S 3242 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO B UM11 IN
-ELE-MECHANICRICA AL
BUILDING
rlayyrr NG. 3242
BUILDING DIVISION APPLICATIONIPERMIT rING PROJECT4ICEN TIFI1.
BUILDING I'ROJI!(YI'IDY:N'fi PICA'I'ION
NUILDIN'G ADDRESS: SANITARY NO. AVPLICAI[ON SUBMITTAL DATE
(
D( M c mer. ctc�,
OW . :SNAME: /� III CO "RACE RSN'jph/1�J III LIC--NIO-
Dl.� �^ rC� ��-(`',y�p/Z I,O�� N/C CON'I'NUhk
ARCHITIiCDENGINIiP AI 18t1iS ' •/ U W`a vri` ❑
CONTACT': PHONIC: IV•/, V BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLUMB MECH
., 2 El ❑ ❑
LICENSED CON I'HAM ORI AiCLARATION QTY FI.FCTRIC PERMIT FEE
I hereby alrr+n mm 1 am wed,al mdse pmvuiens.t Ch:4ncr Y(issu actin is JOB DESCRIPTION
,cc, th Seaton 9lXN)ol oro,ior3nflhe Bnsinosmll Vallfcvniom Cotleandmy BscrscU RESIDENTIAL'
��O v `O IJ0.M � "�0�) I I'ERMI'P ISSUANCE Z2•�
F hdl litircc and eficc ❑SFDWL [I KITCHEN REMODIiI.
QUU
face ntt Cl ss ,G AI'I'LInNC15-RFSIDICNTIAh ❑ADDITION ❑PL.UMBING RE-PIPI:
Nay Dat° J C°mmc ❑MULTI-UNIT [I STRUCTURAL
ARCED fl'1',CI'S DECLARATION PANE!ti
~t]Z I n.dersumd my plans shall ht mall as public record. 1 !n MOOIIICNI'ION
z tor ; 1 UP TO 210 AMPS �•�" [I INTERIOR El CHIMNEY REPAIR
OZ—n LMPROVISMENT El SWIMMING POOLS
1 ZQ — LicrnsN Pmfessi.wl 2111-IgIt1AMl!S
CY{y OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH RENIODEIJREPALR ElDEMOLITION
C C y I hereby aflinn that 1 our except front the Contractor's l icer®"w Ibr'he
p� y eiy or canny SIGNS IiLf:CTRICAL ❑OTHER
ac yV which lrotinsun.l Sratino T031.AItoancssandoc,dvlons Cr+olu:nn t '
Iv 3 W N whish routines s a t.rtnh re crms the,alma nt for
r d.m..it,n,repa.dry xttucwre i 1
F-a 0y j priormitx issmncc.alw reforms the applicant for.uch pcnniun Elcasignrd smmmmnt SI'IiC1AL CERCUITNIISC.
that be is licensed pursuant to the provisions of the Contractor'.License Law(Chaper9 COMMERCIAL:
C1 OICMOhITION
�QO (cll"Hou.cingwilh Section 701X11(Division 3.fthc Businessland Professions Cori "IHMP.MEI'EROR P0LEINS'L
Q.d p C thus he is uxcmpt I...dn.a and the basis lin the allegrJ tactnlvi..0.Any violation.f El NEW BLDG/ADDITION
Section 9031.5 by any applicant fontlnr..r,s.bjcO,,,he applant m a civil voialEyof POWER DEVICES ❑IENAN'1' ❑FOOD SERVICE
�r not Bort than five hundred dollen($500).
F-=Qbus owner of the n IMPROVEMENT
C ❑ preps y.or my employees with wages as their late compileution, SWIMMING POOL ELECTRIC ❑OTHER
F,
will do'hwork,anti th 't tintended tf df (S 9WJ Business
W Ile .and' I :C 1, II Contractor.,L I' t'i11y1 tw of OUTLETS SWffCUES fl%TURES
propcnv who builds p thercon.and who does: h work lihoself ortlhrou,lb
his own employees,provided that such improve Herts am not intended or (fend for NEW RESIDENTIAL Li 1'CfR SV i'f.
salt.IL arcs r,the building.,int,wortenGamld within one year o(comm
pletiothe slot'.MOOR AREA S/SQ.14.
owner builder will have the burden of proving thrd he did not build or improve for pur-
e.suof sale.). DOTAL
❑ 1,us owner ut'hu property,uta cxdusivcly mninuting Is
Inbood cnnhaztnrs to ... ,.,... _.�...._...
consumer the TII aIlusie"'ofJ Prolcoiing Galea The Cnnvnnor's Li- /. I
c Law does not applym an owne—I'propeny who builds or improves them..,..it QTY PI,UMBING PERMIT FEE - i,ti1�
vin.cammms for such pm7ens with u contmcwr(s)licensed pms.ant to the eomraeture I:
License Law. PEE
RMI'l'ISSUANCt
plum_'ount.dc"ec, ,BvQVCfo,thixmaant t•, I I
AI:fER-DRAIN&V1iN'1'_N'ATEk EEM S'I GIIIIiS A lA TYITiC NS
Owner Dara III
W'ORKER'S COMPENSATION DECLARATION BACK PLOW 1'ROTECI'.DEVICE -
hereby ofEnn under penulry of perjury one of the foliating for declmrfs Co
[JlInfluent
ro willforbineCrnit icaool'Consent Labor Code,for the Wrmarmacenmtheson- URNNS-:LOUR,ROOT,n1213A,COND. Y 'kUCI'lI1N
Blinn,to pmvitlal titin by Seaton 391X1 til list When Cuda for the Ixrfinmunce of list
vied fto which thin pamta is issued FIXTURES-PER TRAY
to anJ will mimam WnrAors Compensation insurance,ax retained by Section
""of the"hot Ort,for the perl'.rmance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.40UI'LETS occ7iouF—J ANN
My W..Acr'x C��tnpunv.y+n lnsurunu anierundl'oliey rd'ry^-
CanierI nt ax�A Policy No.l a VY �I GAS-I?h SYS'I'CM-OVlilt4(I?A)
CIiRI'IIICAIF OF EXE. PfION FROM WORKERSGREASE IINDUSTRL WASTE INTERCEPT OR
COMPENSATION INSURANCE BUILDING DIVISION IBIS
Gibissetion nearadbecomplct.it ifthe permit isforonehundmdd.11d SII10) GREASE[RAI'
i or len.' I'hANCIIECK FEE
Icenify'hal in We arfnnmilccot the work lo-which Nis Penni'is issued,Isball SEWER-SANITARY-STORM EA.200 Erl'o
ncntpl.y any Penne in any manner so as to hecmne subject ,I the Winker:Cnntpcn_ ENERGY Plili
m
Z cation laws of California.Dae WATER HEATER W'NENT/ICLECIR
Z2 A,Iwam GRADING —
NOI'ICH10 nNTACANT:IL aacnnatingthis L'edificae of Exemption,yon should WATER SYS'I'I:M/TRI:A'1'ING
.-t SOILS FEE
FN beranadhjeet...hot W.rker'S Cnmpensmion,orkionsaf'hei.al Codeyou mos'
forthwith comply with such provisions nrthis Permit sh.11 be deemed or—ord. WATER SERVICE
d
7 z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH, SQ.Ff. :'AID
I hereby alirnuhat there sa cmutmn:on landing agency tor the performance of Dam Receipt
the wud for which the,weer ie Isencd(ties.311'x/,(:iv.C.) TOI'AI
O Leader's Name TOTAL:
r LU[7 Lull Address BUILDINGF
F 1 1 courts that 1 have brad this application and mate tha the above infomtiaior is
r y
correct.I.,memcmnply with.11�hyand cowuyonh...Irl and store laws retain,m QTY. MECHANICAL PERMIT FEE SEISMIC PH.
U Z hnlldingon.hollion,aml frothy:mlhonartpmsununot,"'this chyu nue.0 ,'n the
abnvomavioned political for inspection purposes. PI?RMII ISSUANCE ELECTRIC IITE
(We)agree m save indenmify and keep hamdess the City.f Cupertino against
liabilities,judgments,costs and expenses which may in any way accme against said City AI TER OR ADD TO MICGH. PLUMBING PEI
in corse4ue.ec of the 6raming of this ptnnit.
AI'I'1,1'ANT[)NUI?Iis'1'A 1, SND WILL COMPhY WI'I'll ALL NON Pf11NT AIR HANDLING UNI'I'(IO 10,000CFM) MECIIANICAI
SOI EGtt NITONS.
AIR HANDLING UNIT(DVEiR 10.0100:1) CONSTRUCTION TA'
Slgn:n lien Gm'maor [)all 17XFIAUST GOOD(W EDUCT') IIGGSWG Nil ITGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
Will a,da acid Section C.(T)rtio More, 'I Cadeatual *Chuper v.12.and the braids aad,Side tl HEATING UNIT(TO IINI,IHN1 BTU)
PP `CU`J/
ty
HGi'ING UNIT(OVER IIXLIXX)BLU)
32
Yes No VENTILATION FAN RWOLE RESID) PAID D.ne Receipt ft
n Will them+pty licz Inn boobuilding o¢ m us
uPae eltipm ntcor d -
eviecs which BOILER-COMP OHI'OR Ip,jXX)
etit hIfll])
mandous air rotational as defined by the Bay Area Air Quality Management T(➢1'Ah:
Disvia^ BOILER-COMP(OVER 100.I00 Of 11U)
❑Yes X<n
I have rend the huammon
rJoos utercomrp: tes necptm'k,Chatrim the Cali- AIR CON UI'HUNF;N ISSUA -DRfh
h+mia Ilctlth&Safety Code.Seai.rs 25505,25533.ad 25534.1 undcnmad that if the NEW RESIUICN'fEAL MECH. SQ.FT Z (Sy p
hu' d.esoteurtendv snot,thatninnt,m,,nsibii'nyl..otifytMlxe ant
. tM1 try men¢which Incl p b to is a c of 'enificalc of
Own OorveA agent
u One 'TOTAL' ISSUE[)BY: '
OFFICE