S 3160 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO BUILDING-ELECTRICAL PE ITNO.
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UIL111NG DIVISION APPLICKPIONIPERNtrf 1'LUMIIINf,-MECHANICAL 3160
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMI MAL DATE
/030v v#►rc. L." ba, e-- � a (?y
�O SNAME: ♦,� C I:: C . I�CTOR'S NAME: I CNO
v N u NIC CONTROL#
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ARCHITECT/17NGINEER: LIC NO: ADD, "' ❑
/VES
CONTACT PHONE: /' BUILDING PERMIT'INFO
/ 5-0 ( ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELBCI' PLUMB MECH
f ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hereby nffrm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QWZ with secfion]OWpdDivisionJofrlre Busincca and l'mfnssinnn CsNc.and myllcemcis RR IDF DENTIAL'
won )'lilt MIT ISSUANCE
HW• in full for.., t. ❑SFDWI. -1 KITCHEN RIiMODIA.
n'U~ License Cl... e G Lic.b
la.'W ❑mc�Comtucmr r '_ ��� APPLIANCF'_S-RE.SID[NTIAL ❑ADDITION ❑PLUMBING L PIPE
A CHITEC'S DECLARATION El MULTI-UNIT [I STRUCTURAL
Z O','Z l undersand my planahall be used a,public record, ' PANELS MODIFICATION
OZ�q 01"IY)2(N)AMPs /� ❑INTERIOR ❑CHIMNIiYREPAIR
1-.,2Lw Licensed Pmfeesional 201-10MAMPS IMPROVEMENT C]SWIMMING POOLS
544 OWNER-BUILDER DECLARATION OVER 1000 AMPS Cl BATH REMODEUREPAIR [I DEMOLITION
W d I hereby affirm that I am exmnpt Eom the Cman cmr's License Luw for the _
iqS O IL U following reason.(Section 703 1.5,Business and Profession,Code:Any city or county SIGNS ELECTRICAL [I OTHER
n1 W O y which requires a permit m consumer,.]It,impmve.demolish,or repair any swerore
y� prior o ill issuance,also requires The applicant for such pmniun Elea signedemtement SPECIAL CIRCUUUMISC. g
did he is licensed pursuant m[Ile prockinrmofthcComrvnm'sLicense Law(Chapter 9
W�pO (eOmmencingwiall Sectio 7000)of Division 3ofthe Htumc,mul Profession,Code)m TEMP.METIIR OR POLE INST. COMMERCIAL
d 6 CsC' that he is exempt therefrom and rhe Iasis for Ne alkgc l exemption Any violminn of [I NEW BI.DG/ADDITION ❑DEMOLITION
^ Sectio 70315 by any applicant fur.pennitonnects the applicant to a civil penalty.( POWER DEVICES ❑TENANT FOOD SERVICE
}<Q nal more thinfvehundreddollurx($5M). IMPROVEMENT
= O Lasnwne niche pmperly,mmy employeeswith wager us rheirmle annpeosminn, SWIMMING POOL ELEC'T'RIC
will do tM1e work,anJ the swewre is nix intended nr oRcreJ for cult(Sm.J(WL tlu,ine.+ ❑OTHER
W 3m and Pndesslom Cade:The Cmarr is License Low does not apply m to owner of OUTLETS-SWITCHES-FIXTURESis 1.
prnpcny who hold,or impmvev thmeon,and who does such work himself or through
his own employees,provided In.t such imprevenlres are not intended or offered far NEW RESIDEN'T'IAL IhXCTR Air
.
aide.If.however,Ne building or improvement is sold wiNin one year of cnmpleriov,rhe SV P(.FLUOR AREA EISQPI'.
.
mer lander will have the burden of proving that he did not build or impmve for our 10 1
-
pose of sale.).
❑I,as.wnet of the property,am exclusively contracting with licensed...ancmrsal T( L: _
consumm he project(See.704,,Business and Pmlesson,Gale:)The commcmr,Li.
ase Law does not apply to an owner of properly who bdldsor impmve thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a commcmafs)licensed pnuwmuo the Contractor's
License Law. PERMIT ISSUANCE
❑I am ernal,m undrr Sa. .B&P C lir this mason
ACI F.R-DRAIN&VENT-WATER(f!A) VALUATION
Owner Date
WORK17R'S COMPIiNSATION DECLARATION BACK FLOW PROTECT'.DEVICE
1 herthy alarm unJer penalty of perjury ane of the fnllnwing dcelvr:niens:
I have and will maimuinaCcnifcare of C.num molt-insure far Wnrkar's Compcn- DRAINS-Iy.O(IR,R(X)p,AREA.COND. STORIES TYPE C(lN$TNUCTION
'nn,us provided(or by Sedi.n 371X10[the IyMn Cale,for tM1c pernrmsance of the
wnrk mill thisannls issuer.
