S 3321 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEQTRICAL PilIT NO.
BUILDING DIVISION APPLICATIONAPERMIT PLIBIHING-,MF,CIWNICAL 3321
BUILDING PROJECT IDEN'I'IF'IC'AA[ON
BUUIL1y11)ING ADDIS: SANITARY NO. APPLICATION SUBMITTAL DATE
f( i 61 if O G C INTHACfON"NAAIIi: L O
1 '7 CLjlp, e / NIC f.ONTHOLp
tC111TECi/ENGINE,R'. — ,IC ^J A))IRPSS: �` V ❑
(l 1 W
CONTACT: PI IONII; BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PlEi XIiCu
❑ El
LICIiNSED CONI'NAC'I OR'S DECLARAHON Q'ly. ELECTRIC PF,RMIT FEE
I hereby affnn that I um licensed under provisions of Chapter9(co mencing RESIDENTIAL, DESCRIPTION
OCZ 11,Seetion TOWpd Division l of the lLivinuwnA hnfeoimtx Co
Woo wi PERMIT'ISSUAN(:13
F,�F nfull force vnde l O [' ❑SPUWI. ❑KI'TCHEN REMODEL
<UU Li, "Cl _ Lic'H APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLl1MBING RIE-PII'Ii
F Z tL Datc Commnor
m6C6 RCHI1I:C*r DECLA '1'1 ❑NIULTFUNI'I' ❑STRUCI'UHAI,
~NZ IunJemm�J my Plana shall be axed u.Public aoN. I'ANEIS MODIFICATION
�OZ1O UP T02W AMPS [I INTERIOR ❑CHIMNEY RI?I'AIR
W Licensed Professional 201-100AMPS IMPROVEMENT C]SWIMMING POOLS
y� OWNER-BIRLDERDECLARATION OVER I000AMPS L)RATE REMODELIREPAIR 0DEMOLI'[ION 6
Q I hereby.(Sent that li
I um exempt nen the Gnmons Cod License Law for The
Ikp'>i a F following 1111,1111.(St 10315,Business and Professions Code AnY city or county SIGNS ELECTRICAL ❑OTHER
y whet 4 Pmol t alar ' p I lira -p' Y.ummuv
F'�'ryry0pirrT l.o q .th pplic If hpc tin fl g Jsmament SPECIALCIRCUFF/MISC.
y Ihat1 Wpru
;,to II p nn ffl C t" au'nI I fChnptcr9
m�00 (cannencin8 with Section 0001)of Division 3 of the Business unit Rmfesrionx Ctdehrt TEMP.M1.1 HR OR POI.Ii INS'('. it, 1FR I ;
Q.d e C that he ix cxca u Thcretinn.unit nee basis for the vllelcd weir, inn.Any sell ntion of ❑N. iLDG/ADIITION ODE OLITION
��y Section 7031.5byany applicuntfor.peunit,mbjms theapplicanno a civil Penalty of POWER DEVICES a' Q' [I❑FOOD$IikVlCli
11111 more than live hundred dollars($500). IMPROVEMENT
F=Q 01,as owner of the PropenX or my employee.with sales a.Ihcirale compcnsatinn, SWIMMING PIDI,ELECTRIC
f$�H willdu'hit ork.and the ars.... cis not amended nfoffered fbrsale(See 70W,Rasineus OTHER
W unit Profession,Code:The Contract Liecow lax does not apply In an owner of OU-1,11IS-SW I'(C1113S-Il X'Gj RE
lropeny who builds or improves thereon,and who docs suchwork millerhithmugh
his own employees,pmvidnl that.such oupmvemcnts am not inn all or offered or NEW It ESIUIiNI'IAI,IihliC!'H SQ IT
..I,.IL howror.the building or improvement is sold within one Year of completion.the SV.IT.IiIX)R ARBA SISQ.IT.
owner-lovilder will have The burden ill Trivial that he did nal build or improve for par-
pu.c of sale.). TUCAL:
I,as owner of We property,ant exclusively tanmmilnl with Il:cu,rd,untrucmm,To
consumer the project(Sec.IlHq.Business and Professions Cady:)The Cona tors Li-
cense Law does not apply to un owner ofpropaty who heads or impmvcs there and QTY. PLUMBING PERMIT FEE
who commas for such projeets with a connotations)licensed pursuant to the Contactor'n
License Luw. PERMIT ISSUANCE.
