S 3396APPLICANTTO FILL IN INFORMATION WITHIN RED LINES, USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING - ELECTRICAL
PLUMBING -MECHANICAL
PE IT NO.
3396
BUILDING DIVISION APPLICATIONMERMIT
-
BUILDING PRcl IDENTIFICATION.
BUILDING ADDRESS.
SANITARY NO. AI'1'LICA'r10N SUdMII'I'A I. DATE
i 64-5 CUP&MAJO C4 950I9..
folZ_ 11 FS
OWNERS NAME: PHONE; CONTRA(7D)RS NAME LIC NO,
(MISiKUSk 4o8-873-328
"/` GNT LN
CN TRUST
ARCHI'I'EC (ENGINEER: I.ICNO: ADDRESS:
❑
CONTACT:PHON .
BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant (Initial)
BLDG FLECI PLUMB MECH
LICHNSPDCONTRACIORS DECLARA'T'ION
QTY. ELECTRIC PERMIT PEE
IhetebyaBirmdrallom Reensra under prpxi.ionc orchapmry anmmendng
:
1013 DESCRIPTION
=Z
�IB
WON
ro... ma, Codaand my license is
whh Sc,irr90o0)nfTli,uipit3pfdm B,Ixires.nrd Pf
PERMIT ISSUANCE
RESIDENTIAL
WF
in full lince,nJ effect.
0 S ❑ KITCHEN REMODEL
QVZV
License Class Lic.p
APPLIANCES - RESIDENTIAL
❑ADDITION ❑ PLUMBING i
F d W
rI.=y
Dale CnnPJelor
ARCHITECTS DECLARATION
❑MULTI -UNIT' ❑S'I'RUCTl1kAL
Z p olpI
und,mi d my planxshull be uosl ns public records
PANELS
MODIFICATION
14 F
OZ —Q
IIP TO1o0 AMPS
❑INTI3RIOk El CHIMNEY REPAIR
F4kE
I.mci,d Profcssimd
201-INNIAMI'S
IMPROVEMENT E]SWIMMING POOLS
Cla4OWNER-BUILIIRR
DECLARARON
Contractor's License Law for the
OVER IN%IAMPS
❑BA'rII REMODI?IJREYAIR ❑DBMOLI'I'IGN
IY W Q
O V
1 hereby a1Rnn Thal 1 am excmpl from the
❑O 1417R
y
�+U.y
Gdlowing retia, (Section 7031.5. 11asine,mad l'rufcnxions Cute: Any city nr lot ly
SIGNS ELECTRICAL
c�
which regolvos a penab to conswn.,late improve, demolish, or repair any stmnnre
prinrlo if,i.xuanea dsorequireslheappleart fordeh pcnnilm filo. signal statement
SPECIAL CIRCUIT/MISC.
icy
that he is littnseJ puromu ffic fanickindoflhe Comracmr's Licenac law(Chapmr9
�g'QO
(commencing withSaran](knifinf Division 3aflhe Business and Pn fc, don; Cale)or
THIAR METER OR POLE INST.
F 1'
0, p N
that he Ix excmpl marefmnt and the basis t'or the alleged exemption. Any violation of
NEW BLDG/ADDITION ❑ DEMOLITION
xn�
Section 7031.5 by any agplicant for a Permit subjects the applicant to a civil penalty of
POWER DEVICES
NT ❑ FOOD SERVICE
F Z Y
not nu.c than live hundred dnl[ary S500O
ONT MENT
EtC
El 1. as owner of the property. or my employees with wages as their ole mmpen,clarn,
SWI MMING POOL ELECT RIG
❑OTHER
W'�
will dot the wnrk,mulme,mctme is not intended ser oR.redfors.le(See 9044, Business
m
and Professions Code : The Contractors License Law tees not apply to an owner of
(lU'1'LI3'rS-SWITCHES-PIX'1'1JRf35
F
t 3—
t no builds or ire a thereon, and who does such work himself or through
w x g
lI
property pot.
his own employees, provided Ih r such im......netit, are not 'awailld err offcral In
NEW RESIDENT( Al, ELECT SQ IN'.
sule.lf. however the building orimpmvanem issold withinoneymr pf contpldion,the
SQ. IT FLOOR AIt1iA 5/SQ, FT.
i
enmadde, will huve the bunion of proving that horrid not build or improve for pm-
pon nfmlc).
'PlyiAl.:
owner of the pr,tarry, ten exclusively contracting with licensed cro raantn to
mm the project (Sec 7044, Easiness and Pridessiona C dcJ'1'ae Carlin om, I_
lease law does not apply m an owner of property who builJs or improves thereon. and
QTY. PLUMBING PERMIT FEE
whoconned,tLtrnuch pnjells wit, acannall"(a) Ileeucd pur nam to the Counalon's
License law.
PERMIT ISSUANCE 9
I am exempt nada Sec. . B & P C for this reason
Iliope
Al.rER-DRAIN & VEN'i'- WATER DA)
VALUATION
g O
1 WORKERS C(IMPENSAI'ION DECLARATION
BACK FLOW PROiMC'L DEVICE
I hereby,Mira ander penalty jury one of Me follnwi
Cr
lcpe
or Workers
�Ihavumo lane nl self inearefer Workcr'a Cempery
defaiby
DRAINS- FLOOR, ROOP,ARI:A. CONE.
