S 3282 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Plittr NO
xUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL, 3282
BUILDING PROJECTIDENIIF'ICA'1'ION
•11I1ILDINGADDRESN SANITARY NO. APPLICAI[ON SUBMI'TFAL DATE
OW ,EhRNaNAME PHONE: �f CUNT C'OR'SNAME; LIC NO:
"LGI� L(/�YISEI�- ZS�3—Z.Z NIC CONI'Rol,p
:HITBC IENGINF:ER: LIC NO: A)U -SS: ❑
CONTACT`. i'DONE; BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BrLyD�G/ HLHC'1' PLUMB MFCH
J ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing
awW ap CZ) with Seolum7XXFofDivisionJofma Busincesand prnfasshms Cnlc.andmPERMIT ISISSUANCEy license in RESIDENTIAL
F�wF in toll force and cited. ❑SI'DWL El KITCHEN RIEMODEI.
aVU Lmcroc Class Lia.of APPLIANCES-RIISIDP,N'I'IAl, ADDITION ❑PLUMBING RE-PIPE,
.F ai. Dam cmttradnr ❑ ❑S
MUU1[-UNIT FRUCT'URA],
Fly ARCHI)'F.f,-CS DECLARATION PANELS
m Z 1 understand my plans shall be used as public farmersMODIFICATIONZOZtnQ UP TO 200 AMPS ❑I:NI'ERIOR ❑CHIMNEY REPAIR
F!?2 t a1 Liceri PreseWonal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
g,t4 OWNER-BUILDER DECLARATIONOVER IgX1AMP$ ❑BATH REMODEIJREPA1R C)DEMOLITION
C C Q I hereby dlina then I am exempt Bore the Conlraln.'s License Law for me
3{� follow in (Seat 7031.5.Rosins v and Pmfewio is Code,An I 1 ❑(YTHY.R
y H g rays it Y city s coon Y SIGNS HhIECTItICN.
W LL¢ prior
rt ts t t t p d Ld p' Y h route
F'=OJ prima I 'I. rty papplicantf such Int file L (Chapter
SPECIAL CIRCUITIMISC. V-/E,/J to/+ s : p -
E y_ mat n licensed pursuant 1 m v aiatnn r m Contractors 1 (cn pTer 9
C�Qa (commencing with Section 7000)of Division 3 of the Rosiness and Professions QNe)or TEMP.ME IL ER OR POLE INST OMMF,RCIAL:
'i'a Q 0 N
that he is exempt therefrom and the basis for e alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
X-1N Status by anyapplicanlfor a prean whiects the applicant n a civil penally or POWER DIiVICES ❑11iNANT El FOOD SERVICE
= ���f�'''�.' n 1 I U td p :155(X11 IMPROVEMHN)'
AZAw_ tali I' p IY Y it y Ili '6:' Then Je unnpcaei :, SWIMMING IN)OI,ELECT RIC
A 1.. IIJ Ili k Id o 1 I n 1d f( df s:Ie Ner.9196,Bas DO'Tf ITER
W m and 1 rntession:Core:The Contractors License Law does not apply to an owner o1' OUTLIII:S-SW['I CHF,S FI' iS
property who builds..,improves Thereon,and who dos such work hierwlfu,though
his own employers,provided that such improvements anot intended or offered for NEW RESIDENTIAL ELECT SQ FT.
rt
sale.If,however,the building or improvement is cold within one yearnfcomplction,mc SQ.PL FLOOR AREA SISV I-1'.
