S 3315 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PER ITNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 3315
BUILDING PROJECT IDENITIF'ICATION
IiIJILDINGADDRI' S: SANITARY NO. APPIICIG]ON SUBMITTAL DATE
/IPO -/-9
OW 'S AMh I E:' CONTRACIOH:S NAME: LIC NO:
M/ NIC CONTROL.
AR T[CY2NGINEEER 1-ICNO: ADDRESS: El
J LL
CONTACT: PHONE: BUILDING PERMIT INFO
er —a (J ❑ Consultant Fees Paid by Applicant(Initial) IH, ELECT PLl1MB MEC
LICENSED CONTRACfOR:S DECLARATION 6Y 5!/Y Qom. ELECTRIC P1iRMIT PEE Lr-Jr/ IN
1 hereby affirm that I ant licensed under provisions o(Chap rr 9(eommc rrang JOE DESCRIPTION
QpZ with Scri,m7fNN1)nl Divi,iurr3of the Bnsinesx ratJ Professions Cade,and nay llrcn,ei" pi;EMIT ISSUANCE C RESIDENTIAL:
Fly= in full force and affect. El SPENT, ❑KITCHENREMODEL
XU~ License Clan Lic.p
6 U APPLIANCES-RESIDENTIAL ❑ADDITION ❑I'LUMBING RE-PIPE
NZ W Date Contractor
C ARCED PUT DF,CIARATION ❑Mlll:fl-UNIT ❑$TRUC'I'11RA1.
FvZ Imalcotand my plans shall herself.,public records PANELS MODIFICATION
IIPT0200AMPS
OZN.Q INTERIOR ❑CHIMNEYREPAIR
OL
tU Licanxcrl Professional 2(11-LINO AMPS PNOVP.MIiNT ❑SWIMMING PO(31.5
OWNER BUILDER DECLARA'I ION OVER IIXXIAMPS ❑BATH REMODHIJRHPAIR El DEMOLITION
Lk CCG 1 hereby affirm that I am exempt from the Contractors License Law for the
LiyS N U fi devong waxen.(Sort im1]0115,Business.nd Professions Code:Any alt,nr county SIGNS ELECTRICAL 11 OTHER
I-E t y wM1leh rryulres o prrmil In consmuct,ul(vr,irnprnve,tlenudish,nr.pun any,immure
F Va"II prior I,,issuance,at,."mires meapplicam for...a ,,air m file u,timduanemem CIAL CIRCULI'/MISC.
04�T that he is ed pursm uato Ilio porwWons of the Connector's License Law(Chapter Y
�Ea (comrnunatic sangelrinse.]on]fXNBofDlvixinn3nfmcBuxineneandPruluiansCnImor IHMP.MHKRORVOICINS'I R
a L Isl
o that he ie wesnp''bcrem Gumption.
fmand the basis for the Any violation of [I- BLDG/ADDITION DEMOI.I'I'[ON
rY
iG ia Section7031S by any applicant fora permiur
ubjects theft"lican 'oo civil prnaltyof POWER DEVICES
than five IF idrcxldollars(5509). TENANT ❑FOOD SRRVICIi
-. IMPROVEMENT
.mom tve
ESQ 0 Lma tar of the pmpeny,or my cmployea,with wages as lheir,ole<empensmion, SWIMMING POOL HLECTRIC
FFO will An the work.and the,imccom is notimended nrnRertJ for sale]secs 7094.Business 01 HER
3 m and P al aoim,Code:The Contractor',License Law does nut apply to an owner of OUTLETS-SWfICIIE,S-FIXTURES
prapeny whe hi ilii or inipmves thereon,and who doe,+u,b work unused nr through
his own employees,provided that such intpmvemrnls ate not immnded or oficred for NEW RESIDENT]Al.Iii,C?A SQ 1'i�
sale.If,however,IM1e building or improvement is sold within one yeamt(completion,the SQ.FI'.FLOOR AREA VSQ.I-K
c,lailder,will have line hurden o1'proving(bar lie did nor build nr Improve fur....
pass of talc.).
