S 3120 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.FidltCrRICAL PER TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3120
BUILDING PROdEC'1'11)EY! h'ICATION
BUILDINGADDRESS:' f SANITARY NO. APPLICATION SUBMITTAL DATE
101170 W has / 0000 78
OWNER' AME: PHONE: CO ORS NAME, q LIC NO:
I G $ �� J� Y a? 57,95 Nrc corv'raol.a
AR il'TI! DE B :!R: LIC NO: Il !SS n ❑
D q UA f
COMPACT: PHONE: 6UILDING PERMIT INFO
❑ Consallanl Fees Paid by Applicant(Initial) BLOC ELE(l7 PLUMB MBCH
S9��t
a e F-1 E:1 0—❑
LICENSED CONTRACTOR'S DL'CLARA'I'!ON Qry ELECTRIC PERMIT I F.E
1 hereby affirm mat 1 em rcenred older mi of chapter 9(amm
cenciag JOB DESCRIPTION
WOO OO with Section)(g0)of Division 3 of he Business and Nofesa!ons Cu deandmylicmtxai, RESIDENTIAL:
WOO PERMIT ISSUANCE
E W F in ivva'v lass effect. ❑SFDWL ❑0ICIIFN REMODEL.
1.UV Date class Co.n pro APPLIANCES—RESIDENTIAL ❑ADDITION �TK'JALLjLNGRE-1`11`17.
.'r%o Date COalDECL
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑S'fRUCN AL
F C y PANELS MODIFICA'T'ION
Z O'4 7.,Z„ 1 understand my plans shall he used as public records
UP To AMPS ❑INTERIOR ❑CHIMNEY REPAIR
i,`&.l'"t�i Licensed l'rnfcxeimal 201-IOXIAMPS IMPROVEMENT EJ SWIMMING POOLS
Aarg•.1 OWNBR-BUILDER DH,CLARA'I'ION
mf,C W Q 1 Wereby affmt that I ton exempt frmn the Contractor's Llcen,u Law for the OVER 1000AMPS ❑PATH BE ❑DEMOLITION
gyp(,06 U following feao(Section 7031.5,Business and Professions Code:Any ciry nr county SIGNS ELECTRICAL 3EIOTHER
W a W y which acquires.pco ti,to a....apel..iter.improee,demolish,m repair any,nucusrc
primmitsi...ber,alsores iresther dicam forsuchpermit mfleasignedmetemcat SPECIALCIRCIIIT/MISC.
} but it.isI,rowd pursuant ratio provisions of the Common's License Law(Chapter 9
�QO (eommeneingwhib Smtinn710(h.fDivislon3oOhc Busimssand Professions Codc)or TEMP.METER OR Po INST ER I
that he is exempt therefrom and the iasis for the alleged exemption.Any vinlmian of N
';L
BLDG/ADDITION [I DEMOLITION
^' Seclion701L5 hyanyapplironl fora pematathjecInhaappllannt tovcivil pcnalryot POWER DEVICES ❑'f ANT ❑FOOD SERVICE
r rex w more than five humdmd dollars(5500).
Z>' IMPROVEMENT
6 wi Lo the work.the propcnyter is enmovideswilh Bred imsate(See 7 T4,Bmsnv,, SWIMMING I'OOLIi1.F.C9'RIC
90 will dome .n,endo se Couturier's
License Lmv does
imitate(See 71N4,Bralits ❑OTHI7.R
mand 1'ndesalons Code 'Tia Cnmmemv's License Luw Anw na apply m an owner alOUTLETS—SWITCHES—FIX'TURBS
property who builds or improves thereon,and who dives such work himself or through
his own c,odoycev,provided that such improvements um not intended or oRerN far NEW RESIDF.N']']AT,FLIICTR SQ ET.
sale.If.however,the building or improvement is sold within one year ofcompldion.the SQ,FT FLOOR ARBA SISQ,FT.
er-builder will have the burden of proving that he did not build or improve for pur-
an"of w1uJ.
