S 3128APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD.mrvG - ELRCTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING- Ati!CIIANICAL
(WILDING PROJECTIDENPIF[CATION
PEtIT NO
v 3128
BUILDING ADDRESS:
SANITARY NO.
APPhICA'1'IONSUBMITI'ALDATE
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OWN1 5 AMC: PHONIi:
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CON 'I'RACPOR'S NAME : LIC NO:
NIC
❑
CON'I'ROLM
11TECT TNG HER LIC NO,
ADDRESS:
CONTACT. PHONE:
BUILDING P13RMJ1 INFO
!%�! fUr B `M / ^� / • �
„[(/(-W ALICENNSED
❑ Consultant Fees ]'aid by Applicant (Initial)
HLDG / tiLO PLUMB MO I
OC'Z
WOO
F IyF
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CONTRACTOR'S DECLARATION
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Scmion](100)of Uivision3of the Pusinesa anJ flnmssiam Cxde, and my license is
in full force nnA cffen.
License Class Lie If
Dole Contractor
Q'rY HLELTRICPERMIT FEE
JOB DESCRIPTION
$E�1IAL;
SFI]WI. ❑KITCHEN REMODEL
❑ADDITION EI PLUMBING RE-PIPIT
❑MUl:rl-UNI'r ❑ST'RUCTURAL
MODIFICATION
E3 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ PATH REMODELREPAIR ❑DEMOLITION
❑ OI'HEN
PERMIT ISSUANCE
APPLIANCES-RESIDENTIAL
E.7 h
4
OZ�.Q
OZ—
ARCHITECI" 9 DECLARATION
Iunderswnd my plans shall he mcA as public records
PANELS
UP T02fM)AMPS
1'ly
CY -�I
tC <
0. O iL U
31L ^
��
Licensed Professional
OWNER-BUIhDIiR OCCGRATION
1 hereby affirm that I am exempt from the Comracmr'x License law for the
fallowing reason, (Section 7031.5, Business and Professions Cole: Any city or county
which mot im.r u Permit m construct, aller, improve, damollsh, nr,,,air any dowlam
prio,I.as ,ton.,anknosoim, the oplilenm for such pernti to Ole a signed statement
201-1000AMPS
OVER Had) AMPS
SIGNS RECI ICAL
SPECIAL CIRC"Dfd LSC.
_
J2
Q�
the he ie licensed gursvum mtha provlxinnx of the Comrvemr'n Licutse Lnw (Chaplu9
d a c K
4•Section
V'y
�y <IL1,
Wa
N�'
(commencing with Section 7") of Division 3 of the Business and Professions Code)or
ma, he is exempl merermrn and the basis Ter rhe alleged exemption. Any violation of
]031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not nmre than Ove hundred dollars (65100.
as owner of me progeny, or my employees with wages us their sole compensation,
willdothewnrk, mud llu xuuewrcis ern intended or ,Rued far sole (Sw.]044, Business
and Pmfw.rionx Code: The Connector's Emma, Low does not appy m an owner Of
'TEMP. MCTIIR OR POLE INST.
COMMERCIAL
❑ NEW BLDG/AUDITION ❑ DEMOLITION
11TE-NANT ❑FOOD SERVICE
IMPROVEMENT
❑OTllf?R
POWER DEVICES
SWIMMING I'OOLIi'CCRIC
OU'T'LET S-SWITCHES-PIX'I'U
who huilds or improver Ihemon, and who docs such work himself or through
property
his own employees, provided that such improvements are not intended or offered far
sale. IL however, the building or improvement is sold within one year ofeumpluion,the
NEW RI'SIDCN'TIAL ELECTR S T.
SQ. F.. FLOOR ARG
$/SQ. Em
er-builder will have the burden of proving met he did ern build or improve for pur-
It
pose of sale.).
E]1, as owner of the progeny, am exclusively contracting with licensed am memna m
T01'AL.41
construct the project (Seo. 7044. Business and Protrusions Cod Jibe Contractors Li-
aeLaw does not apply toanowner ofTit openly who milds or hnprovus themxod, and
QTY. PLUMBING PERMIT '.F.
who cammms for oma projects with n commucmr(M licensed pursetnt to the Contractor's
PERM] F ISSUANCE
License Laus,
C]Iamexcmplmtder Sm. ,B&PCforthisremon
'
OwnerOslo{
WORKERS C 'ENSATION UECLARAI'ION
('Id:rebyattimmunderpenalty nF perjury one of the fallowing declarations:
ALTER-DRAIN&VENT-WATER IFA)
VALUATION
2 ,(q Q
o
ll LJ
BACK FLOW PROTECT. DEVICE
-
❑(have andwilhnnintninuCetifcmnol'Consent,sell-bwurolitr Wnrkch Compen-
.saion, as provided for by Section 37000 the Labor Code, for the performance of the
work far which this permit is issued
DRAINS- FLOOR. ROOFAREA, CONI).
