S 3273 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEcrRICAL PEtIl"Na. 3273 273
BUILDING DIVISION APPLICATION(PERMIT 1'LUMEING-MECHANICAL
VC
ItUIEHISG PROJI'M IDEN9'IF'ICNIHIN
SANITARY NO. APPLICATION SUBMIT-Al.DATE
BUILDING AUUNISS.
DIiR'
OWNNAME.' PIIl1NE: CON'I'RAM ORS NAM(. LIC NO
NIC G'DN'I'RGLN
ARC111'ITCI'/YNGINEHIl: LIC No AD) IiSS' Q El'T
0? IS-hmog 14y'se
37
CONTACT PHONE, (� IUILDING PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG I-LT:M PLUMB MI:CII
8b 4EW ❑ zl� ❑ ❑
LICUNSED CONTRACTOR'S DECLARATION (pry ELECTRIC PERMIT' FH
1 hereby affirm Thal Iran IianxJ under provision of Chapter 9(commencing JOB DESCRIPTION
OCZ Ih Salina 9ggp ofDivisinn3aftho Nuriness anA l'mfevsiuns Cole,vnJ mylicarocix r RESIDENTIAL:
{{LL �-a� 1'IiRMI I'ISSUANCE F+�� in wfull brree anA dyer JV ❑SIl)WI, ❑KI'1'CIIF.N ItEMODIiI.
aUV Liccnw Cls - Lic.a APPLIANCES-R[SIOIiN'DnL []ADDITION ❑PI"UMRING RE-PII'li
�ZW Dmc Conlmcmr ❑MULTI-GNIT ❑$TRUCURAL
6L ARCIII'l l?CTS ),CLARAI'ION PAN
O Z=r Z I unJemaml my lihm"hall M mood as public recsnds UP 'al --P. MODIPICAI'ION
10
❑INTERIOR ❑CHIMNEY REPAIR
F�FI Laoncd Plile"nnal 21 'A AMI'. _7 IMPROVEMENI' []SWIMMING POOLS
OWNER-HUILDHR DECLARATION ❑HAITI REMODEUREPAIR ❑DEiMOLI'IION
(y IY fesu]]Q 1 hereby affirm th I 1 am exempt from the Contractor's Licence Law for the - ❑WH17R
x C UF- following rc'nson.l Secllna](I3I 9,Bmiimss and Protusion,Gd¢Any city oT OamIY s GNS HLECT
3 a NQ which requires a permit to construct,ager.improve,demolish,or repair any slmcture
F'4O{n,.1 priors t « Hr q ire%thapplicantr cape nim nsignedstatement SP of Is
W 'hall JI xt, tl 11 l - nt, rd C n'sI I' (Chapter (AID
W C, (cont b all Section](NNB fDiio l fid Business JI f ' uCode)or II:MI'Mli'll?It UR I NST.
a a CI W tam he is exempt thcrefntm and the basis for the alleged escmption.Any violation of NEW DGIADDI'IION OPE MOLITION
W^vi Scot 0Ili915 byairyaaphwmfina perrea subjects the applicant a civil penalty or POWER DEVICES TEN I' ❑FOOD SERVICE
armor,than live hundred doll...(551X)). IMI' YEMENI,
=Q ❑ T as owner of the property.or my employee%with%'age%as their cle eompon.mion, SWIMMING IKK)1"EI.IdCI'RIC 110 .R
F will Jo'hework,auldne,tiou,n snot imendidoroffined rorsale Ewc.90/4,Business
c
and P...le on,Code:Dee Contractor's License law fres not apply do an owner at OU'I'LIi LS—SWITCHHS—FIXTURES
13- property won builds nr improves thereon,and who does such work himself or through
his awn volooyecs,Provided man such nomove onto arc n I intended or offered fill NEW RESIDENTIAL ELECIR SQ FT.
rale,it.however.the building or m ¢
provennt is-lJ within nnc Ycur of'unnplctinv,Os SQ,17,FLOUR AREA bISQ.fT.
