S 3165 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERNUT PLUMBING-MECHANICAL S 3165
BUILDING PROJECT IDF,NTIF'ICATLON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
V \PPPr �lV
O I?R"NAMT: PHO F.: O CONTRACTOR'S NAME: LIC NO',
NIC CONTROL Is
,� AR 111"hC' 'N INHE J LIC NO', ADDRESS: ❑ ��
O
PfiONh:: BUILDING PERMIT INFO
rf�
El Consultant Fees Paid by Applicant(Initial) BLDG CLEr CI CC
PLUMB MUCH
2s-794
IT Y
LICENSED CONTRACTORS DECLARATION QTY ELECPRIC PERMIT I°EE LK 1� LJ
1 hereby affirm that 1 um licenxd under provisions of Chapter 9(commencing JOB DESCRIPTION
{vO{v]f>'Z with Section 7")of Division 3 PA liminessvnd Professions Care,and my license ix RESIDENTIAL,:
F-00 in full Luce and effect. PERMIT ISSUANCEO
y.W ❑SFD L O KITCHEN REMODEL.
aVZV Li¢nsc Class Cie.N APPLIANCES-RE.SIDIiN'TIAL UITION ❑PLUMBING RE-PIPE
NdL Date Crmtraeeu
F5m ARCHITECTS UPCLARA'TION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O0 n-W7 I nndemmmd my plans shall be used its public to ords MODIFICATION
Cdp UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
[.4�u1 Lieonxad P...mssionul 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
coda-.]] OWNER-exemptiRrn the RATION OVER 100(1 AMPS ❑BATH REMODEUREPAIR 0DEMOLITION
CL'eG a I hereby affirm Incl 1 vat exempt from the Cnmranmr's Chase:Ad,a Law Ru Inc
W 3 U.FV- following reason.(Section]ensu r..1wxr and improve,
d rads Any city or rurmra SIGNS ELIiCI'RICAI, ❑OTHER
F_ O which reyuircs a peril requires
e uire the otter,i t for such
demolish,ter repair any ewcwre
prior if) issuance,also requiresthe applicant forcueh perinn flea signal semnmem SPECIAL CINCUI'T/MISC.
� } that he is licensed Pursuant o the previsions of the Contractors License Law(Chapter 9
�p'QQ feommmnda,with Secnon 711W)nf Divlxlon 3ofthe Bastin.and Processions Code)or TEMP.MENR OR PULP,IN.ST. COMMERCIAL
6"o eG
that he is a empl Nerefmm and the basis far Abe alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^4• Section 7031 5 by any applicant for a peril subjects the applicant Ise a civil penalty of POWER DEVICES
�y ❑TENANT ❑FOOD SERVICE
t more than Five hundred reccurs ISSIXq.
>' IMPROV T1
a
'Aldo
uwncrnl(he due,pProomy,annycnaffNyccs inh wages as ho Nei(Sela congensiness SWIMMING POOhIiLIiC'I RIC
O will Jo dAe work,anJ due,pi inendeJ ter nlProd fmrsulc(SaJM4,Business v ❑DTIIER
and Pnafessions Cale:The Commde,'n Lldmse Law drift nut apply In an owner ofUTLETS-SW ITCIILS-I IXTURF.S X
r pn'peny who builds or improves thereon,and who does such work himself ter through
hisawt employees,provided that such Improvements proveents are not intended serff
offered fur NEW RESIUEN'HAL ELECTR SQ ET.
sale,If, the building or improvement is sold within one year ofcnnipletinq the SQ.FT MOOR AREA $ISQ.FT.
