S 3010 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HIM LDING-ELECTRICAL PEt IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-ME;IIANICAL ' J 3010
IIUILnINC 1'ROJF.LT IDP:NTIF'IG3TIUN r
IIUILDINGADURESS,, SANITARY NO. APPLICATION SUBMITTAL DATE
a s PW-
O Elt'S NAME: I'IIONI?: CON'1'ItACI'fIR'S yAMl3: LIC N �
' NIC' CON'I'Ii(11.#
ARC]IIT'ECTII iNOlNlililt.
LIC NO: AD)RIiSS ❑
CONTACT: PHONE: HUILDINGPERMITINFO
/ ❑ Consultant Fces Paid by Applicant(Initial) ULDG E1.Ecl PLUMB MUCH
0 D ❑ ❑ CJ r
LICItNt Imin reard oOR:SDECLAIof Chap QTY '„ ELECTRICPERMIT, ;'FI3I3
1 herehy effinn that I nm licensed under provisions of Chapter Y(mnunencing - � .IOI3 DESCRIPTION
"Z th Scnion]INHpo[Dlvi,ion3nf ieNu,inessnnd Professinrt code,and my liccnseis R F u
w O PERM111'I'ISSIIANCF.
�,0 .fall l arae anJeA�r�.a 'FDWI. ❑KI'I'CI1EN ItIiM01]I31.
QUV Date 4 Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-1'11'1:
of Date CnmDECL
7y ARCIIIIEU'S DECLARATION I'ANIll.S ❑MULTFl1NIT ❑STRULTUIiAI.
F D o, 1 understand m I h II M used r,public record, MODIFICA'T'ION
z0a,lz YPanss a pa UPTO 200 AMPS
p Z'14O ❑INTERIOR ❑CHIAINRY REPAIR
FAL 14 L.'rowd Prul...imul 201-1000AMPS IMPROVEMENT SWIMMING POOLS
at,YF.� OWNER-BUILDI3R DFCI.ARATION OVER❑NNtAMI'S ❑HATH RtDODEIJRHPAIR ❑DIiM01.HION
C{yah Q 1 hardly affirm that 1 am exempt from the Commnots Licame Low fur the
iry0.,�dS..OEL following..loon,.Semi....7031.5,Badness and probe sain I,Code:Any airy or county SIGNS ELECTRICAL ❑GHIER
1++30,v~ which require,a permit m conswa,alter,improve,demolish,or repair any structure _
0j poor In its roamer,also acquires the applicant(orwcl,permit to fileasigned,aemenl SPECIAL CIRCUit'/MIS(:.
{N{yy Ny Ihm he is licensed Paduam to the provisions ofthe Conoaeor's l.imnso Law lClwpar9
W MC) Imnnnatmingwith Seelon 7IXHbof Division 3ot he Business an I l udoiwucdc)a, 'TEMP.METER OR POLE INST. �%
a y a that he is exempl therefrom and the basis for the alleged exsorption.Any violation of ❑NEW BLDG/ADDITION ❑LE 01.1'17(lN
W.. Seat 7031.5 by any uppllcent permit for n peit sulfur,the uppliannma.,it paallly of POWER DEVICES
m [I TENANT _ ❑FOOD SERVICE
ZOnm more than rapt hundred dollen($5110). IMPROVIIMI?NT
n1,usmncrofthe property,omny employees with wages asieireole cnnpemshioh, SWIMMING PORI.ELECTRIC
L+ willdo the work.and the simulate is notbtendeduroffercJ batiste(Sce.T?U,limmus ❑OTHER
L 3 m and 1'nJesslom Code:'rhe Cnnirector's[.Iran,,law loan mol apply man owner nl OU'I'I.IUS-SWI'I'CfIES-FI X'1'URIS -
propeny who milds or improves thereon,and x he does such work himself or through
his own empinyces,provided that such improvcmmnts are not intended or offered for NEW RESIDENTIAL ELECIR SQ Ff. /
sale.lf,however.the brtilding nr irnpmvrtncnl is v,IJ within aha yc'ur nfcnmplation,lhc SQ.FF.FLUOR ARI3A 5/SQ.IT.
mer-builder will hmx the burden of proving that he did mol build or improve for pur-
into,Isalcl. -
❑ L as owner of is pfopcny,con e,ralio,soly ,all it with licenacd unln¢mrs m TOTAL:
con,mact due protect(S70W nosiness andl 1 .: Care)Due Comrte, :I' ,.