owner builder will M1nc the burden of proving that he did not Fui1J or improve for pup
pn cof'ale.) T AI.:
I,as owner of the property,Int exdnsivuly eoahacfn,Ovid,Ilumscd conlo."a,w
rnshmct Inc project(Sec.7044.Business and Prnlcs6ons Cod l)tc Contrachrt s Li-
'ecl,:wdoexmol apply in anowncria pmpeny who build,re impmvcs thereon.and QTY. PI, IH ;PE FEE
who tnaacts for such Pmjml.vwi'h ucnnuucanq,l liremcd par unnnu lM1C C)mvncna'r
Dcenxe Law. PERMIT ISSUANCE
E] I no,exempt tinder Sec. .N S,P C fordo,reason
AI:I'I?R-DRAIN kVI!N'T-W ) VALUATION
• Owner Uac
WORKERS COMPENSATION DECLARATION BACK Il"OW PROTECT.DEVICE
handy nllmaintain
ai mato C,dildy ill of Con nane of the following or dcdanniuns
�Ihave and will forb Section 3cstenf the Tal,Code.for the
Worker'sce ofthe URNNS-FLUOR.RUUIr.nRIiA.COND. SIORIIjS 'IYI'E CONS"TR11C1'IIIN
svtioq,r pmv,Jla for ny Section 3]1X1 or the Urber Qde,for the perromtanee of the
work❑a which Thi,permit is isxnraT FIXTURES-PGR'fRn1'
n I Lave and will maintain Worker's Conitionsalion 1'uumnce.ax required by Section
37X0 of the Labor Code,for
e performance of the work for which this permit is issued GAS-IiA.SYS'l1iM-I INCA UIITLETS UCC.GROUT' nl'N
My Werke i ',no cnsatup-In.ruranlmiclc cu allll Policy nmypg
Carrier: 6FIXU KLAQ policy No.: Y) CAS-I!A.SYS'IFM"UVCR4tHA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEVINDUSTRL WASTE INI ERCEIHUR
TOM I'ENSA'1'[ON INSURANCE BUILDING DIVISION(TICS
(lids xechonneed nod bemtnplmed iDhepmmit is fair nnc hundroddollas($VXq GREASETRAI' VLANCI IECK ITE
m less.)
Ioyan,taaiinthe perfunnena of file work for w..loc,loan, n.issued, shall SEWER-SANI'T'ARY-STORM EA.21N)Fr ENERGY Plili
not ctnpluy dory Pos''tt in any manner en as m haninc xuhicf'm the Workn'n'Cnngton"
Z vtion Laws of Cmifnmia.Dao WAI ER HF,AI'IiR W/Vii GRADING ITE
z o Applicant �p
NfYfICE'IUAI'I'LIGN'1':II',ober looking this C'unilic:nc o[Iixcnmlion,Yun shonlA WATIiRS S'r'N/I'RRA
F h become subject ut the Woders Compcnsalmn pmvidom of The Luber Code.you mu.vt SOILS FGIi
�+ had with comply with tech provi,ionx or this permit shall be&"-led revoked. WATER SE '
W
p' CONS]RUM RUION LENDING AGENCY NEW RISA A1,P ilK PAID
] Z Date p
U 01 hermr arrnm mal mere�,a cnnmmennn Iendns agency rte me pednrmance nr
fit. 'he work for which nils,conn is,,said(See 3097,Ov.C) T(TI'AI,:
OU Lcndta,Name TO"
Lender's AJdri HUII.DING ITE
r U
I eco ry oml I have local this applicnann unci state atm tau da ve information n
rF+ h corm".)agmc to comply wish all on,.'no county nobrome,vad."no laws"dating m QTY. ME 1F :RMIT PEE SEISMICITE
U Z building compaction,and hereby authorise reprewnmtives of this city to enter upon the
ubnvomm�dinnell pnq eny for inspection famposcs. PERMIT ISSUANCE Ii1.liCfHIC IIiE
(We)agree to save,indemnify and keep harmless the City of Cuperti no against
liabilities.judgments.costs and expenses which may in any way some agaimtmid City ALTER OR ADD TO MECH. PLUMBING FEE
in nscquuna of the granting aim"lernah
APPLICANT UNBIHITANUS AN[)WILL COMPLY WITH ALL NUN-POINT AIR HANDLING UNI'f(R)MAIN)CFM) MECHANICAL poll
Soultc: F u1,AT s.
IJI AIR I IANDIJNGUNIT(OVE IO.000CFMI CONSI'RUMrION TAX
SignmureofApplinn Co tracRR Dam EXHAUST HOOD(WIDUM) HOUSING MITIGATION FEE.
1 A"ARDOUS 1A RIALS DISCLOSURE
Will lbcapplR nr litlnrebuilding naupunt.lore or handle I'll,; onomm"inl HIiA'I'ING UNI'((TO IIXI,gNI BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 100,0g)BTU)
Coit Scdinn 25532(u)l ,`�`�
0Ycx 11 IO VIiN'I'11.A1'IUN PAN ISINGI.Ii RIi$IUI PAID
`` Dae Raeipt a
Will the applicant or rumm building occupant use equipment or devices which BOILER-COMP(3111'OR 100,0N)BTU)
hvanJnur atr aomm�unu a,as dufimrw Q
Yl by the tiny AAir(Quality Manna runt ITAL
an, It
Dimrie l HOILER-COMP(OVER I(NkgNl B M)
❑Ycr xNn
Alit CIINDI'1'IUNEiR ISSUANCE DAIS
I have real the M1 ed,Sections
mattions d5% 5..533..under Chulani rda of the Cala tive
hand a Health o Safety Cole,$c nun,i list i Ma, anis 2554.1 unro rosily
d dot if Ibc NEW RESIDENTIAI.MECH. SQ.lel'. `
buildingJce:oat c'ur mtly h:rvrrenant'nvl'e ix my mxpnnsihillty do notify the aclmam
orinc rets higbn's ems.prior u,i oijamoof u Ccniecmo of Oav,ar",
Owncno andhon cd gent Dam TOTn L: ISSUED BY'. / Q
OFFICE