S 3096 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPEITINO RIBLDING.ELFUI MLCIIANIC L rE ""D 3096
BUILDING DIVISION APPLICATION/PERMIT , . I'INGIIRoB Nr..MEcugNlcAl.
RUILUINC 1'ROdEL'I'IDI:N'I'IFII:AR'[DN
BUILDING ADDRESS: SAN]i'ARY NO, API'IDCATION SUBMI'ITAI,DATE
2z7o1 G4. 1`4ff 6 -62
OWNERX NAME: C PHONL; CONIRACFOR'S NAME: LIC NO'.
JJ .••V�. NIC CONTROLp
RCIIITIiC. IINCINEER LIC NO: ADDRESS: ❑
CON'FAC'P - PUoNIi: - BUILDING PERMIT INFO'
❑ Consultant Fees Paid by Applicant(initial) B{.o(: F.LIiC'I PLUME nt,C"
rVVyi ❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY. t ELEC7 RIC PERMIT, '�Flili
I hereby unner Ina I maI n:dmade.p ' : f Chis r( ng ,r• t JOE DESCRIPTION
OttZ wim Secton 700(rof o'vis ala frac Ra.m<..amd lrofessimm Crale,md mylcense B I:
R211DBN'rIA
Won PI MI r ISSUA NCL
FWZ in full force and effect. ROSFDWI, O KI'r CHEN REMODEL
�UU LiOrw Class. Lic.it APPLIANCES-RESIDENTIAL El ADDITION ElPLUMBING RE-1'11'1:
I-�W Datc Contractor
aoG ❑MULTI-UNIT OSTRUCTURAL
5N ARCIIITEOf'S DECLARATION PANELS
Z O z 1 undesdind any plana shall M used as public records MOUIFICA"f10N
OZ
rU11T0200AMPS ❑INTERIOR OCIIIMNEY REPAIR
FaOFw Licensed Pml'exsin let 201-1011 AMPS IMPROVEMENT OSWRvi POOLS
C ..l OWNER-BUILDI!R DECLARATION
.] OVER 10(MIAMI'S ❑HATH kIiMODEU Ii AI ❑D�.MC)LIl'ION
yo W a I hereby.(rrm cm Iran ebusin Irma the feWers m'e e;A n c Law Ibr me K
YyX5 d which
mosaisoo.lcredo7ouquacnaluess trod Professions Calemayday or county SIGNS ELLLTRICAL �'OTIIER -eC.,
W LL O y which ,,as s a permit to conevaet alcor,al ku,e.dneonnif or repair any uruaum
mr0prloImlmteried puremad .ireetheapplicam for snchpceminohleae Law mncmcm SPBCIALCIRCUIT/MISC. �p Q
mat he in licenced punuvmmthe provisions of the Gmtncmrs License law Chapter
�00 (commencing with Sweet 7000)of Division 3 at he Bmincsxvnd Professions Code)or 'I'HMP.MH EER OR POLE INS T. COMMERCIAL'
tl ..n C ton he is exaraintherefrom uad the basis for the alleged esemption.Any Andoion of O NEW BLDG/ADDI97ON O DEMOIAl[ON
by Section 7031.5 by any applicant Tor.pearti mhje is the applicant to v civil penaltyof POWER DEVICES OTENANT El FOOD SERVICE:
ZQnot mom than five hmdred donees 1550. IMPROVEMENT
❑I,as owner of the propeny,or my employees with wages as their.mlc compensation. SWIMMING POOL EL17CTRIC
EEO will do the work.and the structure is not Intended ororrewd lbr sale(Sec.7044,losineds OOTHER
W as and Pndussions Cadc The Gmwemr§License Law does not apply mon owner of OUTLETS-SWITCHES-FIXT)RES O
pmpeny who builds or improves themon,and who docs such work himself or through
his own employees,provided that such Inapmvenwnrs ore nm in ended nr offered for NEW RESIDENTIAL FLECIR SQ PI'.
sale.IL th
however,the building or improvement is sold within one year ofcompledoa, e SQ.FT PL(N)R AREA LSQ.FT.
er-builder will have the burden ol'provin,Ohm he did mol birld or improve lir pr-
of oaten).
