S 3177 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDI NC-CLCC'FRI CA I. PERMIT NO.
BUILDING DIVISION APPLICATION/PRRMIT PLU]@IN'G-bll?CHANICAL S 3177
BUILDING PROJI?CT IDENTIFICATION
BUILDING ADDRESS: SAN]DOY NO. APPLR:ATION SUBMITTAL DATE!
f 37 3 OoOPY 0#1 GL)ll 7r ✓ a Z <j._c3�
OWNBR'SNAMG PITON& CONTRAC'TOR'S NAMI?. LICNO',
M o rT /t
S/GA,�foriA tiy�Zl Gu570M Ctlf NIC corkol.a
ARCHITECT'/ENGIN11HR: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
441(/6'
/1(/6' /�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELL❑Cf PLUMB MECH
ED,
LICE?NSI?D CON'TRACTOR'S DECLARATION QTY BLECTRICPEI2MIl' FEE /
1 hereby afhnm(].,1 am fieersed under onions of chapter 9(emnmar ang JOB DESCRIPTION
Z with Secdnn J000)ofDivkion3ofthe Businessand ProfessionsCoae,and myliecose is REIDF- VISI[AL:
WOO PF.RMI'T ISSUANCE
C'F Lifall ceneforceClass
and effect. ❑SFDWL KITCHEN REMODEL
<—U License Class Lica APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
y Z W Dam Contractor
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F D m PANELS MODIFICATION
z 0 y,6 l undersaand my plant shall he used ax public records
OZ-0 UI11020DAMPS ❑INTHRIOR ❑CHIMNEY REPAIR
N4'c'W Lkcuwd Prnfcssimml 211.1000AMPS IMPROVI?MLNT SWIMMING POOLS
.J..1 OWNER-BUILDER DECLARATION AVER IgN1AMPs [I BATH RSMODEUREPAIR ❑DEMOLHTION
6 1 hereby.Mrm that I am exempt from the Connector's License Law for the
Gk O G V following...(Section]1131.5,Business and Pianissimos Cade:Any city n euunty SIGNS FLF.CTRICAL ❑OTHER
W 3 LLE" which requires a permit to construct,alter,improve,demolish,or repair any structure
FaOa Emonoits issuance..]...mluira theapplicant Rusuch permit to file a signed sin¢mem SPECIAL CIRCUFUMISC. 11140r4clel Ll/(/V
f } ,hat he is licensed pursoutto the provisions of the Contractors License Lave(Chaper9
X00 lennnmcncing with Section JIMO)of Division 3 of the Business and Professions Code)or 'I T;MR MITCR OR POLE INS, COMMERCIAL,
LL�j C E ,hat he is cormid,herel'rn,i and the basis for the nllcgcd.emotion Any ,ioln,ion of ❑NI3W BLDG/ADDITION ❑U13MOLITION
y Scotian 90315 by any applicant fora permit auhjec,s the appllcan, o a civil penalty of P(1WHIR DEVICES [:]'TENANT ❑FOODSERVICE
^�< not more than five hundred dallur.(5500). IMPROVHMF.NT
Las owner ofthc norm talo enwithwa esas T their...leen,, tion, SWIMMING POOLELECI'RIC S M ❑ pnspe Y Y e P Y 6 penis
OTHER
F will do the work.enA theswcmreis not in¢ndW oroRercd 4asalc(Sce.91WG.Business
Wm and Professions Code:The Contractor's License Law does not apply to ea mune,of OUTLII]ti-SWITCHES-FIX'ILRES
63^ property who builds or improves thereon,and who does such work himself or through
his own emplpyces,provided that such improvements me not intended or offered far N13W RISIDENTIAL ELECT.R SQ FU.
sale.IL however,the building or improvement is sold within one year of completion,the
IT.FLOORARTA SISQ.FT.
ownerbuilder will hove,he burden of proving than Ito did not haild or Impnrve for Ent
pom of sole.).
