S 3838 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P17RMI'INO.
BUII,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3838
BUILDING PROdECF IDENTIFICATION
11111LDING AOORI[SS,. SANITARY NO. APPLICATION SUBMITTAL DAT]
1063u -C�� �L� PLA-Ce- CGiP�R7/No C1� 9 6 -lii/.
OWNER:S NAME: If AN 6 `� LOHOjq�� - CONTRACTOR'S NAME: 1.1C NO:
G llll NIC COMfROLM
PENR IfARCHITEiCI'Ain-INEF}�,'�/� LICNO: ADDRESS: ❑ Yz�
pr lf/V['ZL/L J
CO`NTACT: /u VPIIONE: -r•�p BUILDING PERMIT INFO
ARMI/MC���I `r op)��-772a ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
SJR ,//W 1. tLX�[ D— El— ffl— Q
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affrn mal I on licensed under pmoi,ininof Chapter 9(enmmerciag JOB DESCRIPTION
O edZ with Section Divisinn3of the Busineo and Professions Cede.and mylicenu isTIAL,
W PERMIT ISSUANCE
F u:• In lull tires and ellbet SFDWh ❑KITCHEN RFiMODEI.
QUU License Class Lic.p APPLIANCES-NP_SIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
n Q i Dote Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F=ao a,z I underoand in shall be used as public records PANT-LS MODIFICATION
70y,J YPannsti pu UP TU 200 AMPS
❑INTERIOR [I CHIMNEY REPAIR
rLIZ W Licenced Prmexsional 201.1000AMPS IMPROVEMENT E)SWIMMING POOLS
Q 1 hereby M.that I am cxemPCf alto the ComCI.ARAdmctor'a License Law for the OVER 10(X1 AMPS ON ❑BATA RIiMOUIiIJRIiPAiR ❑DEMOLITION
X 3 i U following reason.(Section 7091.5.Business and 1'ndoxsions Csdc:Any city uta may SIGNS ELP.CTRICAL ❑OTHER
W o.y which requires a Permit to construct,alar,improve,demolish,or repair any save
1- OQ prior to its axunu:,also¢yuiresheapplicont rursudt perntinn flenxigneJ stated t ECIALCIRCUI'r/MISC.
by mmaneislicenwdpnrsuanLtothcprovisit)nsofine Contracwrs l.kerese Lax'ICh
—'001u°tnmenciny with Sedina700snufD......n9ofine Business and Pr afe..ionI Co cl or TE METER OR POLE INST. COMMERCIAL,
e.c.c C that he is exempt therefrom and the out flat the alleged exemption.Any vinon 1) ❑NEW BLDGIADDITION ❑DEMOLITION
ySection 70315 by tiny applicant for a permit subject%the applicant o a civil Penalty of W.-R DEVICES
rn more man five hundred dollars 1351X)). CJ TENANT ❑FOODSERVICE
SSG [:] Las uwnernfthe propny.or my employees with wegesas then,decompensai t.n, SWIMM NG POOL ELECTRIC ❑THERIMPROVLMENT
F. will do the work,and the structure is not intended or offered for sale(See Business
all and Ptndssimns Cole:The Contractor's License law dotes not apply 11 en owner of UUT.ITIS-S ITCItliS-FIX'TURIS
,amplify who huilds lar mtprovcs merom,and who Jces such work hoarsen lar through
his on employees,provided that such impmvememes am not intended or offered for NEW RESIDENTIAL ELECI'R SQ Il'.
,ale.It,bowev.rfle hi iliingor inmoviccrl solid walaincnc yen,ofemindetion,the
SQ.17.FLOOR AREA S/SQ.PT.
erheilder will have the burden of poring that he did not build or improve for put-
pre of sale.), T 7_141 ���
[:]I,as owner of the,mp.rty,am exclusively Marrowting with licensed erroneous o
construct the protect(Sec 70,14.Business and Profession.Cale:)The Contractor's Li- d C
m law does not apply to an owner of proiaMy who buildsear improves thereon,and QTY. PLUMBING PERMIT FEE 'T
who contracts for such projects with a contmeod0 licensed pursuant o the Contractor's y 2 4
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for this mason _
ALI'lIR-DRAIN&Vii EN/ (EAI VALUATION
Owner Date
WORrrude, COM ofiN$A yIONon DECLARATION RACK FLOW PR .D"VICE / D
I hereby affirm undo Penalty til ofCo following for declarations: � I
nation.