of the p n,fif,am exclusively cnmmeting with licerad coroucmrs Io
conMmcl the pnnjeer(Sec.7844,Bavine".1111 Professions Cad,:)9)m Cn u,,iltndI -
mon,Law Roesnot applyatanowncrofp ny who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
whomntreets for suehpmject,wah or(s)Ii....edpuanvnuo the Codemons
/ License Law. PERMIT ISSUANCE
I ❑Lm emand under5 .R&PCfnr this Temno
ALTI?R-DRAIN Ye VENT-WA' VALUATION
G e Doe - 5'
WORKI!R'S COMPENSA'I'1 NDIULARAI'ION BACK FLOW PROI'EC'I'.UIiV ICE
hereby nation under penalty of pc jury one of the mEmwing dcCh mmons
❑Ihamandwdl maintain a Cenl6cmeof Consent I—Of-inmm for Worker's Comper- DRAINS-FLOOR.ROOF,AREA,CON[). S'ICRIES 3'YPE CONS flit IC'I'ION
mtior,as pm ided for by Section 370 of the Lem,CIA,for thc perforreanom of the
work for which Ibis 1xmmir Is ismcd, 'FIXTURES-PER'FRAP
I have and rill maimain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,fur the perhrrmrne,4 e,work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.ORO UP APN
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4IRA)
OFR'1'IFICATEi OF EXEMPTION FROM WORKERS'
C&PENSA'1'ION INSURANCE GRFASFIINDUS ERI,WAS'I INTERCEPTOR IRADfNGDIVISION FE
(Pliksemrimencetl not fee nnplemJifiw,eurilis fnrrmelm11.Imd Jollam(SI 0) GREASE IRAI'
nr less) I'hANCkIHC'a
Ia'nify that in the perfnrmunecna the work for which dtispcnnil is isa¢d,lshall SEWER-SANITARY-STORM EA.2h)IT
..it employ ,nny pet on m my n an er,so as as favenne adjecOo the Workers'Camper- ENERGY P
z smion laws of Caldomm.Date 'y{IFtt./ITEt(� F:N3'IGL13"
z Applicant ' - GRADE :E
NOUCE E'O APPLICANT:If, her making this Certificate of lixmnption,you should SYS'1'&RI!A NG
E-t r�i Incemnm subject to the Workers Compcnsammn provisions of the Who Gds•you must SOILS M.
ronhwido onnply with such pmvisionsnr this pered,ball hedcemcdrevaked. W'� SERVICE:
Q
CONSTRUCTION LENDING AGENCV N II '.SII LP IL S PAID
U 0 l hereby affirm that there is a comau tion lending agency for the performance of ❑me Recdplp
the work for which his permit is issue)(Sec.3097,Co.C.)
Of+ leader's Name T(YI'AL:
U lenders Address
'�.."t' 0. 1 verify the,I Imve oerd this applicmion and Imre that the above iafornmion Is U ,- RUILf NO[l!E
F•r V1 morcel.I agream comply whhall city and county wobeaecsand uam lawamlatingmTY MECHANICAL PERMIT . FEE
U Z modogcnmwdinn,and hereby umhnriu mprtsenwivcs of this cilymentcr upon We Q SEISMI li
nhovwmentiandl prnpe ly f r inspection purposes. PERMIT ISSUANCE
(We)agree ea suse,indemnify and keep harmless the City of Cupertino agaimt ELIicrRIC FF. adisex
Iiabilitica.judgmenla,coos dad expenac.which may In mywayaUoevg.ioslmhl Cry AMERORAOD'rOMECIL
in PLUMBING PFEEm,eve,c.of Ibc......in,cf thio pema t.
APPLICANT UNDERS'rANI \ND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10,00n CFM)
S(IURCEREG 'IONS. MECHANICAL FEE
AIR HANDLING ON[]'(OVER 10.000 CFM) CONSTRUCTION FAX
or
mmmfA,fl,arVCbrarral - Dme EXE{AUS'1'II(XHOWMIJI70 I Io35ING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
WIIl the applicant or lhmrc huilJing awcupvnt Marc nr bundle hmnNon¢mumrinl HEATING UNI'I'(1'0 IO,ORBBTID
asned by the Common.Municipal Cale,Chapmr 9.12,and the He.IN and Safely
Section 25532(a)7 HEATING UNIT(OVER landfill R'N)
❑Yea El Ne PAID
VI!NTILA3'ION I:AN(SINGLII RE$ID) Dale Reeeiplp
Will the applicant or Imam building ocn@am use equipment or devices which BOILER-COMP(31111 OR 1(X),0110 EI'U)
hazardous air confammerwae defined by Ne Buy Area Air Quality Management T(''? Yea ONo BOILER-COMP(OV R10,NX)RTU)
I have read the hamrdmIrml,ials n rs under Chane 6.950 rhe Gdl- AIk CONDI'OONER FIANCE IN
yommcn , _ ((
GimiugdoesnSmrretlyhaeatena 25545,25533and25534.E to mady the
Ohmifthe NI!W RESIDENTIAL.MI!CH. SQ.FI'.
building Janine,,lecher
have.¢rant that it 1s myts ofaC ri asnotifytheoccupant
of the rcyuirenteva whlah anal hearer poor m Isnuvnca of a CcniOeme of(kvup:racy.
Owner ar amhorizud'gem - Dme TOR'AL: ISSUED RY.
OFFICE