S 3904 (2)APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
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-OTYOF CUP"RTINO BUILDING - ELECTRICAL.
DUAI,DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMIT NO.
S 3904
BU1LDINGADDRE.SS:
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SANITARY NO,
APPLICATION SUBMITTAL DATE
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'Amoink
OWN-I'll HE
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CORACIORS NAME:
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CONIROLM
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:IIITE /L'NGINEER: LIC NOS
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AI�2kE'S:
gel WSI 4f• LA-foo- c-A 01
IF PHory'Ii:,C
BUILDING PERMIT' INFO
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Int �srnRN �3•L-s383
❑ Consultant Fees Paid by Applicant (Initial)
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LICENSED CONTRACTOR'S DECLARATIONQTY.
I hereby am,m that I am licensed ander p v,sicrs of Ch rue, 9 (comtnsimmg
wnb Scetion ]01Nq of Divi%mm3 oohs Business nnJ PmfcssiensCode, ands liewai.
full fome and effect.
L 7
Faultsc Class Con
Fault Com actor O
ELECTRIC P17 MIT FEE
JOB DESCRIPTION
RESIDENTIAL_
❑SFUWL El KITCHEN RE-PIP).
[I ADDITION [I PLUMBING RE-PIPE
MULTI-UNIT ❑ STRUCTURAL
MODIFICATION
❑INTERIOR 11 CHIMNEY REPAIR
IMPROVii (] SWIMMING POOLS
11 BATH RECO JREPAIR DEMOLITION
(]OTHE
PERMITISSUANCE
gPPL1ANCLS-RESIDENTIAL
^
) i ANF.LS CC/' (
// UP TO 200 AMPS
ARCIIITECCS DECLARATION
I understand my plan. shall W cud as public recnNs
Licensed Professional
OWNER.BUILDFR DECLARATION
1 hcrehy affirm mot I nm amin't from me Commcmr',a License Law for the
following m:ram, IScenic,90115,llntinexr and 14 Ar"irns Cadc'. An lty
which requires a permit In t pm e t p
to'nsissunnequl%n rsyr II far L niuo ren nee sgmunsen
that he is licensed pursuant t e provisions oro ors 4 1 aper
[commencing with Section] 1 of i%ino. Ilius .p Protrtiion
that he is exempt therefrom i. for lege "ntii dva , Any v glaoon
Section 91Y.i15M1Y any upplic rood permit .the pbcunno ret t'ttp'caltyo
o anore ban five hundred J l (E5f0). Ip�ltlg^jglh
F1 I,aarwnerofdr,roper, s I . 'g as Illau,ol uatirn.
wMd.the oluk,ondffic, us mndedmrferedf le(See70Ys, Business
and Professions Code. The Contractor's Licenu Law does nal apply m un owner of
pmpedy who builds or improves thercer. and who dries such work himself or through
his own employer., provided that such improvement% arc nut intended or offered for
sale, If, however, the building or improvement is sold within��J1nfomradetion. the
201-1100AMPS
OVER ItHN1ANI I'S
S Al.
10
SPEC) CIRC% /MISC.
P.TERO OLE INST.
CQL
❑ NEW BLU ) EMOLI'i'ION
TENANT FbODSERVICF,
IMPROVE ((((�������,
❑OTHIik
)'OWE IiVI
OL F,LECTRIC
OUTLETS-SWITCI{ES-FIKT
NEW RESIDENTIAL. ELE(7rR SQ tiff.
SQ. IL .1] RAND 5/SU�Ff.
cane(-huilder will have the burden of proving that he did m prove lit, par-
`
you of sale.). `
(] 1, as owner of the prc,.Y, am exclmively contracting with con ors m
ttnnuuct the project (Sec. ]044, Business and Profcssion�"7�rmmcto, s U.
sen, ructth smut applyman owner of propcny whish proves thereon. and
whoonte ,a projects with a counWaoro)license the Connactoh
L"eme
lamd19Cfor this rcamn
TOTAL:
QTY PLUMBING PERMIT FEE
'
3 Q Q Q /L
tp/ j
�iQ
I
PERMIT ISSUANCE O
'
Z ALTER- DRAIN&VENT- WATER(
VALUATION
(
W'ORKER'S COMPENSA1]ON DIiCLARATIO G
�f
O
BACK FLOW PROTECT. DEVICE
I hmeby uf8 rot under paral,of perjury one of the fnllmving dedam '. •
I have and will maintain a Cenificate of Consent self-insure for Worker's Compsn.
hares provided lac by Serf ion 37tH) (If the Labor Code, for the performance of the
work for whmh this permit is issued.
