S 3830 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING-ELECTRICAL PERM]T NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3830
I QQ /A� ('� BUILDING PROJECT IDENIH IwCATION SANITARY N0. AVPL/IC'ATION SUBMITTAL BATI
ItUI1.DINC�IRE v.� 1/t-5-5 -At/ f l'Lo
OWN�R's ME: ONE:7 7I CONTRACTOR'S NAME: LIC NO'. NIC CONTROL
I c/ G511
tCI 111'EC'DEN -ER: LIC NO: ADDRESS ❑
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) `BrLDDrG ELECT PLUMB MECH
XJ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby art,—thus 1 am liccn¢d undo provisions d Chapmr Y lu,mmenet JOB DESCRIPTION
WOO win Section 7000)of Division Tofthe Busimssuod Prafic,nen.Code,and mylicenu is RESIDENTIAL,
a�� in full lister and efTt O PIiRMI'I'ISSUANCE
Qr ❑SFDWL ❑KITCHEN REMODEL
aUU Linnsc Cla Lica Comment, s T�—a APPLIANCES-RESIDENTIAL QADDITION ❑1'I.UMlt RE-PIPE
co � DTt• �R.
y A.shall
T'S DECLARATION PANELS ❑MULTI-UNIT ❑S'P DUTICA IO
Z~O h-L L undersand my plans shall he uud as public taus., ODIFICAT]ON
OZ�C UP T021x)AMPS El INTERIOR CHIMNEY REPAIR
m Licensed Professional 201-1000AMPS IM PROVEMENT 0SWIMMING POOLS
�yf�
OWNER-BUILDER DECLARATION OVER 10(M)AMPg ❑BATH REMODEI/REPAIR [I DEMOLITION
z
x Q 1 hereby arm ot I aesempt from the Commerce,License Law for the
uaXl3 LL Rnm U following reason.(Section]1131.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
b"¢ which requires a permit to construct,alcor,improve,demolish,inrepair any structure
J priorto its issuance.also requires[lie applicant forsuch Permit file a signed.statement SPECIALCIRCUIT/MISC.
E y d
that he is licensed tto the frte Contractor',License Law 9
'ya�l pSectio pmvisinn,n p ?
W�00 tcommm�cing with Section TX10)of Uivisinn3OOhc Business and Not Code)or 'TEMP.MI?T'IiR OR POLE(NST. COMMERCIAL:
e that he i,esempt thercfrun,and the bash,.for the alleged ect mpiinn.Any violation of ]NEW BLDG/ADDITION CUP MOLITION
W H Section 7031.5 by any applicant lot apermit subjects the applicant ma civil penahy of roW'IiR DEVICES ❑TENANT ❑FOOD SERVICE
o more than five hundred dollars(85(X0.
F Z Y IMPROVEMENT
_< will
Lsowner ok.nc paro,wrty�or
druclmmyemntended winwagif as talei(See compensation, SWIMMING PI L ELTRIC
SFC will dotficwon,Codec he Contractor's
pots LndnseLwdoes sale not
Business El OTHER
pj m and I'rofewions Cole:The Comr4emfs License Law Jas not epP1Y m an owner of OUTLhTS-S 1E5-FIXTURES
ms
0.3 property who builds or improves thereon,and who does such work himself(it through
his own employees,provided that such improvements Ere not intended or offered for NEW RESIDENTIAL R SQ FT.
sale.If,however the building or impmvrment is.sold within oom
true year ofepinion.the
SQ.ITT FLOOR AREA bISQ.FT.
ow er-builder will have the burden of proving that he did net build or improve for pur-
goo, salt.).
