S 3057 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bun.nwG.na.kcrRICAL PHtil,NO.
BUILDING DIVISION APPWCATIONIPERD91T mNG PROJECT IDENI IFIC 3057
I4111LDING PRW I:C'1'IDIiY'1'INIL'A'1'ION
HUR-DINGADUtF.SS: SANITARY NO. API'LICAI'ION SUBMI'rl'AL DATE
OWNER' A is PHONE. CONI'kA ORIS NAME: L.IC NO:
R
✓�GCJ Ohl-^/ NIC CONI 1101.p
ARCHITI':VHNOIN.'R: LIC NO: ADDI11iSS:
o w yit[ ❑ D 53
CONT PHON[y,' cr�C- C.".7147-5,O) BUILDING PERMIT INFO
�yl� I Q _'^
El COO Fy!(s Paid by Applicant(Initiaq SLOG_ ELECT� PLUMB hfIiC1J/
f/YJ[JACENSEDCONfRACTOR'S DECI R ION V QrY, FLECPRICIERMIT FEB IJ! DE
1 herchy affrnt than[;,at 1i,cnsed ander pro lata s of chap,,,9 mm,nneneirg JOB DESCRIPTION
CZ with Section 7000)of Division 3 or Business and Professions Code.and my feel is RESIDENTIAL
eel O PERMIT ISSUANCE
F in full force anJ,feet 416 i� DSFDWh ❑KITCHEN REMODEL
license C Lic.p
Q 2 APPLIANCLS-RESIDENTIAL. ❑ADDITION OPLUMBING' PIPE
1F Dam Cantmnor
F A CHITECT'S DECLARATION"' PANP.LS DMULTI.UN1'I' ❑STRUCI URAL
i ndmdwnd my plans' . ,sed as public, MODIFICATION
p'l UP'1'02(OAMPS DINTHRIOk DCHIMNHYRFPAIR
I..ZFy�j Licen 201-lap AMPS IMPROVEMENT C]SWIMMING POOLS
I '1Q OWNER- ER DEC ANON OVER IIkp AMPS [I BATH kIi.MODEflREPAIR DDEMDLITIDN
I herchy affrm that i in exempt from a Contmcmr's Li ase Law for the
3 F following rcmon.(Section]fIJLS,Business an 'r..fessions C .Any city nr county SIGNS Ii1.liCMICAI. ❑OTHER
y o E whin v t , i 1timplore.' en p ry stmmum
poi t t 'I. ,I pll tl i llt IIInured4lmorlot SPECIALCHRCUITIMISC.
} that he dpursuant In n. ftl ( t t c L I' ICha,wr9
1?I,..00 (commencing with Sen 7ap) fti .i J fthli Ines. ndP f ss ns Coomer TEA1P MEIP RPO 'INST L
66 p that he a exempt therefro n and the ba.is f r th LI g d exe pt Any violation of El NEW BLDG/ADDITION D DEMOLITION
NSection 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER Dtikue
^ TQ0 H - p '
DTE'NAN
T
DFDDD SIiRVICIi
net 'him I hundred II . 550)) IMPR0VIPvUzNT
'I n, SWIMMING1O CC1RIC ❑0THERoI p , nY Y plb:a:th . .
C 'Aldo0 k h t t t t dJ ll df :'I S 7144 Bl sv
WadProfession,
_ Code: m C t t License Law does mu applyt dOUTLUfS SWITC 'S- 9X"IRES
propcny who hu Ids or improves,hereon and who does such k hunsdf or through
his awn employees.provided that each improrcm,ms arc not int,ndnl or offered far NEW RE'SIDP L EL[ SO pl'.
sale.ILhowmer,Nebuildingorimprovementissold withinoncyeararn
fmpinioo,the SQ,17,ILOORARIiA ASG FT.
pervbuilder will have the bander of Proving that he did not build or Inlprevc for pur- /�/
,r of.odo). r .1 / '2-
n I,as owner of the property, an asCluslvely contracting with,,coria(,Contractors to
construct the project(Sec.7144.Business v,ad Proession,Cade:)Thu Cnmmnor's
cerise
-
c seLawduesnotapplytoarownerarpropertywhobuiWsorimprovesihereon,and QTY PLUMBING PERMIT FEE
who contrnce infmch projmts with a contmoor sl Iicarl personal to the Convector's SS
License Law. PERMII'IS_,MJANCE ,��„_,.��s
❑I amcsanlp(under Sec. ,R R.PC fomea
hisrson
ALTS -DRATAV"I'-WA l' (EA) VA1.UA'HHN
Owner Date
WORKER'S COMPENSATION DECLARATION B ;LOW PROTECT.DEVICE
I hereby affirm under penalty ofprpry one oftbe following declarations:
�ID l have and will maintain a Certificate of Consent to udf.nsum for Workds Comps, D S-FL)wRI R- I k "'D, ORIES TYPE CONSI'RUCI'ION
sation,as provided for by Section 3701 of the Lamm Code,for the performance of the
work far which this penal,is ie'srM, P URT:S-PHRTRAP
1 have and will malnmin Worker,Cnmpensw nn Inxurmnec,as rnluhoot by Sect un
370if flhc Labor Code,for the Emotional ofthe work for which this permit is issued G1,,,_-EA SYSTEM-1 INCAOUi'LETS OCC.GROUP APN
l My Workers Compensation Insurance carver and Policy number are: C 2 '3 S-� .•-w
Cartier: Policy No.: J
CERTIFICATE OF EXEMPTION I7RONI WORKERS' GRF.ASI%INDUSTRL WAS'1'F:INTERCEPH)N Z
COMPENSATION INSURANCEMILDING DIVISION_FEES__
'Ihissatiunacedno,heovmpletul i fthvision,is far one nnndmddol lam($100) GREAS WE 1'
nr lessJ PLAN /FIE
I cenify that
in the perfomlunceo[the work(a, h,,h,hi,permit is issued,I shall SEWBR-SANITARY-STORM EA.2W PT.
not employ any Parson in any nlannerso as to hecmne subject the Warkers'Compel. F:N G 'F.li S
Z anion Laws of California.Date WATER HEXIER WIVENT/BLIICTR
O Applicant GR D G H
NOl'ICI:TO APPLICANT.If,after making this Certificate of Exemption.you should WATER SYS'f13M/I RHA'I'INC.
become subject to the Wurkadx Con,memio.......Won,of tlm Lnbm'Cn le,Yra anus SO FEE
forthwith comply with.such Provisions or this wrrlit shall he deemed revoked. WATER SERVICE
DCONS Idedthe'RUCcIONLENOLNOAGENCY NEW RLSLDIiNT1ALI'LA1H. SQ.FT. P D [).to RO,ei,,M
V Q work
ch this probem is.
sued(Sconstruction leading agency for the l>rrfnmance of
the wars Na which this prmit is issued(Sec.3T9],Civ.C.)
u' Lender's Name / t � li AL. tl
V Lender's Addruxx 'I'1Y Ah:
,>, L[7 BUILDING PEE
I unlly that 1 have rnW this ii,lieatinn axon smm that the above information Is
IaII correct.L agree ro comply with all city and county ordinances andsmm laws relatingm QTY. MECHANICAL PERMIT FEE
Vz building convection,and hereby arthorire representatives ufthis city it)enter upon the SEISMIC PTE taw}
above mnnioned property for inspection purpose's' PERMIT ISSUANCEZ .S
(We)agree to save,indcamify and keep hvrndcv the City of Ca,mono aain
gst ELECTRIC FEE
l isfelinies,judgmenrs,elsouadexlmrses wfunction,in any wayaccmu"guno,aid City ALTER OR ADD TO MBCjj.
in sequence of the granting of this permit. RING ITH
APPLICANT IIM
ICANT UNDERS'T'ANDS AND WELL COMPLY WITH ALL NON-POIN9' AIR HANDLING UNIT 10,000CFM) MF.CH NICAI.FEE
SOURCE RIIGULATIONS.
2 y AIR HANDLING UNIT RI,ap CFM) CONST UCI'IONI'AX 6 7
S1g VCnmr� r D' / EXHAUSI'I IOOD(WMUCI) 11 SIN'MI'I'IGATION FHB
DGE. ATERIALSI .CLOSURf?
Wlll,ha applicant orfumry ildingm a store or handle haardous,nmerdtl 118A'1'ING UNIT(TO llro.11llr 111 U)
as defined by the Cupertino Municip e,Ch,ac,9.12,and the Health and Safety
Code.Section 25532(H? 01
l''' HEATING UNIT(OVER 1 ,0X1 B'HD
❑Yes 11w PAID
VENTILATION PAN(SINGLE RESIDE Date Rcoqu#
V WIII Ito upPlirnm nr hour,building rccupan,use equipment nr Aevicw which
,mit haeanlnux air comaminamx its defined by the Play Area Air Dually Management
BOILIiR-C'(1MI'(9HP OR 1110,1100 BTU)
District?
D Yes SQDIo BOILER-COM P(OVER 100AX)BTU)
AIR CONDITIONER
Ihavc mailtheh ode, uvmn,1555,25533 an under Chapter anNi5ofthe Cele- �7 ISSUANCE DATE
fomivDeath,doesffi Safety Codacaciles2.55a5,25533and25934,I Indetsumd thatifOle, NEW RESIDENTIALMliCfl. 9Q,PI'.
i budding dice na,carr, buvm,wnunl.that it is myteipnminilily In nnliry too rccupant1 �
1¢1116 mwttd pri Tat Dace nfa CerJjfje'�tc poneY. ��fj
Ovimroreutnodz agern T �L
Dam : ISSUEDBY: Ae
OFFICE