as unit
rovichntot by Se Certificate ofCe Labor sclfi,for
rthe Workers Comyen- DRAINS-FL 00 , ACOND' STORIES 'TYPE CONSI"RUCTION
satilan,us Provide)for by Section 3]1X1 of the Labor QsJo.Ihr the pernsnnance of the
work for which this permit is isned, Fl%TURLS-PER TRAP
Cl have and will maintain Worker's Compnscion Innumnce,as required by Section
3700of the Lahr Code,for the performance fthe work fill which this permit is issued. GAS-EA.SYSTEM-I INC.JOUq.ET OCGROUP,_ APN
My Worker's Compensation Insurance carrier and Policy troller am:
Cartier: Pulley No.: FA
GAS- ..SYSTEM-OVL6
CERTIFICATE OF EXEMPTION FROM WORKERS' GRIiA51%INDl15TR1,WAS'I'0I EI R
COMPENSATION INSURANCE BUILDING UI VISION FEES
(Thlx nedinn need nm lav utmploted lDM1epennit is fumnc hundred dollars(5100) GREASE TRAP all
or less.) PL CH. FFI? Z s y0
I certify that in the performance rDhe work for which this permit isissiod,Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in oily manner xo us ht bit.ome.ruhjecuu the Wmkcrs'Cnmpcn- E E O( iE
,Z scion laws rf California.Dam NATER HEATER WNENT/ELECTR
0 Applicant GRAD] FEE
'z' NOTICE I0 APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYSTEM TRRNTING
? become subject to the W..o r',Conmcnwronn
.......ins of the Labor Code,you must SOIL E
{A forthwith comply with such provisions rr this .it shall be Jeemcd rm'nked. WATER SERVICE
1 CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMII. SQ.FT. PA1U ate Reeeipta
U 0 1 herchy nttirm that heir is a construction lending agency for the Performance of
the work Bur which this permit is issued(Sec.3097,Co.C.) 2
Lender's Name
F T
Lenders AJde,,
y I rem y that I have read this application and slam deal the alcove information is BUILDING PEE
F (n correct.I g. ,,comply wbh all fly and coumyoninnotc,and stet.law,releling or QTY. MECHANICAL PERMIT, FEE,_,_
U building construction.and hereby authonrc representatives of this city to enter upon the 17i'\�It '.4EISMICIIiE_ 2
ehovo-menti.ncd Pmpeny far inspection pulp as, p,RMIT ISSUANCE II II I lS I In I I F.LF: F.f �•�
(We)agme m save,indemnify and keep harmless the City of Cupnino.gaunt t - t - 1
liabilities."ohmengmvisand expenses which may in any way accede agamstseid City gCl'F,R OR ADD TO MECH. B� PLUM NG 'E
in consacqual of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.(X0 CFM)II I AY 2 1C E
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10.000 CFM) CONST ON TAX
Signature ol'Applie,call aracwr Date E%HAUS'f HOOD(WiDUCT) IRII HOUSIN MI ION FEE
I(AZAR DOUS MAT 11 RIALS DISCLOSURE _
I.
Will the applicant or future building occupant store or handle hazardous material HEATING ON 11(11) 1X
101. 0 BI'U)
as defined by the Cupertino Municipal Cock,Chup¢r 912,and the Health and Safety
Cole.Section 25532(a)'I HEATING UNIT(OVER IIX),000 BTU)
E]Yea ❑No VENl'B.AI'[ON FAN(SING LE RESID) PAID
Dulc Raccipt p
Will the applicant or tumrc building occupant use equipmetn or devices which BOILER (311P OR 100,(n)BTU)mit hazardous air contaminants as defined by the Bay Arca Air Quality Management IT, 1.:
District? BOILER-COMP(OVER 100,000 BTU)
❑Ycs ❑No
1 have read the bnzurdous mwcrials rc der,Chaffer fi 95 of the Cali- AIR CONDITIONER ISSUANCE DAT]',
y 25533 an un p
fomia Health&Safety Cole,Stations 25505,25533 emJ 25534.I umkamnd that if the NEW RESIDENTIAL MECH. SQ.FT.
huithing docs not emmnfy have son' t,that it is illy uslotry m notify the meupral
of the remit s dement t�%..Ft poor to issuance of a Ceniicu f u ncy.
Owhe.or.uth zed age m _V11e/ V if
I pL ISSUED BY:
OFFICE