S 3157 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 3157
BUILDING PROJECT]DEN'I IF'ICATION
BUILDING ADDRESS: SANTI'ARY RO. AI'1'LICA'I'ION SUBMITTAL DATE
?S8A- 17 Q
OWNS?N'S NAME: ` PHONEE 6 C(INTRACr MS NAME: LIC NO:
C0 /j(J NIC CONTROL#
gRClll"f1iCf/ENGINEER: LIC NU'.
"'DRESS ❑ r� /�
t�v1p f2/elCq 021376 / SC0 47`�/ S2 V
CONTACT: PHONE: BUILDING PERMIT INFO
tb)iil p,-¢NGj C Z 3 76 ❑ Consultant Fees Pail by Applicant(Initial) BLDG PLUM PLUMB MECH
six 4
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby union that 1 am live...d under pmvisinm of Chapter 9 monomania, JOB DESCRIPTION
paZ lh Section]003)of Divivi- loflhc Bo.mr,s dProfc..imns Cuile,andnry license is / RESIDENTIAL:
.a,_ wu / PEIt MI'I'ISSUANCIi
HLL ,full furtc and c¢cm. 7 � ❑SEDWI, ❑KI TCI IEN REMODI],
QUU License Clam Lick ( APPLIANCES-RBSIUF:NTIAL .pIADDITION [I PLUMBING RE-PIPE
vFi a a Ume!�— $-9 n contractor
H<m ARCHITI=S OECLARAI N I PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O 1 undersand my phor,hall h used as public records MODIFICATION
OZ—C UP'1'(131N)AMPS
[:)
INTERIOR El CHI M NEiY REPAIR
�I Licensed Prom,tronl 2nLItNX)AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER OECLARAI'[ON
CYE', OVER 1000 AMPS ❑BATH REMODELIREPAIR El DEMOLITION
C Q I hereby affirm that 1 am exempt from the Conaanors License Law Tor the
ca3 d U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS IiLECfRICAT, ❑OTHER
W LLy
which requires B Pound iconsumer,alter, p deatioll,th,to opinion,amrurc
cal prr I t aB ih pl li It Ip niu file. 6 lu:nemcn SPFCIALCIRCUIT/MISC.
y thwh : Ip mu a thep '. m [m C I w L I (Chopter9
O (coo g lhSe 7(XHq fD'.i 3 fth B .' . lP C )ser TEMP.METER OR BULK INST COMMERCIAL:
Q.n,e C 'hat he is exempt ¢fmm and the boos r the a ed a ns tion of ❑NEW BLDG/ADDITION ❑DEMOLITION
XM" Smlinn7(DL5 any.pplieamfory perms ubja¢ c� tis I mo civil penahyof POWER DEVICES
W^w [I TENANT ❑FOOD SERVICE
nonnnrc Thu tvc hundmildnllar (Ss(w)' IMI'ROVIiMF.N'I'
~5l) ❑ I,mnw rzol Thu pnupeny.ori Iell ss 1 'ngcs as Theo(.nk enntpensalinn, SWIMMING POOL ELIiG'rRIG
F wdl dol work.and tha.wewni not ince ed or nlicreJ mi-sale(Sec.]lWi,Business []OTHER
LLI- m and('role..' s Cale'I' ContI on. Li use law Jaz not apply m an mane,of OVTLfTS-SNITCIIIS-FI%TURFS
�'$ pmpeny
_be
b -ds upmves In u,and who does such work himself or through
hi,awn employ pmviJtul tbal, b improvmnenu arc not intended or offered for NEW RESIDENTIAL L'LECTR SQ[l'.
vale.ll:host, , chulliinsori mprescomer i,suld within nncyear of anntplctinnthe D ` SQ.1.T FLOOR AREA b/SQ.Pr.
nerhuilder have the burden of proving that he did not huild in improve for pur-
pose it sale.). -
1,as owner f the p o,i am cecluaimely cartrarth, all licensed contractors In T 1 sZ
on.oua the project(Sec.7(W.Business and Professions CrWc)The Comment's Li-
ven,Law does nor apply loan owner of,ro,city who molds
i-cemclawdoesnotapplymanownerofpropenYwhomold.s or improves thereon,and QTY. PLUMBING PERMIT FEEqsF-
wh-..... is for nu¢n prnjau withaannrurnga)lie'll,dlparsualtothe Cenractar'.