C]1,m owner of meny,e Propam exclusively contracting with licensed contractors to TOTAL:
omtruct the project(Sec.7044,Business and I'mfenainns Cndep'11he Conuuemr's Li-
cerise Law dersnot apply Er)enowner ol Property who builds or improves Theorem.and QTY. PLUMBING PERMIT FEF:
who,,,.t to,for such projers with,,combatants)teetotal pursuant m the Contractor's
License law. 1117RM IT ISSUANCE
I] 1 not exempt under Sm. .B&PC for this reason
ACTBIi—DRAIN&V ENT—WATER(EA) VALUATION
Owner Dam
WORKER'S COMPENSATION DECI.ARAd]ON HACK FLOW PROTECT DEVICE
I hereby affirm under Penalty of perjury one of the following declarations
• ❑T havv und will maintain aCuni iancofCmOwnno aelfinmro I Wnrkur'.x Compe.- DRAINS—FLOOR,ROOK AREA.COND' STORIES TYPE CONSTRUCTION
cation,as provided for by Section 37M of she L.Ma Code,for the performance of the
wk forr.Lrlidu,permit is issued. FIXTURES—PCR TRAP
and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for the perfirmance of the work for which this Permit is issued GAS—E STEM. TLHTS OCC.GROUP APSE
My Worke loop ramian so pec ea r nue Policy nn c
Camcr. � Policy Nn.: 'h�-`. '7RG0/ CAS—P "1'EM. IiA)
CER fIFIC TI!OF EXFffffff (TION FROM WOIt KIeRS'
COMPENSA ION INSURANCE GHFA. US'I'RL WASTE INfERC. TOR
BUILDING DIVISION FEP.S
(Thi,seuti m need nut he completed iDbe pemdt is I'uon
r e dollars Signred dollarsSign
less) ERF. TRA 00 PLANCHI7.CK Il!F.
I certify that in the performance ofine work for which this permit is iswel,l shall SEW ilt—SANITARY—STORM Efol
ma employ any person in any munncrsom to eceome wbjecfan the Wmkrv'Cnmpen- ENERGY FEE
muen laws of Cidamia[)are WA' R WNCNT)FLECfR
z 0 Applicant GRADING PEC
Z NOTICE TO APPLICANT:If,after making this Certificate of Excmptiom,you should WATER SYSTE•M/1'R SOILS PEE
bt,cocite suljer,ra(Jr.Workers Cmmpau,ad i pmvision,of the Lalwr Code,you rmcrt
Lkl forthwith,tandy with,.h provisions or this permit shall et,heard revoked. WATER SERVICE e
6 Q
CONSTRUCTIONLENDING AGENCY NEW It1iSI1lGNTIAL I'LMI1. SQ,17' ' PAID
Ihareb ITum that is lending for the r[onnaoce o1` Date Receipt
L) 0hereby gv.) M1'
she walk for which this permit is issued(Sea 3(007.Civ.CJ
� Lenders NumenMA TOTAL,:
L) Lers Address T I
�x 4I BUILDING FER
f+ 1 certify mut I have read his city
and oun.cid state mat the aMwe iws reading
e aeon is
0,
rex burdenlagree racomply d hereby city und cnunryordivesosand,tnm lnperumgte QTY, MECHANICALPI?NMIT
L) z building comwmion,and hereby aahnnze repreunmtives of this city to ether upon the KIi15MIC FEE
ahnve-mentioned progeny for inspection pmgrsw. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep eamdes the Ciry of Cupertino again. ELECTRICFEE
Iiabilities,juEmons,enstsund expenses which may in my way accrue against said City ACtER OR ADD*10 MECIL
consequencein of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS A ) L C MPLY WITH ALL NON-POINT ATR HANDLING UNI'(TO 10,010 CFM)
Sfr�tRCE HF:GULA�S. MECHANICAL FEE
u� H9-9e AIR HANDLING UNIT(OVERIB,XXICM) CONS I RUCTION TAX
Signaturecant/ mmct Dam EXHAUST 1100) W/DUCF) I IOUS INC,MITIGA'T'ION PEE
I IAZ RDOUS MATERIALS DISCLOSURE
Will live applicanmr parent,building accupantsmmor handle ale'dou.nmeriul BEATING UNIT CIG 100,0X1 B'1'IA
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Ilealth and Safety
Crile,Section 25532(n)? HEATING UNIT(OVER 1111,0011 BTU)
E]Yes El No VENTILATION FANS I NO LF REST D) PAID
e Late RtteiPtM
Will the applicant or future Wilding occupant use equipment or devices which BOILER—COMP(3HI'OR IIq,IXMI B'T'U)
snit hvznNons air contaminants ns ddined by me Buy Arca Air Quality Management All
District? BOILER—COME'(OVER 100,01X)BTU)
❑Yes E]No
I have revel the Instructions nmtenuls requirements under Chapter 6,95 of dm Cale. AIRCONDRIONER ISSUANCE DATA
forma Health&Safety Cotte,Sections 25505,25513 and 25534,I undemto i mut If list NEW RBSIDEN'1'IAL MECII. SQ.PC �®
building docs not currently have a tenant,that it is city responsibility to malty the rxcupant
ol'the turyircmentx whichmust btmet prior to i"amcc of t Cordifiam of Occupancy.
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE