S 3073 (2) - APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECFRICAL PH ITNO
NUU.UING DIVISION APPLICATION/PF,RMITPLUMBING-MECIANBCAI. 3073
BUILDING PROJECT IDENFIFICNUION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1'['All LATE
NH n
OWNH "NAME: I'I I(1NE: CLIS THAI OR
Vie
NAM I:: LIC NO.
NIC CON'I'Itl)Lp
ANCI{IT CI'/ENGI HER: LIC NO: AU R S: - ❑
N 2 'I �3'.
CONTACT: - PHONE: BUILDING PERMIT INFO
/� ❑ Consultant Facs Paid by Applicant(Initial) BLDG ELECT PLUMB MIiCH
LICENSED CON"FRAC'IOR:S DEChARAI'ION QTY. ELECTRIC PERMIT 'FEE
I hcfehy athm.mat Into license under pookinnx..I Chapter 9(en;:llnencing JOB DESCRIPTION
WO, tth Smlinn]WII)nfl)-lsion3ol'Ihc Conuacmr dlKrnfgins Cwevnd mY licm:sa lx RESIDENTIAL:
W O PERMIT ISSUANCE
H O Wlullfnrcc andeffc "7 �7/ >3$FDWL ❑KU'CHIiN REMODEL
U �ryJ�ylc�-e. �Li< X—/� APPLIANCES ❑ADDITION Ll PLUMPING RI;-PIPE
IFirQW 'nse ❑MUI.TI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATION
p,prn PANELS MODIFICATION
C) c
�? Iundemm�J my plmry nhallMused as public re
OZ
UP T021XIAM1'S
El INTERIOR ❑CHIMNEY R1711AIR
F.N.F❑❑'W Jmnsed Pruless inmal 201-1000AMI:S IMPROVEMENT SWIMMING POOLS
�•1.a,�j OWNER-BUILOL'R IIECLANA'I'ION OVER IIxY]AMPS ❑BAl'H k1iMODliVItHPAIk ❑DF:MOL1'fION
C C Q I herebC,Wy aflirm than I inn excmpl from the Cmnracmr's License I.aw fur the
W3�F- lidloxing reasua ISection]11115.Business and Prulessions C.dc:Any city nr county SIGNS ELECIRICAL �OTHER
F W
� which Icy Pet l .t t it P dip' y slmenre
GN applicant such TI8daencnt
y pnon .. Imsd
SPECIAL CIRCUITIMISC, p
that he is licensedp to the prosisions oftheContractors LLa (Chapter 9COMMERCIALIaC0O (commencing with Section?000)ofD Osion3 DI B : svadProf:. :CrdOor TEMP MEI'Ek UR POLE INST.
m p•o C 'hat he is exempt tMrefrmn and the basis far the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
W..m Section]ID 1.5 by any applicant Alt o permit subjects the applicant to o civil Icaully of POWER DEVICES ❑TENANT' ❑FOOD SI?kVICI?
I ,,marc than live hnndrcddollars X500). IMPROVEMRN'I' -
�=6' ] 1,vuuwnnofthcprulwny.onny mnpluyeca..In w."e,it,thcirsoI.l... ens;Bun, SWIMMING POOL ELECT RIC
F� willdothe work.and tire.structure is not intended....dieted rissole See.704L I{uwnecs ❑OTH Ek
3m and Professions Code ILe Contmaors License Law does not apply to an owner of OUTLEI:S-SWITCIIIS-FIKTUkIIS
propcny who builds or improves thereon,and who doessuch work himaelf or through
his nun employees,provided that such improvenelmre onot intended or offered for NEW RESIDENTIAL ELECT? $Q FT.
sale.IL hawcver.the buildin6 orimprovemcnt is Veld within one year of rnmpleiinn.the SQ.FT.R(XIk AREA 5/SVJeT
owner-Builder will have the burden of pmving that he did not build or improve torpor
..... r f 'HOFAL.