Eicensc Law, PERM]IISSUANCE �O
❑1 in exempt under See. .B&11 C formic reason
Owner DateALTER-DRAIN&VI?NT-N'A'ER(1' VALUATION
/ 1
WORKER'S COMPHNSATION DECLARATION BACK FLOW PRUIEC['.DEVICE C/ 7
Ihereby of re under penalty of perjury one of ate following dcdanrlons: ` ( O
' I] I have and will maintain a Certificate of Consen to self-insure for Worker's Cameo. DRAINS-FLOOR.ROOF,AR CONK STORE TYPECONSTRUC['IOh
station,as provided for by Section 3700 of the labor Cale,forme performance of the
work far which this Permit is iaaaed. FI\TURES-PERIRAI'
1 haw and will need air Worked re
Compeation Insurance,as required by Section
3700 of the labor Code,for the perlor i ecof],work lou which this pernit is issued. GAS-IiA SYSTEM-I INC.4 OLI1'LF?r5 OCC GROUT' APN
My Wolker'. Prance carie,and Policy/M�tM:r ,4r�7 p 9
Carrier: �� Policy No% U112Z GAS-PA.SYSTBM�OVER4(P.A) ' �� JM,�2'��•Za
CERTIFICATE OF I?XliMP[ON ONI WORKERS -! GRFASPINDUSTk1.WASTE INTERCEPTOR INSURANCEl
BUILDING I]IVISION FRES
(This section mord not M completed ifthe permit is lbrone hundred dollars OMNI) _
or Tc.s,] GREAS13'fRAP
I'LANCHBCK FE
lemonythat,,athe in orfanyniumer,arniance nhewurkfm whichthis1.pee Wo'is e"'Ci,lshml SEWER-SANITARY-STORM EA.Np IT
not a ploy any pennn in any manner su us to became xunjem to the Wmkcn'Compen- ENERGY P' V g
Z. Applicant
of Califumia.Dam • T
z O Applicant WATER HEATER W/VIiNT/F.hECTR GRADIN iE
q son ICE 10 APPLICANT:If after snaking this Ccr Birnm of Exenpmn,you.fork] WAIIiK SYSTEM([RENTING
afecome x,lbja,f m the Workers Compen..her prism w of the Labor Cuda,you must SOILS 4 7
fnnhwithcnmply wilh,.ch provision-,this permit>hill be deenmd rooked. WATER SERVICE
aQ
'= Z , CONSTRUCTION LENDING ngagen NEW'RRESIDENTIAL I•LMB. SQ,FT AID
Ihereny effinn ohm mem ieacomlmction lending agency
fur the performance of
U O Date ItaciplM
V. the work fm which mi.pumtit i.i.ared(Sac.309].Civ.C.)
Q Leader',Name T O
} Lender's AJJrcn TO f Z t
f' Q. 1 century that 1 have mad this application and seam Nut the above information is BUIL 1.'' iF.
EZ) mrref l agree to scruple with all city and county ordinances and sate laws relating to QTY MECHANICAL PERMIT FEE
U Z building S arrUctian,:md hereby authmira reprowmntiverofthia city tacmmupn.the SEES a1C 1E T
abovementi-tedproperty orrospecti-tt Purpxtta. PERMIT ISSUANCIi
(We)agmen In ser c,indemnity and keep ha,mles,the City of Cupertino against LEE
-' C Irl]i s 2
liabilitim,judgeaenu ensu and expenses which may in any way acrme against sold City AUTERORADDTOMECH.
to co
nseyuence< meg ming oftpermit. BE
ENG FEF.
AI LI NT U DM (ANDS AND\V[LL COMPLY WITH ALL NON-POINT AIR DANDLING I1NI'1'1'fO IQgNI CVM)RCI IEGU ATI S. MECH [CAL FEE go
AIR HANDLING UNI'I'(OVER 10.000 CFM) CONSTR "PION TAX
am o pp nUC'onRDO Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HA]✓gR0005 MATERIALS DISCLOSURE
Will the applicant nr foam M1uilding racupant start nr handle Maurdou,nouerial HEATING UNIT 60100.00)BTU)
as Jdiacd by the Cupertino Municipal Crede,Chapter 9,12,and the Ilealth and Safety
Calc,Serum 25532(u)'! HEN]INC.UNIT(OVER 10,00)BTU)
C3 Yes Emit—
VENTILATION PAN(SINGLE RFSID) PAID Date kcreiptK
Will the applicant or future holding overpant use equipment or devices which
WWSnit naeadho,sircnntnmines asdefined by the Bay Area Air Quality Managnnani BOILER-COMP(3HP OR HN),N)OBI'U)
❑Ycc FK1 BOILER-COMP(OVER W.DN)B'I'U)
r ad me m.aJauz ma¢riaLsm is unJvr Cha mrfi95 of me Cali- AIR CONDITIONER
y25533a p ISSUANCE DATE
fir tie Ilauath Sn(aty talc Sectimas 255(15,255]3 and 25534.1 undemand IM1at if ted NEW RP:SIDRNTIAI.MECH. SQ.FT
bu Ilutgrntly hu cd¢nunt,mmlt i.my rvs)t-mhility to nosily thcoccupant C(����
cur hl It X,Sooner pd-r to i....act of u Crior"am of Occupancy.
urloo ri'm Date T ' L: ISSUF,UBY:
OFFICE