1 ant eacmpt under See .H&P C Iia this reamn
ALTER-DRAIN&VEN'T-WATER(13A)) VALl1AT1ON
Owner Due
�\ WOR KF.R'S C(IMPENSAf1UN DECLARATION BACK FLOW PROTECT.DEVICE r
/ I hereby union under Penalty of penury one of the Bellowing declaration: A
Ihnveamd will mainfmn xCeniticvte of Conwnuo xl(-insure fin Workere Cnmpen- DRAINS-FLOOR.ROOF,AREA.COND. III STORI S LCONSTRUCHONcation,as provided for by Section 3]00 of the LabmCode,for the perfor ance ofthefnwhichthispermitIxi,cod FIXTURES-PER TRAP
w have and will malnmin Workers Compensation Insvrvnre,a required by SectionJ(XmnfThe LaborCode.fill the periamance of the work for which this Permit is issued GAS-EA.SYSIEM.I INC.i OU'1'LGTS OCC GmiIP My Wr , n,i n sur 'T and Policy urs bcr 'Ca rice olicy Nn GAS-f:A.SYSI'13M(IVEHJ(EA)
CEN1'IPICAfE OF !XEMVIfGN(;ROM WOI KERSGHIiA51]INDUSI'Rh WAS'II?IN'll?RCI3PT012COMPINSIM ION INSURANCE --HUH.DING DIVEU
1'Ih6:ataio—cadootbe u..... lifthc permit ixfonmubundred Jnllud($IlN9 GREASE IRAP
nr Ins.) PLANCI IECK FEE
I anify Then in ThcperfurTnanccofthc worA EnwM1ich Thie permiT ixisxnal.l shall SEWIiR-SANITARY-S'Ix)RMEA.21Xm IT,
not enmploy any person in any manner w u
as to become subject the Worker'Com sen- ENERGY PFai
Z sution Lawsof California.Dae WA'I'17R IIHATER W/VENTAILECI'H
z GRADING
2 Applicant
GRADING FEE
NOI'IC17 TO APPLICANT.If,after making This Ceraticutc of Elwell mer,you should NATER SYSTEM/TREATING
.N. SOILS FEE
F beammc aubjed m the Worker's,sam- nee, provision,hal of the meed Coda you nmxt
LinbwnM1 amenity won such pmvi.ione nr this permit shullMJaTned rcvuACJ. WA"(Eft SERVICE
0. PAID
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL('LMB. SQ,FK #CON1I.1C'1)1d(t)cN
ate oveipt x
I hereby affirm that there 1%a construction lauding agency for the parllnmance of
LLP - the work for which this permit i,issued(Site 3091,Civ.C.) 'TOTAL:
C) Lender',Name '1 UI'AI:
rW Lender.Address
C I ccnlfy that I have read This application and state Thut'he above information is :'
Er N correct,l agree to comply with all city and county oNinanm,.ad, to law,ad,d ng m QTY. MECHANICAL PERMIT' FF,F:
U ,Z bouldingcongoarli I.andhereby radial,represcnredves ofthia city To enter upon the
aMnc-motioned pmpeny for inspection Paul PERMIT'ISSUANCE R
(We)egos ra uavc,imdemnuty and keep hamdcss the Cay of Caper ino ugamst
Iiahihnies,judgments.costs and expenc%which may in anyway acetic agdnt said City ALTERORADDTO MECIL EE,
mequcnce of The gramme of mhin permit.
APDL CAN" NDERSTANDS AND WILL COMPLY WITH ALL ON-POINT AIRHANDLINGUNLF(1'0 IROMICFM) h FL13
SOUR I;RF 1 ILA'(IONS.
AIR HANDLING UNI'I(OVER HI,000 CFM) 'ION'I'AX
Son.I of filbeam/ omaen' Ute EXHAUST HOOD(W/WCq IGCSING MITIGATION FEIT.
IIA.ARDOUS MATERIALS DISCLOSURE /
ill the vpplicam or lulure MmilJ ng ia'cupum store or handle ha erdnux nmuleriul IIENHNG UNIT I TO HXI,IXX113'1'U)
a.dcf A by the CuKm...Munic^Dal Core
e.Chapter 9.12.and the Health and Safety HI3A'TING 1191'1'(OVER 100.000ETC)
Code,Section 25532m)?
❑Ye. VENTILATION FAN(SINGLE RESID) PAID Be. pert p
Will the applicant or failure building receptor use equipment at device,which BOILER (311P OR 100,000 11 IT)
mit haiardoux air cuntaninaaa as defined by the Bay Area Air Quality Management )l'
District'( J BOILER-COMP(OVER IW.(XX)ETC)
❑Ye.
I have read to haeardnus materials w,necner,mender Chapter 6.95ofthe Cali AIR CONDIllON1iR ISSUANCE UAPF,
forma Ilealth&Safety Gxk.Sations 25505,25533 and 25531.1 understand that it the NI?W REsiG 3N'DAI,MECIL SO.193
IF,
docsnnT enncntly M1vv
;I,,'her h ismy respmxibil'aym rodytrritio'em
of t1e1I gquirnII,.'a poor am lsmanceol'a Cenificate of ismunce(31;1 Cenificate of OerafancY.
Owner or authonud agentUu¢ Tfyl'A L: ISSUIiD BY'.
OFFICE