r of the proper,,am exclusively contracting with licensed contractors m AL:
cmy'ma the pmjcct(Sec.70W4.Business and Professions Code:)[be Contractor's Li-
canelarwdoesnmapplytoanownerofpmpartywhohalldxorimmnvesnrerear,anti QTY. PLUMBING PERMIT FF.E
who ro n rob for such projects with renunciations)licamed pursuant ri me Contractors
License late. PERMIT ISSUANCE
❑�lane cxeniptyf1r'cr See. — —,B&P C lot tbi.,reason
GoneL.a.� ✓ me AIJ ER-DRAIN&VENT-WA I'ER(EA) VALUATION
WORKER'S COM P15SAI'JANDECLA RATION BACK FLOW PROTECT.DEVICE o O O
01 I hereby affirm under perelly al'perjury one of tine following dcebnmiar, (�
❑Ih.veond will maintainsCeniftcate dCanxrnl lowlf-inmretir Workers C,rr,r- DRAINS-FLOOR,ROOF,ARBA,CONDSTORIES 'I'YPECONSTRUCTION
,.boor as Provided far by Section 3701 of the(,he,Code,for the performance man
walk lin which this hermit In I...rd, FIXTURES-PER'I'RAP 'V
❑I have and will maintain Workere Compensation Insurance,as required by Section
3700ofthe LaMv Cedle,for,he peHnmmnceofthe work for which or, urinal is issued GAS-IiA.SYSTEM-I INC.40EPILETS (JCC.GROUP APN
My Workers Cnnipcnsution Insurance carrier and Policy number um:
Carrier: Policy Nn: MS-IiA.SYSTEM OVER 4(EA)
CHRTI FICA I OF EXIiMPI']ON FROM WORKERS'
COMPENSATION INSURANCE CREASI'JINUUSTHI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(]'lits ecctiunnminot he unnplGeA if IM1e prmiit In fur ono hundred dollars($1[X)1 GREASE'I'RAP ��-or less) PLANCIIFAK PI?I5
I ceoffythm inthe pirfarmanre.finewnrk fur which this permit is issued,l shall SEWER-SANITARY-STORM EA.210 IT
not employ any action inany mortician m to become subject to the Workers'Compen. ENERGY FEE f
O� cation Laws ifCabl ni..Uma WATER IIEAIER W/VENT BLECTR GRADING FEE
O APPliamt
N N0IICEi TO APPLICANT:If,afar nnakin,'his Ceniticate of Exemption,you should WATER SYSTEM/FREAI'INC,a $OILS FEE became sooner,m the WoOcr,Gm.pensmron provisions of he Labor Citric,you moat
fanhwlthroniply wimsuch provision.+ser thispermit shall le damned revoked. WATER SERVICE
a �
CONSTRUCTION LF.NDINGAOENCY NEW RESIDENTIAL PLMB. SQ.I'E PAID
7. I fareh hirh his hot Per iii ixsed(Sea 30landis.ugcney lot the perlirtmmnaetil' One Receipip
me work for which this prnnil is issued(See.3119],Civ.CJ
Lender',Name fair
I(
L)
Lenders Address IAL:
I certrea
certify mut I have d this uplAwittion and sane nation,hcho"i 6
nnna0rm i+ IiUll . lilt
r�-ry7 correct.l agree it)comply with all city and county ordinances and.since laws relating to QTY, MECHANICAL PERMIT FEE `
V rte- building consuuctiorand hereby authorize representatives of mix city to enter upon the SEIVdC
:move-mcromand pr.,,Iy for inspection purposes. PERMH ISSUANCE: O
(We)agree to save,indemnity and keep harmless the Cily of Cipriano against E C FEE
habilities,judgments,cmcx and expenses which nmy in anyway acerae against said City ALrER(IR ADDTOMECH. "-�
eynerecol dr,runtingoflhi.,pcmrl, M LNGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNIT(TO 111,(X18 CL.M)
SOURCE REC/�ILATIDNS,
MEC ANICAL r[
X AIR HANDLING UND(OVER 10,000 CFM) CO SI'RUCTIONTAX
SgraurerfApppl~icaardlCCoo'n`catactoor V Ilene EXHAUST HOOD IW/DUCP) HO 'I NO MH[CATION IME
HAZARDOUS MATERIALS DISCLOSURE
Willliteupplaarrt nr Price huild'mgnccnpam,lemor handle hazanua,mrmriul HEATING UNIT U 010(I,OIXI L,TU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safely
Cuba,Section 25531(a)^ HEATING UNIT(OVER I W,IHgI BTU)
❑Yes E]No PAID
VENTILATION FAN(51NGl.l1 RESIU) Dam Reeeipla
Will the applicant or Into.building ovcrpznt ase equipment or devices which
10 emit hamrdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP LIHP OR IPO,IXX)BTII) .L.
Dinlricfl
❑Yes E]No 'I'UBOILER-COME'(OVER 100.000 R )
�
AIR CONDITIONER
I ham.af the haardouxnnverials requirement,resider Chapter 6.95 arthe Cali. / ISSUANCE.DATE ''l�
fomia Lleallh&Safety Cixle,Seciiorry 255()5,25533 and 25534.I understand that ridD
ee NEW RESIDEN' AL MECI I. SQ.FR / � .1 I � � L/(aAC7
building does not currently have a tenant,that it i,my resgmsibilay,In notify the occupied [[ ( VVV
o(Otc mqufmmem,which mu,l be ores prior co issuance of a Cenilicnte of Occupancy.
Osacarrauhorizedagain DaTUFALSS01DBY:
OFFICE