SSI,aert
s owner of,ho property,a.radm wily annb.ctins with limned contractors to TOTAL:
s.mat Ne projem(Sea AWG.Badness and Professiore Code:)The Comniou",Li-
move law ]apply to an owner of property who builds or imposes,hereon,and QTY, PLUMBING PERMIT FEE
ommeteamet� injects with a commends)licensed pursuant to he Contractor's
License Law. PERMIT ISSUANCE
❑lam ice S (�_ .B&PCfa this reason
AUTCR-DRAIN&VENT-WATER(EA) VALIJATION
ter Date ^
Il 'S COMPENSATION Il1?CI,AItA'1'ION 13ACK FLOW PROIT,CT.DEVICE O 'V
I hereby oIT ,mode sonahy of perjury one of the fallowing imeNta,ionc:
I fore and wi mainwinu efificam mf Consennn self-insure for Worker's Crnnrym DRAINS-FLOOR,ROOF,ARHA,COND. STORIES '1'11-ECONSTRUCTION
,atioa,as provided for by Section 37W of the Uld,Core,for the perfi n lance of the
wad for which this permit is issued, VIXYTIRES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as respired by Section
3/00ofthe labar Corma
Core.for the performance ofthe work for which]his permit is inured, GAS-LA.SYS'[TV rtll#t�3T1(Jrl'.. S (ICC.GROUP ANN
My Workers Compensation Insurance cancer and Policy number am:
Carrier: Policy Na.: CAS-EA.SVSTF. iRG(F
cpwrnEcArn OFF.XEMPI'ION FROM WORRIERSGREASIFYINDUST '1L'IN'I'EItci
COMPENSATION INSURANCE BUILDING DIVISION IMFS _
(Thisscrin need not he completed]if the InnniO,fora.handred dollars FS 100) GRHASHTRAP
or Ics.J PLANCIIITCK TEF.
I viably that in the Performance ofthe work far which this permit is issued,l shall SLWIik-SANITAR STORM 13A.200 FT.
not employ any person in any manner so as to become subject to the Workerd Cocks.. ENERGY ITE
O Z .anon ldws of Califoom..Dam WA'IT:R I(PATER W "' :LFMR GRAD( f PIT
Z Applicant �_,...��-�
h NOTICE TO APPLICAND:If,after making this Canificale of Exemption,you should WAI HIR SYSTEM/TR�ATIN(i
F! hecnme subject to the Worker's Compensation provisions of the lxhor Coda,you nmst SOLI_ l:'
(W� fonhwi,h emnply old,such pmvi,mounr this permit.hull he deemedm nkcd WAI FIR SHRV10E
Q
� z CONSere is.construction
AGENCY NEW kIiSIDEN'TIALPLMB. SQ.FT. PA Date Receipt#
V k forwhichithi thanhere iss ed(Sec.30Wndie.agency finite penDnnanea of
the work for which this permit is issued(Sec. C- CJ
�'E'-' Landers Name
TOTAL:
RLenders Address TOTAL:
Cy I rectify tlml 1 have road this application and state thin the abewe information is l, NG FPLC
F-, W correct.]agree to comply with all city and county ordinances and nate lows relating to QTY. MECHANICAL PERMIT FIT'.
U Z building nmspucfint.and booby awoince m,rewnttnives of thixcity to emm open the 551. IC ITT J
above-mentioned property for inspection purposes PFIRMI'F ISSUANCE
(We) go.In me.indemnify and keep harmless the City of Cupenimr agoins, E URIC F131i
liabilities.judgments,costs and expenses which may in any way...re.gaind said City ALI ITR OR ADD TO MECH.
nscquence of th�SIR" f this permit. PL BING IEE
APPLICANT UNDS.IND WILL COMPLY WITH ALL NON-POINT AIRHANDLING UNIT(TOItI,(XXICFM)
SOURCE RECUhA MECH (CAL FTE
AIR HANDLING UNIT LOVER 10,01I CFM) CONSTRUCTION TAX
Signature o'Applic.n,/ a'2 Date RXHAUS I'HOOD(WI0UC1) HOUSING MITI GAT ION FEL'
BAZAR USM TP.RIAI ti DISCLOSURE
Will theaplowm]nr future IndIx handle hondlous modem] HHA'I'ING UNIT TO 100,TLX)ll'1'U)
as definN by the Cupertino Municipal Code,Chapter 9.12,and the Heal,h and Safety
Core,Section 25532(a)Y HEATING UNIT IOVITR 100,000 BTU)
❑Yes [3No VENTILATION FAN(SINGLE RESID) PAID
Date peat is
Will the applicum or furore building occupant use equipment or devices which
havtrdous air contaminants as defined by the Bay Area Air Quality g Mara ement BOILU:R-COMP UHP OR INLFW BTU)
'T(YfAI,:
,
'�
El Yes
❑N 1101LI?R-COMP(OVEI(IIXI,fi1X1 RTD) #
s, I have read the hvenh,mmerid, is under Chaterfi95of be Cali- A]R CONDI HONER ISSUANCE DATE
eymmmen
humid Health&t currytlyhaeaonsu 25505,25533and evassiii.I to radiwml tocol the N13W RIS11313NTIALMECH. SQ.FT ^ �� y
of thing.idemoes n currently must the met L that it is ua re ofd ibiliry to nmify the occuppanty, L
of the requirements which must he met prion..issuance of n Certificme of(k<plmncy.
Owner or amhoriecJ xger, Ilam TOTAL ISSUED BY:
OFFICE