FIXTURES-PERTRAP
❑1 have unit
vewill maintain Workers Compensation Insuruncq ns requircJ by Section
3]W of the LUMr Cale,fnnhe per(.rmance.f the work for which this pemrir is issued, GAS-EA.SYSTEM-I INC.40UTLLTS OCC.GROUP AI'N
My Wmkpcnsatinglnsumer,canicrandl'olicy nllmbCj are��2./
Currier: LM1 1h'1/t— Policy Nn.Ql 7 GAS-EA.SYSTEM OVER4(EA)
CERT)FICATE 01:EXEMPTION FROM WORKERS' GREASF%INDUSTRL WASTE INTERCEPTORCOMPHNSNIION INSURANCE BUILDING DIVISION FEES
(This semina need not be cmoddedifthe permit is fnrnnehrodrNdollars(fIDO GREASE TRAP
or let,,) PLANCIII!CK FEE
I,mthythaf in lheperf.rmunmafthe wnrk for which diNfrrmit is issued,lshdl $I!WER-SANITARY-STORM I. .
a.t employ any person in any manner,ommbrcomes.bjeit)the Workers'Compen. I A ENE r( 9iE
zZ ation Lawx.f Califirmnt Ude WATER HEA TER WNENDUE LEC
O Applicant GR rIN/( FEE
.x fn NOTICE IItI APPLICAN'L If,idba nni ing illi,Crebrienteor Exempdnn,you should WATER SVS'I1IiMf1'RIiA'I'INO
hemme,ubjecr m the Worker's Cnmpenadinn poMwo a of the Labor Cork,you oma )I 9 P
Lak1 Bmhwith comply with such provisions or this pronal shall he deemed revoked. WATER SERVICE NUv
Q
z
CONS'I'NUC'I'ION LENDING AGENCY NI:W RE$II3ENTIAI.PLMH. SV.IN( PAID (late Reculpr#
L) O t hereby affrmthanhere is a connmed lending agency for the performance.(
the work for which this permit is issued(Sec.30x47.Civ.C.)
F•' lender's Name � TOTAL:
0
O LUkt lender',Address T(yfAL:
a I cendy that 1 have raid this application and sure 0mt the mdse indi,n inion In BUILDING
N ember.I agree to comply with all city and county oninamois and state laws relatinge QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby authorize representatives ofthiscityenrerupee SEISMIconstruction. m n rh
T.
Air -1
above-mentioned prnpcny for in,pection pmponcs.
(We)agree to save,indemnify and keep harmless the City of Cupertino again. PERMIT ISSUANCE F.LF.CTRI FEE r �O
liabilities.judgments,costs and expenses which may in any way areme natural said City ALTER Olt ADD q'O M ECH.
PLUMB GFF.E
inconsequence of re hgranting Fthis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 1(1000CFM)
MECHANI LFEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER IIIJ)0NI CPM) CONS'TRUCTI NTA%
Signature of AppluenotContracmr Dare EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAI'ERIAI 9 DISCLOSURE
Will the applicant or furore building mcupant store or handle humrdous material IIEA'IING UNIT(TO 100,000 R'I'III
as defined by the Cupertino Municipal Cade,Chapter 9.12,and he Health and Safety
Code,Section 25532(1)1 HEATING UNIT(OVER 100.(101)BTU)
Yes E]No VENTI LAI ION FA N IS I NGLE RES Ill) PAID
Date R'empt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100.0010BTlf)
emit hm.urdous vii eon ameriats es defined by the Bay Area Air Quality Managemam TOTAL:
Owner' In
0Yes 7 N BOILER-COMP(OVER I00,000)ITU) 2
AIR CONDITIONP 1
I have read the hamrilno, t�Id-_a r.y.imments under Ch adder fi 95 of the C.li� ISSUANCE DATE/J
forma llculth&rSaf`r n Iioa 5505,25533 and 25534.1 once unit Nd II the NEW RESIDENTIAL MECH. SQ,IT.
building n rcu n cot //rr Lthd it lx my re,pnluihility tam lythe c}upum �(r-
.f yuiren r met Prior to issuance of u Cenifcar (kcu�nCy� C
/m
I rout 1 agent Dam TO'EAL: ISSUED BY.
OFFICE