owner huilder will have the harden of proving that he did not build or improve fur pm-
*[[.it xownsc 'y C/
.its owner of the pmpeny,um exclusively aofessi ns with d The C contractors i. (O/
mseLa the project(Sec.o Business and Professions Cote:7 The Gnnnmor,Li-
censelawJxsnotapplymannwnernfPmpenywhohuiWtorimproveslheram,and QTY, PLUMBING PERMIT IT?E
who contracts for such projects with a ei ntlnmor(s)licensed pursuanno Ahe Conimnnr s
License Law. PERM]PISSUANCH. f
I um excion under Sec. ,B A 1'C far this reason
ALTER-DRAIN&VIiN'I'-WA'L'E ) VALUATION
Own DatePaP
WORKER'S COMPENSATION DECLARATION BACK FLOW ttPR(U[CT. 'VICE,
I btschy am.under penalty of perjury one of the following reconfirms: �J
❑I have unit will maintain a Certificate of Consent self-insure for Worker's Compete- DRAINS-PLOO(RROO . F. OND. ST IES TYPE CONSTRUCTION
noon,as provided for by Satins 3700 of the Lbor Code,for the pedr
nanee of the
work for which this permit is issued. —7 FIX'fURIS-I'IiR'IRAI' D
❑1 have and will maintain Workers Compensation Insurance,as ngnm J,yaeea
3fiXl of the Leber Cale.fnrthe perforame of the wooansion
iA�'I Hoed. GAS-F.A.SYSI'T:M-I INCA OUT 5 OCC.GROUT' APSE
My Workerssompensation Insurance caricr n icy numnuma1U
i l
Currier. r.: \1 GAS-EA.SYSTP,M-OV1iR 4lBA)
CERTIFICATE OI � OM KERS'
COMII U ANCE ��p�p GRWSP"INDIISTRI.WASTE!INTIiRCEPI'ON DIVISION FEWh AfisoucaustandaLJ lI � RBASE TRAP lc,s.) uI_� WW PLAN tEn r which this permit is issued,l sill s
EWER-SANITARY-S'ICBM EA.200 FT.not employ any person in any mac vubject a'the Wnrken.'Compete- ENE T E
Oz satins Laws of California.Dan — WATER HEATER WIVEN'TIFLECfR
Z O Applic:mA GR. D 'PEE
v) NOTICI:TO APPLICANT:If,after making thise nu Nnuld WATER SYSTEMITRCATING
a ; become subject to the Workers Compensation pn nsw of the labm Core,you must SOLI_ EF.
ITa forthwith cnmpcy with such p... iom;of tlf,peAmit shall be deemed revoked. WATER SERVICE
2 Q
UO ffiCONSTRUCTION hIiNDINGAGENCY NEW RESIDIiNI'IALPLMB. SQ.Ff. PAID Dam Roeendif
I hereby arm that there is a construction lending agency for the perfonnunee of
w+. the work for which this permit is issued(Sea RN7,Ci,C.)
0I~ Lender,Name TOT 1.:
WLendnb Address
I certify that I have read this application and state that the above infurmmhm is BUILD G
aFi D7P correct.l agree to comply with all city and county ordinances and state laws reining to QTY. MECHANWAI,PERMIT FEE
Uz building cumonetion.and hereby authorial representatives of this city eemer affair the SEIS F'i I
abswe mentioned property for inspection purposes.
WO agree to save,indemnify and keep mindless the City of Caffein against PERMIT ISSUANCE EL I FEE
liuhilities,judgme ;costs and lxpenseswbich may in any way accnmgainst sail City ALTER ORADD TO MECH.
is run' Pence- egmming of this cmtit. PL M I GFEF. - t
APPLICANT I' ERSTANUS WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNI'1'1I010.A1IXl CFM)
SOUHCfi RB gT10N5. / MECH ICAC lF.Ii
AIR HANDLING UNI'I'(OVHR IQfXNA CPM) CONS UCTION'1'AX
$Igl uurvu ppicanVCnnWdnr 5/SII_ta�_- EXHAUST HOLD IWIDUCf)
HAZARDOUS MAI'HRIALS DISCLOSURE HGUSIN I'rIGAI'ION THE
Will the applicant or future buildingecapuot store ter handle hazardous material HEATING LINE I'110100,0X7 B'Ha
us defined by the Cupertino Manicipol Gale,Chuper 212,and the Hcalfh and Safety*
Code Section 25532(x)^ HEATING UNIT H)VER 100,10X)BTU)
❑Yes ON. VENTILATION EAN(SINGLE.RESIDE PAID
WillDae Bec It
and the applicant it future building by the B use equipment or devices which BOILER-COMP 131111 OR 10d"BTU)
emit hazorrnuz air confxminnms as JeOned by fine Buy Area Air Queliry Management )TAC
DisOim f
❑Yes ❑No BOILER-COMP(OVER 100,010 BTU) I
I have read the harm idma mmeri:ds requimments under Chapter 695 of IIIc Cul- AIR CONDITIONER ISSUANCE DATE
Luna Henhh PeSafety Cole,Sections 25511.5,25533 and 25534.1 uudcoduad Ihw If Ole NEW RESIUEN'HAL MI9CH, SQ.Fr.
haldimgsloes out currently have a tenon,than It is my te,pauibility to unify the recupnot
of life requirements which must he met prior m isnance of a Cerfi ien a of0....Wcy. C
Owner or authorized agent The TOTAL: ISSUED BY:
OFFICE