❑ Lia owner of the pro.70,4 on esclns and enntroedng with:)Her l...Cmc cturx i- '101'A L:
rase Ia d project(Sac.o an Businessrop property
who or,ui ds or impro Conuueon, nd
selnsvdoesnot such ply man ithaofprnpenywhosedprrimpmvcs thereon,and QTY. PI,UMRING T PEE
who contracts for such projwa with u mmtuaorts)licensed pursuant m The Commmni s
Licerve Law. PERMIT ISSUANCE
lam esempt under Sec. ,B&P C Mrthis reason
ALTER-DRAIN&VENT-WATER I' ) VALUATION
Owner Dale 0 v
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ^
1 hereby affirm,under penalty of perjury one of the following declarations: .J
] Iho,c.adwill maintart.Cenilirmeof C.Mrouto self-insure for Worker's Compen- DRAINS-FLOORROOF.AREA,COND. STORIES TYPE CONSTRUCTION
Trion,as provided for by Suction O00 of the labor Code,for the perfomnancc of the
work lin which his pcmnt i.Is.,ald. ]gX'rURES-PEN']'RAP
I have and tad]maintain Worker's Compenxotion Insurance.as vi.mrN by section
37(X1 of the Labor Code,for the perlbrm:race of the work for which this pem,it is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work yyrr-� 991h a and Polic
Comer: V J Q )=Z pandVo nun :'�,-DO GAs-FA.SYSTEM-OVER 4IEA) ✓l
CERTIFICATE OI'1i%Eh1PT]ON FROM WORKERS'
COMPENSATION INSURANCE. GNEASFJINDUSTRL W'ASTF,INTERCEPTOR BUILDING DIVISION FEES
(Tbissection Decd not be completed d dee permit is forme hundred dollars(SIM) GREASETRAP
or less) PIANCHECK FEE
I venify that in the psfronance of the work for which this pi,not is issued.I shall SEWER-SANITARY-STORM EA.ZMI'L
n a employ any person in any manners,arm become subject m the Workers Compen- ENERGY FEE
O Z ration laws of Coldornio.Dam WNI ITR HEATER W/VENT/ELECTR
O GRADING FEF,
z Applinnn
NOTICE TO APPLICANT:If,after making his Cetificate of Exemption,you should WATIiR SYSTIiM/TREATING
F ? Ircconm subject to the Worker's Compowlion provisions of the Labor Code.you must SOILS hl9i
forthwith comply win such provisions or this permit shall be Jenne)revoked. WATER S12RVICE
a0
Z) Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ITEMS. SQ.PT. PAID a Rceeip tg
U O 1hcnbyaRnn the, he.is.construction lending agency fon he pcdv.ncc.f
the owk for which this .it is issued(Sec.3097,Civ.C.)
lsnder'.,Name 'TOTAL:
U Leaders Address TOTAL:
I certify that I hove mail this rnm1wrte m and state that the aMwe in&nm tion Is BUILDING PEE
rn ctmes, Ingrec ei aunply with Cll city and county...hearers and state law.clefin,in QTY. MECHANICAL PERMIT F U
UZ bnudiog c<nsp..fice,amts berebyumh..dprt
eo mrecmmivcsof tho,ay to case, e SEI, ER
nbuve-mentioned property for Imsp.nlon Mmoles- PERM]'(ISSUANCE
(Wc)agree to save,indemnify and keep harmless the City of Ce,maO against li 1'RI E
Iiabiliue,edgmems,costs and expen.ws which may in any way recrucagaimst said City At.]ER OR ADD TO MECH.
in asequence of the granting of this permit. P IN
APPLICANT UNDERSTANDS ANO WILL COM PLY WITH ALL NON-POINT AI R HANDLING UNIT(TO 10.001)CPM) IV IAIIYA;NECACF-Ej
SUURCE UTATIONS
6_/_�jQ AIR HANDLING UNIT(OVER IO,gq CFM) CONSTRUCDONTAX
S' tau' ApphcameCnMosefur� ��/ Date EXHAUST HOOD(W)DUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will he rind leant..linare hrild'mgnecuprm,tutu on hi lie ht,ambrsmmei hal II HAE INC,LINE'L'(TO 1M00)If I'U)
m drimcd by nc Cupen'mn Mcniuipnl C:dc,Chapter 9.12,and the HnJth imd safety
fide,Section 25532(0)9 ❑EATING UNIT(OVER Babbitt)ItI'ED
6
�Yes VFNTIhN'ION FAN(SINGLE BESIDE PAID pate - Receipt
Will the applicant or future building occupant use equipment or devices which
unit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) TOTAL: 77�
Dinner? BOILER-COMP(OVER 10(1.10(1 BTU)
E3 Yes (
1 have rex)the hazardous materials
AIR CONDITIONER requirements under Chapter 695 of the Cali- ISSUANCE DATE
Ibmia health&Safety Calc,S.......25,505.25533 arl 255341 understmm that d the NEW RESIDENTIAL MECH. SQ.IT
bui ldingdncs only haw mman6 nl ince nryrc siMlliymnnlil'y etc a'mpam
nl nwhiJ'1,mu6 x,mt ,R)'Cenifiamc"I Ovupancy.
o..rd,gem ])am TOTAL: ISSUED BYe IOc /-)A 2yT) .S/CG/
OFFICE