S 3305 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
clTv of curFR rlNo BUILDING-ELECTRICAL PF. IT NO
BUILDING DIVISION APPLICATIONOOPFRMIT PING PROJECT IDENTIFI I' 3305
IIf111.DING PRf)AIdT,T tUEN1'IRICAI'[UN
BUILDINGADDRESS: SANI'T'ARY NO. APPLICATION SUBMI'1'I'AI.DATE
2ry�Z4 IA � IHONE:41,
0900 STeiiii C2cEK SLVO.
1 CON'TRACTOR'SNAMIi: LIC NO,
1V1 NIC
fy C(INTROLp
ADARCH]IPC'FENGINEER: LIC NO ADDRESS: ❑
coNT'nCf: I , � rxoNE: BUILDING PERMIT INFO
❑ Consullant Fees Paid by Applicant(Initial) BLDGELJLECy PLUMB MOH
l ICNA� �A �o CL 2S2 �o9 q'� ❑ IHI
LICENSED CONTRACTOR S DECLARAI'ION QTY ELECTRIC PERMIT FEE
I hcmby alum,hal 1 am limmed under provisions ofenap,er 9 mommenam, JOB DESCRIPTION
Z with SOc,i r0W0)arDmki,m 3Mme Buanessand Profcssiom Cole,andnry licemeis RESIDENTIAL:
FOO in full force and what. i' PERMIT'ISSUANCE
W ❑SFUWL ❑KITCHEN REMODEL
�UU Lissom Class 1,icOf APPLIANCES-RESIDEN9'I Al. ❑ADDITION ❑PLUMBING R'F-PIPE
tidal Date Contrummr
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANELS
Z O,-Z I understand my plans shall the used as public records MODIFICATION
OZ^� UP'f02(XIAMPS [I INTERIOR El CHIMNEY REPAIR
4l❑❑"Ix11.1<cmcJ l'nduesionel 201-10ft)AMl5 IMPROVEMENT (]SWIMMING POOLS
ky; OWNER-BUILDER DECLARATION
5 OVER 1000 AMPS ❑BATH REMODI?UREPAIR ❑DEMOLITION
C W d I hereby affirm that I am exempt from,he Cantrnnor s License Law for the
caU OTHER
3 a U following reason.(Section]031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL
O m which requires a permit In construct,alar,impress,demolish,or repair any structure
pdo t t .: L 1 ,h 'ppl tf chM a fl g Jsw,ema, SPECIALCIRCUITIMIS . i
�� Iath it : tl tis p fm C t" t l : I fCh tpterJ
(sun nriamgwolb Sem of 70"bisf Divaion3ml the lia' m andP f:: mGdc)nr TEMP.MIiGiROR POLI?1 S'T.
H e.O C nn.,he is exnnpt therefrom and the basis far the allege)exemption.Any violation of ❑NEW BLDG/ADDITION C3DEMOLITION
0
Xmu. Section 7111 LS by any applicant for pnnil subjects me applicam,oaeivil Penalty of POKER DEVICES if j
W^sit ❑TENANT ❑FOOD SERVICE
Z),
net more than fee hundred Dollars($SW). IMPROVEMENT'
d ❑ Lo0—orofthe propaneton mycntployeecteoffmil asrle(S,t.7044,rrnr,, SWIMMING POOL ELF.CI'NIC
50
�O will PromWer,mW e: he Caramels,,Liswp4e Law does nt rept m.o mn owpine„ ❑GTIIER
and 1'mfessions Code:The Rmamma's liceme Law tices not apply m an owner mr OUTL1i I'S-SWITCHIiti-Ir1X'x1RE.5 2 O
�' pmpeny who boils,ter improves thereon,and who Jces sue:work himself m thrmush
his own employees,provided that such improvements arc nm in¢ndcA or ol(ered for NEW RISIDENTIAL GLEC!'R SQ FT.