[] 1,teof
eIp pnY ant : ycontracting 'll d' I I to
t t the p 1 TS , B 11 :Co..,'e.liveC t 1'- • CJ`/-Cs7A�[/w
,c Law covi nor applytV.Vo o,Ver ofp perry Wild:or mprovc:thJ QTY. PLUMBING PERMIT FEE
who contracts forxuch projects with acvmjowoddlicensed p mode Grntral.r's
Licen.,e law. PERMITISSUANCE
I vin exempt under See. .It&Y C for this Venom
ALTER-DRAIN&VENT-WATER IIIA) VALUATION
Owner Date
W o RK12R S COMPENSA'I]ON DFCLARAI ION BACK FLOW PROTECT Ii
[hereby ottirni under penalty of perjury one ul the following declumdoro
I have mal wlllmuimaimr CcnlBcnm of Co;sed msell'.irvmre for Worker's Conl'e'l DRAINSft,OOR,RO ' . COND. STORIES *I'YI'IC CONST RUCTION
satiun,ns pmvidcd hot by Suction 3700ofthc labor Cud,.for the perfomtmme of the
work for which this pmol soo,d. PI%'DJNI?S Lm TNAP ra
1 have and will maintain W'orker's Compensation Insurance,re required by Saban
3700 of the Labor Code.fill'be purbmnanclef the work for which this peril is issued. GAS-EA.S - 1 *)L .E'S (ICC.GROUP AI'N
My Workers Compen.mion Insurance carrier and Policy number are:
Carrier: PnIicY No.: GAS-IiA.S :NOVF.Ri(IiAI
CH R I'IFICATE OF EXEMPTION FROM WORKERS' GREASI%INURL WASTE INTIiRCP'
COMERNSATION INSURANCE nJ BUILDING DIVISION F_EES
(fhiswaion need urn becampleted ilme mi is foram hundred dollars ISI 00) G]
nr less.) GREASE'1'RAI' ] PhANCHECK PEE
Icenity lbaimmc perlbnnanmuf the work furwhwhl hi,enfin is issued,I slaF SEWEN-SANfrARY-S'1'OItM EA.21X11*1'.
last employ ally person in any manmr sat as m boeuma sunieal tome W..l e,Cnml't- ENERGY FEE
zZ saf'm Wws of Cabb'Voin.Dao WATER HEM Ea wevENUELECIR GRADING FEE
Applicant I _
= NOTICE TO APPLICANN'.If,after luting this CvmB.a of Exempnnn,you should WATER SYSTEM/TREATING SOILS FEE
P
, become subject to the Workers Cnmpenxaion previsions of the Irbor Gde,yin must
f3I forthwith comply with such provisions m this peril mall He deemed revoked. WATER SERVICE
(S. 0 PAID
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.EL Dale cccipl M
UQ I hereby nflinn t hat there iaucnm Vollinn lending agemry forlhe perGamanceul
w F the surd,Por which this pernitls inwVd Scc.30rD.Civ.C.) 'TOI'AI:
0 U I<ndcr's Name
Lenders Address IDEAL
tO. I certify that 1 have read this application and ,are that the above information is BUILDING HIiP
(y V) corm.l agree to cumply with all city and county ordinances and sum laws relming m QTY. MECHANICAL PERMIT I'EF: SEISMIC PER -
U z building constmmiom.anti hereby mdorne mpmwnutivek of this city to enter upas the
al ave-ntcmioncd propenv for inxpev ion purposes. PERMIT'ISSUANCE ELECTRIC HER
(We)agree to save,Indemnity and keep harndcss the sty of C.,V no against
Iiahihtic,Wjudgmenu',eu %an}dd- cnsns which may In any wiry rescue against said City ALFER OR ADD*10 MECH. PLUMBING FEE
imm�scg NT)INDF gntyyQf 11tf 'u peril.
APPLICANT INOP �' D'AND W11.1.COMPLY WITH ALL NONPUINT AIR HANDhING UNIT(TO III,fall CI'M) MI3CHANICAI,1 E
SOf]RC R Aj/ 10 :,
X � AIR HANDLING UNIT(OVER III,IXNICI'M) CONSTRUCDON TA%
/ Signalm f pphcandColnmetor Uare EXHAUST HOOD IWNUCD HOUSING MITIGATION HE
IIA%ARDOUS MATERIALS DISCLOSURE
Will the r,fcamnr future building oecupam dnre ar handle baeurdous material HEAT]NO UNI'I(TO 100.000 If
as Joined I,the Culwrlinu Municipal Code Chaplet 9.12,and the Health and S:dmy
Core,Section 255)21n11 HEATING UNIT'(OVER lgLk X)IO U)
�Ycs 0 N VI?N'I H,AI'ION PAN(SINGLERESIM PAID
' X '
Uum Rcreipt
Will the applicantorfaunbuilding evc,mil useequipment ordeviouswhich µ01.E?-COMP(3HPOR I(p,(X ❑TU)
emit M1ararJus air as defined by the Bay Area Air Quality Management
X
-
- TAC:
District? BOILER-COMP(OVER I xtocto Bru)
[I yes ❑No
I have read the hweNuns materiae rets imVients ander Chapter 6 95 of the Cali- / AIR CONDI'l IUNER ISS ANCE DATE
f mia M.Health&S:dey Cada Seetinne 25505,255?l and 25513.1 undetswnA that it the. N17W RESIDI NT'IAL MECII. Sp.19',I
9', ��,
I... gdo, mlcurrumlyha
avealant,thalhlsmn.
, .pu lobilitym .auu
notify tbepmn --k yC[ OA
of the r.yuircnrenls which tent by Inc( n
prioo issnancc of u Ccnifmnlc of Oncy.
vpun '
Owner or autlauimd agent Dale LILA" 710 ISSUED BY.
OFFICE