S 3346 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPLRTINO ILUMB NG-MEC'H'NICAL ','i " NO 3346
CAL
BUILDING DIVISION API'I,ICKI'ION/P13RM1•F PI.(;[IROG-NIBCBANIFIC
I4UILDING 1'ROIKCT IDENTIFICATION
BUILDINGAUDRESS: SANITARY NO. AI'PLICAI'ION 11111111l'f1Al.DAI'li
o 'fie Rol Fz s z — . `?S'
OWNER NAME: PHONIl: CONI'KAC'I RS NAM/{'.: I� LIC NO:
3 NIC CIINI ROhp
�51,f little
ARCHIL ECfIENGINEIiii: LIC NO: ADDRESS: ❑
CON'I'A T, 9 I)WNH: BUILDING PERMIT INFO
2 0 1 3 C 3 6 ❑ Consullanl Fees Paid 6y Appli ant(Initial) B1:1 ELECT PLUMB MO I
LICENSED CONTRACIOR:S DECIARA'1'ION QTY ELECTRIC PERMIT FEE LDE
1 hcrcby affiml that 1 am licensed under provision,of Chapter 9(co notaw-mg JOB DESCRIPTION
0OallZ will Section 2(x0lof Division 3ollheBirmss,avd Professions Cnle,ond my license is RESIDENTIAL:
W p PERMIT ISSUANCE
W u O in full force uneg(rcq. A,� 7 0 3 -3'j ( ❑SFDK'1. ❑KITCI{IiN RIiA10Dlih
U f' License Clas S_`X-�—Lic,a
6 U APPLIANCES-RESID6NTIA1, ❑ADDITION ❑I'hUMBING RI:1'1l'li
F Z W Dae Cn ievDECL
`''G a ARCIIITISCfS DECLARATION ❑MULThUNIT ❑STRUCNRAO
~m Z I understand my phum,,ledl be used as public records PANELS MODIFICATION
OZ`e� UP TO 20D AMPS El INTERIOR ❑CHIMNEY REPAIR
F4LW Licensed Pr,fesionsl 201-10DOAMPS IMPROVEMENT SWIMMING I'OOIS
z x Q I herebyuNinn hat NEE -nonaempt holm the RAI]Oor:License I.e.GsnM1e OVER 10f0 AMPS [I BATH REMODEIlREPA1R ❑DI'.MOLFHON
xW following reason.(Section 703 1.5,all,inc„and Profs„inns Csdc Any city,,county SIGNS F.LECr1tICAL •h []OTHER
LL:3 a h which require.a Permit m commict,ahcn improve,demolish an
or repair y mm6
cmlJ G-/' i' N
0; p.mt t '.: also issiuim,dicapplicnat! such permit fle a%igned.ttmcnl SPECIAL CIRCU IT/M ISC. �=
f } )hath licensed pursuant I the p ns f theC I torr, La (Chapter 9
r_C) (comm 8 lh Sectio 21X10) fl) ':ions fth N sinessa Jl I .. Cde)ser I EMP.METIER OR POLE INST. COMMERCIAL:
a a c 5 that he,,exempt therefrom and the III for the alleged exemption.Any violation o1 ❑NEW BLDGIA)DI'I'[ON ❑DEMou rioN
4x.'m"m
Section 7031.5 byany applicant f,rn permit subject,floapplicant nracivil penaltyof POWER DEVICES El TENANT ❑Pool)SERVICE.
nal more Ihan Eve hundred dollars(1510). IMPROVEMENT
=Q C] I.as owner of the property,or my employees with wages as their sole contlamvation, SWIMMING POOL 'LF,CTRIC
F. will Jo the work,and the%micame it not intended or ollcmd for sale(See.91H4.Buxines, ❑O"f HER
aimand P f :Code.The Commrlw%"I 1 mw r1 l n'Ply l el of Oil ILF - CHES-FIXTURES
progeny h M1ld: improvesth d h does h kh lI th,ugh
his owemployee,,D J d that sixth p n' t t I J d J I,r NEW )E TIAL ELE,CTR SQ PE SQ.IT FLOOR ARBA $/SQ PB
Ise.It,n vera the building nprwem. t sold within may r pl tion the
m-bullder w111 have the huMet of proving than he did not ddd or improve for pur-
paae,t'de). 'C L:
1,as Owner at the property,um exclusively contracting with liceawd c,ntrncen,1,
msuoe the project(Sec.7044,Itusiac,,and Pmfos,iom Ctutc:)*the Contractor',hi.