owner-builder will have the human of proving that he did not build or improve for par
rywa of Dale.). L
F1 1,as owneroflhe property, re exclusively coma cle"with licensnl conleactnn m
anomer Inc project(Site.90,14,9ueimcss and 1`mfessimir,C..sle:)'I'he Clarawtor'n I,i-
cruse Law deasnnlapplyloanowner ol'property who builds or improves thrown,and QTY. PLUMBING I` R F FEE
who contracts for such projects with aeonnactnrtO licensed pur o ed to the contractor's
License Law. PERMIT ISSUANCE
El Ian exempt tder Sec. .B&P C for this mann
AT*17R-1)RNAM IN&VENT-WA'1'1:R EA MAI UAI'ION
Data
wn WOp CIEIt'SCOMPE SA'I'IONDE -ARALON BACK IROW i'k(YI'ECT.IJIiVIC,Ii
vl Ihereby atR1 nder penalty of perjury one of the follmang declamtinme
v I have and will maintain a Certificate of Consent an self-insure liar Worker's Comped- DRAINS-FLOOR,ROOF.AREA.COND. STORIES TYPE CONSI RUCTION
s tion,as provided for by Section 3100 of the Labor Cale,for the performance of The
work for which This permit is issued. FIXTL R IS-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance,as required by Section
3700of lha T,ubor Coda,for the pc if rancuof thPer
e work for which This on is issued. GAS-IEA.SYS'DeM-I INCA OUCLHIS OCC.GROUP AI'N
My Worker's Cnm.tenla inn[a...aree,anill and Policy amover ane:
Currier Policy No.: CAS-IEA,SYS'I'IiM{)VBR 411EA1
CURT IIICATE OPEXEMFI'DON FROM WORKERS' GREASE%INDUS I'RL WASTE[N I'IERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be cnmpleRdtone .it is fortune humlml dollars(SWO) GREASETRAP
I'hANCHECK Pti'
or less)
I certify main the performance ofthc work for which this perusal is issucal,lshift SEWER-SANITARY-STORM EA.200 FT
not employ any person in any rammer sus as et hecomesuM1jen m the Wotkcri Gmtpen, ENERGY PEG
aZ sai..n Laws in Cultictia.Dom WATER[trip WNEN'Il. "RI GRADING FER
zO Appl'uanl I
y NOTICE TO APPLICANT If,after making this Car ificae of IExemption.You should WATER SYS RGA' G
Y mus SOILS FEE
118�
F brume suompywit Workers Cumpensmiis provisions of the mrd Code. T
a
forthwith comply with weft pnwisinna or anis prmtiuhallhdeemed reroked. WATER SER
Q
P CONSTRUCTION LENDING AGENCY NEW H&SN' 'f1ALP MIT. SQ. PAID
Iherchy xtlinu thus there innnaam¢linn lending agency for the perfomaincc of m Receipt to
L,O the work for which IUs Tomb.is Ismer(Sec.3041,Civ.C.7
O H Iamdcrs Name TOTAL:
} W Lender's Address 1"JR.DIN FEE
lA 1 crc.Ihm 1 have real this city
ane:cion and sutra mal the starve w%%dation is
F h c med.l agree m'sumplyand wire yaunyand nmrewma Ves ordinances ond stat to entruperingm QTY MECHANICAL PERMIT FEE
U z building construction.and hereby authatiae mpre.wnmtivm of this city reamer upon the SIiISMI PEE
aMave-mentioned propeny for inspection pu puxrs. PF.RMI'I'ISSUANCE IELIECfREC 'EE
' IWc)agree m save,indemnify onA keep homilcks the City of Cupertino u8oinsl
Iinbilaics.Pldneclns,costs and cnpcnnc whish inky In any way uccruc n8mnsl saiA Gly ALTERONADD'IOMECIL PIAOMBING NEE
' nscgncncu of the 8mndngot in is....real.
APPLECANTUNUBRS'TANDS AND WILL COMPLY WITH AI,L 10.100NON-POINT AER HANDLING UNIT 10. p CPM) MECHANICAL PGB
So i. .GULATIONS.
AIR HANDLING UNIT(OVER IB,(XX)CFAQ CONSTRUCTION TAX
Saga mol APpl'unVCommcmr s Da E%HAUS'f HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MAIERIALS DISCLOSURE
Willlhcapplicaut...far oze huilding..ccnpanluore...hand lc hnmm..uXnaten:d HF,ATINO ONET(TO IBIrr0013'1'lJ)
ns defined by file Cam r a,,Municipal Cuda Chapter 9,12,and he I Ieallh and Safety HIEA'1'ING UNIT'(OVER 100.00)I1'TlH
Cole,Section 25532(ay! /
0Yr, Com" V F,NTMTION FAN(SINGLE REISI DI PAID Dae RecciplM
Will the applicant orfmore buildingsucupa.I use rquipnard or devices which
,it naeardoes un nmmminanTv ns JefdAir Quality Management ROILIER-COMP IJHP OR 100.0k)BTU)
' :o T L
Distict! d,�s BOILER-COMP(OVL'R 100, 0O[11'U)
❑Yea
sire AIR CONDI'T'IONER ISSUANCE DATE
1 ora •.1 the na.am n 1 menu ander anopia.h.95 m the rah-
remia Health& rt .Sccan SR.2553}and 25534 1 utWersland that if Inc NEW HESIDIENTIAL MECII, SQ.IT. / �� / 3
nuadi I 47
Tor t I h aT,2511 d 11114,1 mnmdymel%aapam
orth, Ircnt rs whit mustamae nanoissuana if C�•niJiylWf(�'� T
/ 2 TOTAL: ISSUED Ely /
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