S'fORll?S TYPI3 CONS'fklJCi'ION
Section 9900 or We haver Code, fonhe perfomumee nl the
then. us providedfpr Section me Labor
hick this mi i.
work for which This
FIXTURES - PER TRAP
eeirani. rkJ.
❑ 1 have and will n Workers Insurance. a. required M1y Section
oIle, f nmee. the w
My ofthe Labor)...., Tnr theperfso,... ofthcwork for,
e. .,is it zeroed.
GAS -EA -SYSTEM -I INC.40UTLi?TS
OCC. GROUP APN
,il
Wnder'r Cnmpanxmlon Ituunmce,trier and Policy numb,'urea
Camcc Policy Nn.:
Co
CAS - F.A. SYSTEM -OV IeR 4 (IiA)
11
CI7If1'I FICATE OF EXEMPTION FROM WORKERS'
GREASE/MDUS'l RL WASTE INTERCEPTOR
COMPENSATION INSURANCE
BUILDING UIV1510N FEES
Mi s sect inn need not be cnmplotedifthe I is future hundred drift.
pcm,i
GRI' T1idF�.•-�
nr Ins.)
I'LANCIIF.CK FEE
lerstlylhat in theprrformanceofthe vend lnrwbich Rim,mo, Mitred bha
SE 11Qy 'ANI'PA STOR Stir IT.
rel employ airy tenon m any n"'n'tur eu as m bavmc subject m the Workers' Compen
1 V FFE
Z
zQ
cation laws of California. Dale
Applicant
WATER H13AIER WNCNT/[ FF
T
RAD(
GAIIINC IiE
h
NOTICE 'rO APPLICAN E If, all,, making this Cenilicalc of Exemption, you shouli
!Mrr?R SUS'ICBhI g2 DIG
a^�^
ham onsubject m the Worker's Compensation provisions of the labor Cale. you mus
SOILS FEE
G
fnnhwilh lieu ly with such prnvieinnserdik,rmit.hall bedoci (revoked.
WAIHR SERVICE LJ I
Q
CONSTRUCTION LENDING Y
NEW RESIDENTIAI. PLMB. SQ. FT.
(AID Receiptp
UO
lendingagency for the performance or
1 hereby affirm that them is ngfra
the work for which this permit u issue] (Sec J(19], Co.iv. C.7
sued Sec.
W E"'
O V
Lendsea Name
TOTAL:
.Ti W
[r
Lender's Address
1 eeniry it I nave read lie, appremian nml ,at, (fait tar nnnve iafermmien ix
TOT' L:
BUILDING P:
j rj7
correct. I agree to comply with all city and county ordinances and state laws relating to
QTY.. MECHANICAL PERMIT FEE
V Z
building camstmction, and hereby authorize representatives ofthis city to enter upon the
SEISM(
abrvomcminned property for inspection purfxt.cs'
PERMIT ISSUANCE
I d-ECTRIC HE
(We) egresave• indemnify and keep h.,Icss the Cay of Cupenim against
t m
Iiab111firs.juJ'annat.smasand expenses whlehmay In any way aarue aio,olsaid City
AUUHRORADiI'I'OMIICIL
b'E
in mined ence ofthe gradingofthis permit. in
APPLICANT' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
AIR HANDLING UNIT ('1010.010 CFM)
MECIIANICAI. T
SOURCE REGULATIONS.
I:;O $
AIR HANDLING UNIT(OVER 10,M) CFM)
CONSTRUCTION
nmresfApplican/Comracmr Date
EXHAUST HOOD IW/DUCT)
HOUSING MITIGATION FEE.
HAZARDOUS MAI ERIALS DISCLOSURE
Will the applicant or future building ar'.panlstnm or handle hamtdous material
HEATING UNIT (TO Bd,Nk) RTU)
us defined by the Capon i np Municipal Code, Chapter 9. 12, and the Health and Safety
Cotle, Section 25532(,)?
HEA'I'INC, UNIT (OVER 1010,0001 B'I'U)
❑Yes ❑Nn
VI?N'fILA'I'ION I'AN(SINGLE RES III)
PAID
Dore RaeiplN
Will the applicad or future building occupam use equipment or devices which
BOILER - COMP (3HP OR I W,oaT B'fU)
unit I...rdnux air comantiona, u, defined by the ILry Are;,Air Quality Mana,ment
OT
❑Ycx E, No Dimricfl
BOILER-COMP(OVER 100OM)IB'IU)
I have read the hvaMous materials requirements under Chapter 6.95 of the Cali-
AIR CONDITIONER
I CIi DATE
2 53 2.5 34..1 die
fomiu Heahb&t urretlyhaealions25505,255]3end ^_5594.1 undetamnd Ilett.par�
Finald
NEW RI191DEN'flAh MI?CH. SQ. PI'.
da:.r not currently have a tions
rend
That it is ¢t notify the ora art
� �w
of the relirachnentn which maul he mel pdpnn Iss rmare of a Cadificafeof (bcupmry,
Owner or ma had d]agcm Date
TOTAL
ISSUED TTY: 7732
OFFICE