S 3325 -APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELRCI'RIC'AL rEITNo. 3325
BUILDING DIVISION AI'I'LICATIONIPERDIIT PLUMBING-NIiCHANICAL
BIBLE HNG PROJF,LT HWN'I'I FICATION
BUILDING SANI'I'AR1'RO. nl`I`LICAI'ION 1 tilllthf l'If L DnI'li
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OW F.R:SIII M If. PHONE: I
s I;(LVI'RACf 'S AME.: St LIC NO. NIC COIYI'ROLp
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C.ORCIITE'fC:]'nGP PER. L ADIiSS: ❑ ^` Ol
UN : DQ 6UILDINO PERMITI
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❑ CmmmItant Fes Paid by Applicant(Initial)
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LICENSED C N'IRALTOR:SDECLARATION QTY F,LECIRIC PERMIT FEE
I hereby art! m;u I can Eaen.rd ander nnMki......I Charon 9(eo.I....enci0g JOB DESCRI ION
q�p I)lh xllon9�xl�ttl U^wA CIII'TE( UECLAION yl until licumrle' *--A—DWL 11'
rr Jf
alp w ^` HERMIT ISSUANCE?
H JI 'o¢c un I - l 'rteDWL ❑KI'IC1113N RIiMOUIiI.
QUV E.ic N'PLIANCFS-RfSIDINTIAL LIADDITION [I PLUMBING RE-PINI:
Z me ComraOne
yQy _ ❑MULTI-UNIT ❑STRUCTURAL.
F✓po Z_ I understand my Planashall b:awdas pubiworsoNe PANIitS MODIFICATION
ZOZ�O UP'1'02W AMTS ❑IN'ITR10R ❑CHIMNIiY REPAIR
F4L, L.,rd Prnlnaslonol 201-IMOAMPS IMPR0VEMI:N'1EjSWIMMING POOLS
<.�'$'� OWNHR-BUILDITR DI!CIARADON OVER HIM) ❑BA'T'H KEMODEIJREPAIR 0DCMOIJ1ION
C Q I hereby affirm that I urn exempt from the Counnon's Liccnac Law lin the
Kp a U fallowing rcaam.(Section]131.5.Business and Pre erasions Cade Any city or county SIGNS ELECTRICAL (JTHI.k
❑13 LL h¢ whim requires a permit no construct.alter,impmsr.demolish.or repair any structure
1�-�p-1 prion n I' req th pplic of hpe tin fl g J.nnmem SPTCIAL CIRCUI'UMISC.
f'!Z} (hath n: Ip Brat tire p ns Ito c tt rtnl f' (Channel9 COMMERCIAL:
Who (wnncty ywthSui nRHO) IU "luor 3 t,he Bu%hue—andP f 'dnas Ctdc)or 'I{1MPML"TERORPOLL INS"C.
aqx e C thin he i.csentpn 11....mm tail the balk hume.11,Mese n luoi.Any eiolaro t e f (]NIiW 111.DG/ADDITION (I DIiMOhI'I'ION
Www Sectiun9(DlS hyany applicant burn permit subjrcn theapplicanr macivil peraltyof DEVICE: ❑I'IiNAN'T ❑FOODSI:RVICI!
E,Zy
out more than fisc hundred allarx($500). IMI'ROVGIEM'
f=QO ❑Lac owner of the pmpeny.or my cmpluyws with wages ns theinole rompcnaabnn, NG PER 1.13 RIG
F ❑OfIIER
will Jo the work,and the structure is net intended croRerrJ for sale(See.'RIW.Business
3 and 14nfcsniun.Code:The Cnnm,un,Lir;ensc law Jac.not apply en un nwncr n( Olr EI' _ti Cilli'-FIXTURE?S
pmprty who builds or improve,lhcrcnn,Bred who Anes Duch wurk nimxdf nr lhnmgh
Itis own mnpinycq.,provided tom ouch improvemennx arc nor in cau&d nr"hired lar P )IiN'fIA ?C'r SQ I'1'.
sale 11.however,The building or impmvemem is sulci within one year ofesurdetion,the SQ PI'.FLOOR AHI!n 5/SQ.PT.
.
nwaarbuilder will have the burden of proving that he did nm buildbuild,),humane fmpnr- 69 = �!/ j '� s•s-O
pom.Lalc). TOTAL: (/6 , -
1,as owner of the propenY,am cxdusivdy connwing with licensed nnnranoo w
construct the project(Sac.7044.Badness and&nPossi tax Gdep 9fic Camremur'n Li-
c .cLawdtasBolapplymm
un.wncrofppeny who builds o.....rovcs Tic.rore.and QTY. PI,UMBING PERMIT IEE 14ADO
who c w
mcts lot such prnccnx with a conlntna(s)licensed Pu seam Indic Commaur'.
License Lrw. r6kl'C Lrt phis rcaam 1117RMIT ISSUANCE V S�y7—B
O 1 am esentpt under See.