sale.If,faster,the building or improvement is sold within one year of c, plelon.,he SQ SILT ^
�r
rte Auilder wall have the burden of proving mm he dad not build mr improve for put- L=
seas),
,owner ofine pmpen,am mewsmdr"maturing with licensed aawmn,to 'H(rA:
construct the project(Sec.7614.Business and Professions Came.)The Cmmmnar's Li- r\ 9
cense Law Jces not apply to an owner of pmpeny who builds orimproves thereon.and QTy. PLUMBING PERMIT FEE
whir contracts for such projects with a convection)licensed pursuant to Lha Conroetors I 1
Law PERM I'I'ISSIIANCF. S 1
lam ,B&PC nrmil recaul )
O dl U ALTER-GRAIN&VENT-WATER(HA) 'p`, VALUA
l 7 S MPFNSAf10N DECLAItAT10N BACK PLOW PROTECT.DEVICE
'
l hereby alBmt unry of perlury one of the fol lowing tlmlurminns:
❑ Ihuvcundwill nruintainuCertilicuwmfCnnsennosell itavumfar WnrAcr's Compen- DRAINS-FLOOR.ROLE AREA,CONn
,own,as Provided Ia iby Section 3900ol'Ihe Labor Cala far te hperformance of the S'T'ORIES 'TYPE CLNN'1'I<l1C'I'ION
work for which this lrnnit is issued. FIXTURES-PER TRAP
❑1 have and will mainmin Workers Cooperstown Insurance,a require)by Section
3900ofthe Labor Code.for the performance of the work for whichmis Fermi,i,ismed GAS-EA.SYSTEM-I INC.4 OUTI.F rS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Pal icy nu rider are:
Carrier Policy Nm.: GAS-PA.sysTpm.OVEIt 4(EA)
CERTIFICATE OF EXHMI'I']ON FROM WORKERS'
COMPENSATION INSURANCE GREASIIFNDUSTRL WASTE INTERCI VIDIO
BUILDING DIVISION FEES
(This seenart ed not IN,completed Hart permit is formic hundreddmllars(5100) GREASETRAP
or less) PLANCHECK PEI:
Icertify that In the performance mr,bm work forwhich this pemdl is issued,Ipull SEWER-SANITARY-S'I'ORMFA.2gll4.
not employ any persmn In any manner,..nn.m asceome mtbjeo m theta..kat Cnmpen- I:NIFRGY FEE
Zz onto lawsof Califamis.Date WATER I WATER WARN PVLECTR
Applicant GRADING FE I:.
` NOTICE TO APPLICANT IL after making this Certificate of Exemption,you should WATER S YS'TEM)TREATING
abecome subject to the Workers Compensation provisions of the Labor Code,you mus, SOILS FEB
W forthwith evnnpay with such provisions nr tis is permit that be deemed revoked. WATER SERVICE
Q Q
CONh ']ON ItNUlNGAOliNCY NEW RCSIDIiNT1ALl'LM11. SQ.IeL PAH)
affirmthatmereem isi,a
U O leereby arm aommmedom lemams agency mane peaammnee or nam Reae x
the work rat which this permit is issue)(Sec.300 I.Civ.C.1
l-" LenJer's Name 'I'OL:
V Lender's Addtco; 'TA L:
I certify tem 1 have matl this applicminn and scam that the above imllammion 1, - BUILDING PER rvl
rFIn mrmm.I agree m comely with all city and coamry radio amees and sura laws mialtm r, QTY. MECHANICAL.PERMIT FEE
z boilding nmammion,and herebyauthmlre repmxnm,ivcs mf,his citymether upon the SEISMIC FEE
aM owhortiuned property for inspection purposes. PERMIT ISSUANCE
(We)agree msave,indemnify and keep hafmdes,dm City of Culmrlanm against ELECTRIC FEE
liabilities,judgmcros.sorosani expenses which mayor any way vecmeagnium said City ALTERORADD'I'OMI.CIL
re rnsagacnce of the granting of nis pconit. I'LUMI3ING PI3E
APPLICANT ORDERS'LANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM). C MECHANICAL heli
11 AIR HANDLING UNIT HOVER 10.000CFMI CONSTRUCTION TAX
r.m[ Herm I m EXHAUSTIIOOD(WIDUCI)
\` 1 I IOUSINGMITIGKD PP.E
DOUS MATERIALS DISCLOSURE
Will,he applicam nr furore builJing rrapan,store mr handle haeanlaue material HGTING UNIT LM 1(X1110)BTU)
as defneJ by,he Cupertino Municipal Cale,Chapter 9.12,anJ the Health and Safety
Calc,Section 25532(x)? HEATING UNIT(OVER IIX),IXXI BTU) s
F-11Vcs E]No (SINGLE ILPAID
VEN'I'lLA'I'ION PAN(SINGLE Duro Receipt N
Will the applicant or future building maters use"rimamol or devices which
emit hazmdom air contamina ,as defneJ by the Bay Area Air Quality Mi nagemen, B0ILI;R-COMP(3HP OR 100.000 BTU)
yIAL:
Disaicr? BOBER-COMP(OVER 100.000 BTI?)
❑yes ❑No
I have=it the haumlous materials ler Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
cyuiremenu um
mmia Ileallh&Safety Calc,Sections 25505.25533 and 25534.1 undemand that if me NEW RESIDENTIAL MECH. SQ.Ef.
ties n Icurrently have amnam.nat i,is myre nsibili,y to notify the mcupatn 1/
mf,he irer antswhichmue pi 'factional kir ancy
tk Rill
Bite
'IUFAL: ISSUED BY:
\ U t"w,- OFFICE