BOILER-COMP(OVER 101,0M If1'U)
❑Vcs ❑Nn - .
I have read the hazardous materials dements maker Chamr 6.95 of the Cul i- AI R CONDI'I'IONPH
m,2 P ISSUANCE:DA'I'li
fontdigdoes n Safety Code Sections Lina 25585.e 533 u,and25534.1 oodcrsmnd malitNI!W RESIUP.NTIAI.MECFI. SQ.FI'. Sr-��� [/
buildinguirememnmmdy lure be mot Uha,ir isatyce ofit usidmnoify thepancy.n[ (/ OY' O/]'
of ma reyahemama winch must be me pins a.issuance oft eenlrmme of Occupancy.
Owner or authorized agent Dam TOTAL: ISSUED BY. to
�o
OFFICE