cameI J t pplyl fp perry n bald—improves there d QTY.. t', PLUMBING PERMIT PEF-
I wh tmmsGru al pmlco,ewthnc huoq,)I Lmall,rshut„the C, occurs
License Law. PI Rh11'IISSUANCE
❑I am exempt unser See. .B&1'c for Ibis txasnn
ALI1312-DRAIN&V I3NT-WATBR(ILU VALUNHON
Owner Data
WORKER'S COMP17NSATION DECLARATION BACK FLOW PR(TI'ECI.DEVICI3
I heathy nfumn under penally of perjury one'It the following dcdamtinns:
❑ Ihave anA will mmmmnaCrnificnlenf Cnnaenl loselGinsure for Wnrkeia Compo,- DRAINS-IIOOR,ROOF,AREA,COND. STORIES 'I YPECONS'I'RUC'170N
smimn,as provided for by Section DW of the LaMar Cale,for the performance of the
work for which this permit is..sued. / IIXT -PERT
❑I have and will maintain Wmke75 Cnmoensetinn Instrunca,m required by Semion
3700(if the lalmr Code,for performance ofthe work for x Inch this pemtit is issued C STEMI NC.J :I:S OCC.GROUP AI'N
My Wor m ar eon Inmrnnce currier and l'nfiey ppau JJQQceS5�a�
Ca,d,,c Pol icy No.: Ire - iA.gYS'1'fiM.I1VIiRJ A
C iTIIJCATli )P[%EhIFIIQN MOM WORKERS' D ,"r [ CIiYIOR
COMPENSATION INSURANCE
BUILDING DIVISION PERS
G'hl,ecemonenlnot he completed iOhepanni,is barium hundreadollors l9 l til GR BASE TRAI'
Lj nr lcss.l PI.n NCIIF.CK IRiF
I coolly main the perfannence(,(,he work fiawhich this permit is issued,lshds/V S13WR11-SANITARY-S'fORM l3 2011 FI'.
notctnployany penin In mymunnersamu,becme
osafe,In lho Workers Coupon = ENHIRGY FEE
OZ Saliwo laws of Calilnmia.Data WATER HEATER W/VENT/EI.ECIR GRADING ITE
Q Applicant
NOIICE'IOAPPLICANn It'.ut'mr making lhls Crom,mcof F.amnonnn,you should WA'I'IR SYS'I'I INIORVA1'INC,
a ; hcannesuh'eatmie Workers corn f in lunar Code,ria mu,t SOILS FEE
1 Compensate.pro it thal o
L31 fnnhwi,h comply with Hoch prnvi,inns or lois perntil shall he deemed revoked. WAl'IiR SERVICE
Qae
,7, CONSTRUCTION LENDING AGENCY NEW RESIDEN'T'IAL I'IdtB. SU.PI', PAID
Date RecciplM
1 M1ereby affim,that there is land Ner.30 lending7,C,agency for the perfinmmtt of
L0 Trwed Ibrwhich this parmit is issueA IScc.311W,civ.C.)
>0 Lender's Nanta 'rOl'Ala
L Lender's acuity, T
'�'� a 1 certify thin I Lava mW,his npplicatinn:cul slam thW 0o above inlimnatinn is - - BUILDING PEE
r to
correct.I agree mcon,ply with all shy and county anlinnnces end sone lows rclmingm �QTY..:. MH:CIIANICAL PI3RMIT /FEE `
L 2 building communion,and hereby aathorim representatives of this city to coal upon the : _ SEISMIC PEL
uho....II tluncd porosity for inapemto,,purlio,k,. PUIt MITISSUANCF
(Wy a,me w nave,indemnus,,ify mod keep hiatthe Cif'of Cupartno again,, IiLECfRIG PP
liahilitim,jndgments,costs and expenses which may in anywayacenre against said City AUD;R ORADD'FO MIRTL PLUMBINGR 3
lotmseq,rencc of is grunting ufiis Iwrmit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH At.1,NON-POINT AIR HANDLING UNII'(TO 1 kht)II CFM) 11
SOURCE RE( ILA'IIONS. 1 MI?CIIANICAL I*1313 (J
`y�� rd O�it�Ta `0121 P AIR HANDLING UNI 10.04)CFM) CONS'IRUC'IION'1'AX
9gnatureof Applicara Conweor D:nc4 "HAUSTHOOD(W/DIKE) HOUSING MITIGATION FIil3
HAZARDOUS MATERIALS DISCLOSURE
Will l lar.,lleant.,I! mbuilding okaupau atnan
rc or hdl.ham
mrdonsatcri:d HEAII NO U N II'jO I(X),(NX)11'1U)
as defined by the Cnpenion Municipal Cede,Chapter 9.12,and the Health and Safety
Calc,Section 255321x)? IMAIING UNIT(OVER 100,00 BTU)
❑Yas LIN"
VFNTI LAT ION PAN IS I NO1.ERSID) PAID - --
T Date Reccip
Will the applicant or future budding occurylm use equipment or devices which BO Al
(3HI'OR 100,000 B'I'D)
each houndous air umtumimm�a m echoed by the Bay Area Air Quality Va-.......I 'I'Al -V
Di.arim?
❑fav ON. POILI:R-COMP(OVIiR IIXIpIq BTO)
HIR CONDI'I ION17R
Ih � middle htuM -materials q , Ie Chapala,6.95 if Cd ISSUANCE IJA'PE
forrin Health&StualyCoda,Stations 25505 25531 ad S534 1 understand Ihm tithe NEN'RESIDENTIAL MECIL SQ.EL
houwlfgl ot elatedly
h t Ithatit . ya ,dit,l ifY tl,:µehpl6l �I
Z' 1"
t gwinenu wh ch mu : coa Cehlf
OarchrIneem
Ihm TOr ISSUED IIP, L G)
OFFICE