STORIES
TYPE CONST KUC'IION
FIXTURES - PER 'DI /
1 have and will maintain Worker's Coutl'cnsation Insurance, as required by Section
37M of the Labor Case, for the peffommaac, of the work for which this permit is issued.
GAS -EA. SYSTIiM-I IN 4 TS
OCCGROUP APN
My Workers Compensation Insurance carrier and Policy number art:
Camey: Policy No.:
GAS - EA. SYS 'I EM-OVER 4 BIA
GREASPJINDIIS'I U. WASTE TNT Ib EI'
C13RfIFICATE OF EXEMPTION FROM WORKIiRS'
COMPENSATION INSURANCE
RUT DING DIVISION FPAS
(Ibis nem ion need not he cnmtplctedilala Permit is for one hundred dollars IS 100)
or less.)
ORGSEI RAP
PLANCf : PCI?
I certify than in the perfrmnance nOhe wmkfor which this permit is issuaLlshall
coe subjano the Workers' Cooper-
n in any mner so am s bem
not employ any peeoan
SEWER-SANITARY- STORM 13A. 200 P.
ENERGY TIRE
WATER BEATER WNENT/ELECTR
GRADING ,
O Zsmion
7
C.
Laws 9u1i ornia. Date
Applicant
NOTICE ]'O APPLICAN 1, II', ager nmkin sunpunn, shoal
become subject to the Worve, Cnmpcne;n vision � her Cnd run x
WATER SYS'IENJHEATING
SOILS FOL?
WATER SERVICE
PAID
1 Date Receipt if
�+
��
C1.
7 Z
U -
Lk. F-'
WLender's
forthwith cmnply wim such provisions or 1l ashe rcvA
CONSTRUCTION GAGE.NCY
Hicrebyaflinn tha mea isaamrnry emllpj vey 1"i2peljQ�� o 1
'he work for which this permit is issued lS ], C1JIp`)li 7. IJsA
Lender's Name
NEW RESIDENT JAL PLEAD. SQ. ET.
'TOTAL:
Addre.xe juTOTAL:
BDILDING Il?C
'ca it tate thin tie uis va inbnmwion ix
1 ready that I have rend this amIi
Y. MECIIANICAI, PERM IT F131?
SEISMIC FEE
rail
Ci,7.x
urrwn. l agree cl amply city and v m rdin
uildingcon>ction,andhemherebyaothorire enerupon tm
bw
PERMIT ISSUANCE
ELECTRIC ME
alxwe-mennionan Property for inspection Purposes.
(We) agree to save, indemnify and man hamlless the City of Cupertino agaimn
ALTER OR ADD *10 MECH.
PLUMNING RTE
Ii.Nhues,judgntnnts,mnsand expanse, which may in any wayammeagainn said City
in megomm of the gmming of his permit.
AIR HANDLING UNI' I(TOIo.dgo CPM(
MLCIIANICAI. WE
APPLICANT UNDIRSI'ANDS AND WILL COMPLY WITH ALL NON-POINT
SOU/RIC[ RGC�/111.A1'IONS.
AIR HANDLING UNIT(OVHR 10,000 CFM)
CONSTRUCT ION FAX
,f ALI � /A \ 1,1^ r
1 ,V VMI A J- '„�.�r - y 1T
Signature n(ApghcuHAZA DO Date
HAZARDOUS DISCLOSURE
BXHAUS'1'I1000IW/WCq
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,(0p If TO)
Will the applicant or future building mcupam Boa nr handle haeallous mmedul
bidding
5e defined by the Cerenin t Municipal Cole, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)'!
({EATING UNI "I (OVER 100.010 ETU)
VEN'I'I LA' I' ION I'A N IS I NGLE RES I H
El Yea No
PATO pore Recelgtp
!\
Will the applicant or future holding occupant use equipment or devices which
.. do., air coal aminmts as defined by the Bay Area Air Quality Management
BOILER- COMP (311P OR 100,00) BTU)
I
isaid?
❑Yee E] No
BOILER- COME(OVER IWOM BTU)
AIR CONDI"I'IONER
I have read the harardous materials rtyui mmems ander Chapter 6.95 of the Cal i
ISSUANCE: DATE
NFW RESIDENHAL MHC({. SQ.Fr'.
Tarin Health & Sulcly Cnde, Seetinm 255115, 255]3 and 25534, l eaderxmnd that if me
huilding does oat endently have a amem,flat 11 is myre,comihility la mudl'ythorecnPam
of the requlmnentx which man be ten prior, issuance of a Cc lilicme of tkcupancy.
I
ISSUED BYo_
TOTAL
Owner rr amhurireJ ager Date
OFFICE