cense Low dtws nutapply to an Owner al property who huilds nr Lnprove,Iherran,and QTY. PLUMBI IP IT FEE
who cn inner,r,r xuah Prnjcm,wilt a cnanrumor(el Iian,cJ pwsu;nu m the Cnnmmtiv',
Bloom Law, PI?RMI I ISSUANCE
E] I arta cxcntpt under Sec. .It&PC rnr 11111 raa,on
ACTOR-DRAIN&VENT-WATER(EA) VA LUA'I I )N
Owner Uwe
WOR KHN'S COM 1.17NSA PION DI!CLA NAT ION {ACK 17LOW PRUG7CI DEVICE
1 hcrcby alllrm nock,preahy In 1n'riary time,1'dm following dmhmniun,:
❑ I huvcunl will nauimtai I a Cemr,,amof C,n.cnmwlhinwm fin Worker',C'nntpcm DRAINS-IROOR.ROOF, COND. S'B)RIES 'I'YI'li CIINSfRI1C1'Il1N
,mion,acs provided for by Sermon 3'110 tit the Iaaur Codd,Tor the perlineranu:al the
work lit which his permit is issued. FIX'I URI!S-PERT RAP
I have and will mu ten Worker',Co..jEwo colon In,urancu,a,"'Orrell by Section
391X1,1'In,Lahor Cola 6rthc Pill nanca,l'tbnworkh"'I c11thio' I',ixmal, GAS-IEA.SYSTEM-1 INC.40UTLETS OCC.GROUP MIN
MyWorkcr'.axyppe/RSIgII'hAaranee carrierPoli y'No.:�a coni _
Corrin: J 1 P g !a Fad and
.: GAS-EA.SYS'IEM-OVER 4(EA)
CH R I'IFICATH OF HX IN PITON FROM WORKERS' GRHASEIINDUSTRL WAST INTERCEPTOR
COMPI7NSAr1ON INSURANCE BUILDING DIVISION FEES
(Thi„comnmeed nm becnmpWmdlfline,mn,i,IbroncbundnJdollars($10) GH BASH TRAP
or Ic,cl PLANCHIECK hili
I rends that in the perfnrmnnare Of the work lin which this —it i,i...ed,Ix hall SEWER-SANITA 15I�$TORMPA:
not employ any pram in any monnuf,.a,to Mrnme,chPO,o pw Wn ken'Compen- ENERGY PHEi
Z %ari3O Lues,of California.])me WATER THEATERNLNT/FL'EC'I'R
Z2 Applicant • 1 GRADING Igili
N
NOTICE'fO APPLICANT.if,alter making 1111,Certifcae of lixenptinn,you should WA'11iR SYSTEN EATING SOILS F1217.^ 9 /
a; Eccome cahjcct m the Work Ys Compenmtion provisions of the latbm Code.you moa forthwith
a Q forthwith comply with such provi,ion,,,,his pni
ea shall hre-
ked.deemed reked. WATER SERVR :!'DI•
= z CONSTRUCTION LENDING AGENCY NEN'RESIDENHA6I9.N11t__ SQ.IT PAID
Darn
I hereby affirm that Were it.edlmrcdon lending agency for the pcffummnce of eniplx
the work for which this peammtit i,issued(Sec.3E92,Civ.C.) TOTAL:
Q Leader',Ne TOTAL:
} Lender',Adidas, BUILDING IT
G 1 certify that 1 have read this application and,muc that IM1e above information r,
Fan correct.l agree to comply with all city and county ordinances and ante laws relating,, QTY. MECHANICAL PERMIT FEE SEISMIC FEE
U Z building conswmion.and hereby amherire mpm%cOtmivc,Of this city In enter upon the
above-mentioned prolany for inspection p.,I,c,. PERMIT ISSUANCE E1 I. RIC FE
(We)agree to save,indemnify and keep harmless the City of Cupertino against
habiliono.judgment,.costs and expenses which may in any way accrue agairo said City ALTER OR ADD 10 MECH. PLUMBING FE
mi
in consequence of the granting(if this pert.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT OO E LjXX)CFM MECHANICAL) M
SOURCE REGULATIONS.
y ' AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
gnmurc nfA plicanVCnntrenor Du EXHAUST HOODfWIDUC) I IUUSINGMI'RGMIONFEE
HAZARDOUS MAE RIAI S DISCLOSURE
Will theappllewn or Imam huildlog tacupant wac or handle ha<ardou,material HI?AI'INGUNITCFO 100.0(IRTU)
it,defined by the Cupeninn Municipal Ctdc.Chapter 9.12 and the Ilcallh and Safety 1112ATING UNIT(OVER 100.010 BTU)
Cala Section 25532(a)'!
El yr, No VBN'I LATION FAN(SINGLE RHS ID) PAID D:nc Receipt
Wall the appl'wanl or Enure building occupant use aluiEann ,sduvice,whech BOILER-COM PU3HP OR (O.0m)BTU)
' canis ho,a,dons air,mune man,us defined by the Iia,Arca Air Quality Managnntent 'tOTAh
DLnrict7 HOITER-COMP(OVER 100.00)HTU)
EJ ye, ElNo
AIR CON DIDON F.12 / ISSUANCE DALE
Ib ' alety 1 n I n under i1c oo )Inc Callit
1 47�
tom H hh&1 I ry1l J Sections 55115 is O' 125514 1 I der
Ilhe ry1:W RCSIDI:NI'IAI.NIECil. SQ.IT y
buil l' bJ t' � nlyl a nl t n Y I 'I Ityt alYO cupid
,fineo,ire tens ,mdOnal,I w r0p toss.......c ona C:n'l,.tc d(Xa pt txy
Ownemuunhnri,aingcnl Dnle TOTAL: ISSUI!DItV: T m
OFFICE