AI:fPER-DRAIN&VENT-WAILR THAT VALUATION
Owner Dane
WORKERS COMI'I7NSAT10N DI!ChARATION RACK FLOW 1'R(JTI[CI'.DEVICIi O to O
1h,ebyallinn under pe nutty of perjury one of the Billowing dmlanaienx:
(] Ihan.1 1 willntainm:n it Ccnnne
ifcumot Cca,lone(-insure fur Worker,CnnTcn- DRAINS-IsI.00R,ROOF.ARIA.CON U. STORIES '1'YI'HCONS'181JC'I'[ON
0adon.as provided for by See.1.n 191X)of I.nbor Crile.for pedammnce III be
work for which this pern is issued. IIX'1'URFS-P13N TRA('
El I have and will maintain Worker's Compensation Insurance.as required by Section
3700 of the Lahor Code.for the perfmntance ofthe work for which this permit is iswwT GAS-F,A.SYSTI:M.I INC A OIITLIH'S OCC.GROUP MIN
My Wnr 'urJlpc y10 uranin cunicr aJSyl Ppligy na}tlX.r-1_J
GAS-F.A.SVS'TI!MOVER4(IiA)
Carrier Y `n a 1�1y p(y ��fMa,
CI!K'fI1sIGIlli OP13XI3MITION PItoM W<I KERS'/O! GKLASRENDUSI'U.WASTE IN'I HItCEI'I'OR
COMPHNSATION INSURANCE ``II �/ BUILDING DIVISION FITS,
or le".)(Hila wction nertlnm m
be mplctcd ifnnc peril is fnrnnchundrWJollars(SIIX) GRFASE1'LANCIIE A L TRAP 'Z 0
�
I cattily that in the perfnnnnnce ofthe work for which this Perin is issued.Estill SIiW'T:R-SANT TARY-STORM EA.20014. :.
nmulnpiny uny gars ni uny manner so us�buol�n 'o uthe W.rkurn'Comprn- BNI!RG
Z'
xmion Lnwa of(%fl►.m' .D:ua R r 1 Ts �- WAITER HHNIBR W/VEN'1'/ELECTR GRN 'FP
��••11 NOTICE'If)AI' I A :II;:Jlcr looking this Ccniliewc of Exanpunn.You shnuW WAIT ER SYS I'IiMG BI!A'I'ING SUIT I Js
Z)
bemII IOAlathe ANTWorker c Cnnnpcnation Pmvisinnxof the labor Cole,you must
Ce forthwith comply with Inch provisions or this perminshall he deemed revoked. WATER SERVICE
YJ
CONSTRUCTION LENDING ACI!NCY NP:W RESIDENT(AT,I'LMg, Sp.pf. I'NU
5 z1hereby:dlimuhat them is nsonvmetiou lending ugcncy fee he ferronnancc of [)are RtteiptK
w - the wurk Iur wbicb this permit I.Ineuwl(Sec.309'1,C.I.C.) 2
I" '1'A L: _
D IandaL.Name TOTAL:L/1/y
U , 3
r B.1 Lcudds Address _ BUILDING IT& 6�• QI
1 1«reify n ed 1 have road obi..applicmiun and ,are thin the above information is
F., N crtect.I agree mcaody with Aid,and manry onlinanmz and ztam taws mmregn. QTY MECHANICAL PERMIT FF.E SBISMIC PVT 14q. 60
U Z building con.aruction,and hereby autrai7c representatives of this city nil enter upon the
abnve.ntcnlinnr I poo,emy for napcction purposes. YI!RMIT ISSUANCE ELEC'TR y+16.3
(Wel ugtac m save,I knlnl1,and keep hurmlexv Pic City rel Cupcninn against
Iiabilitic..judgments,costs and cxpcnacs whichmayinany wuysecoree,nnusaid City AI:TER OR ADD 90 MEECH. PI.UMBI,
in consequence of the granting of this Permit.
APPLICANT UND17RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(In IQg)()CEIM) MIiCH (CAL�.E
SOURCE.HIiGI'. TIONS.
APR HANDLING(INET(OVER 10.000 CI'h1) CONST CTION TAX
SlguanuolABron/Cr [)are EXHAUST IROD(W/DUCT) I MUSING MITIGA'I'[ON ITh ,09.07
HAZAanto 'OUS 1111 ERI LS UPSCI,OSURIi
Will the applicantm future buldmigneaapuam coo hurdle hvanlnusmmcnal 1117ATING UNIT(TO IIIU,IXX)BTU)
as defined by The Cupcninn Municipal Code.Chance 9.12,and the Health and Safety tIIiATING UNIT(OVER IIX).WfI B'IVI
Code,lection 25532(0)!
❑Yes (J Nu VENTILAITIALMEz
LE RE SP U) PAID
—Daro Rettipn p
Will Tire oppPicamur tulurc badddingo.....a me actipmm�.or dcvires which 11011,¢X- h).Par If I'U)
mit haamJoas air eumantinnm.c defined by nue tiny Arco Air Quulily Mmeagerncnt
Di"ciefl ,�✓ BOILER- HSLbMdRED)
E]Yes `{ms`s
P hove read the hamNotn matcndx requirements under Chapin 495 of the Call AIR CONISSUANCE DATE
litmia llaltb Ni Salcey Gdc.Scainnu 255(15,25511;uu12553;.1 nndenr:mA Inm if the NIiW RESI{, SQ.h'1'.
b Iding'i nanneadyh�veu R9tunl,Dauhi.....:cpu.txlndity eo mnily d:a,.,tism !� 9
of the repliru I o %hien iwnl nilbe lnct�iJ nsc alnCenifcom rel(kenPen¢YCenirrme nfucalnenaY. {�
owT,.r Bann >ed ageni�! DaD,ne IMIA1.:yN4.33 NSUIrDBY:
OFFICE