OD
ej
R - FLOOR. ROOF, AREA. C C.J
STORIES
TYI'Ii CONSTRUCTION
�S r
FIXTU E - "S
I have a will nvimvia Wmkda C�pensution Insurance, a%required by Scctinn
3]W n(t fa me perfo co the work h J�jtro�d �''�ual.
My Work . o� n�nm o Yulicyar /! 1"-�
Caricc mY No.: WV
OCC GROUT'
APN
GAS-EA.SYSILM-I )IRLETS
GAS-FA.SYS'1'EM-OVIi1t Ot]iA7
_A
CERr119CATCoil EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASFJINUUSTRI, WAS TE '. tCEfTOR
BUILDING DIVISION PEES
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(I his section recd not bcwmplered it the penin is for one hundred dollars IS Iq))
or less.)
Iccnilythuinthcpcdimmunecof facial, lorwhichthi. permit is issued. l shall
not employ any person in any manner so as to become subject m me Workers' Compen-
stir. Lucas of Calif o..ia. Dula
Appueant
OREASE'IRAI'
PLANCHF. KPEI3 '3 f
SBW ER- SANITARY -S'IUR A. 2!
ENE 'Til'
12
WAq'ER IIIA\TIiR WIVEN'I'/ELI!
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NOTICE A)APPLICANT:If, aria, making this Cenilicirm al Exclliamc, you should
become subject to the Worker's Compensation previsions of the Lahm Code, you must
WATER SYSTEM/IREATING
SOI SP.G
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IbnhwilM1 comply with ... h is i,lonsor this permit %hall he deemed revumd.
CONS '1'RUC'TION LENDER; AGENCY
l herebyatfirn thmthee is. construction limdingagency fonhe performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
WAI'FR SERVICE
PAI Date Rcsaint n
NEW RESIDENTIAL PhMR. SQ. FT.
0 O
< TOTAL:
LandcfAddress
BUILT F flore
I certify that I have mad this li,lier ion and slate that the above information is
cored. l agree to comply with all city and county ordinances and state lows relating ct
malhu,,o.t—flon,anal I... hymtmnim epmNertativc, uflhiseily taamerupon the
abrvcmcmiuned pmpcnY for mspccmon pagmtts.
(We) agree to %ave, indemnify and keep haute,, the City of Cupcnino againzt
"a""' .fudgmems. costs a dexpenses which may in any way accrue against said City
' - sec of the tram t of hro ltnntt.
nP .IC ItNT UNDP'T N) A WILL C )MPLY WIT ALL NONroINT
QTY. MECHANICAL PERMIT FEE
Sit. :b
PERMIT ISSUANCEr
EL RIC PEE QorJ
AUIERORADDTOMIiCII.
PL 4111NG TEE D 0
AIR HANDLING UNIT (TO 11).100 CFM)
MECHANICAL TEE 3 r -70
Sl I 'GI .A' I S 21
AIR HANDLING UNIT (OVER IO.lXO CIM)
CONS 'TRUC '1'ION TAX
. germure of ApphcanUCemor or Dmc
EXHAUST HOOD OVIDUCT)
EE
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle bazrNrus material
HEATING ON] F(10 I01LWl1 B'IU)
as def by the Cupertino Municipal Code, Ch ipm, 9,12, and the Heahh and Safety Code, Section 25532nd?
HEATING ON IT(OVER I ftorr0 BTU)[3Yes
VENT] I.Al]ON FANS INGLE RE.SID)
❑No
Roo ifulNWill
the applicant or future bildingoccupat use equipment ar devim, which it hazardous air commninants u%definul by me Bay Area Air Quality Managmrcnt
BOILER-COMP (3HP OR I(N),IX111 BTU1Tns?
n
BOILER -COMP(OVER II,(hadB'ID)
❑Yes ❑NoI have mad the hazardous materials requirements under Chapter 6.95 of the Cali-
Allt CONUHll1NER
NCE UA'I'Eto
NI?W RESIUENTAI, MECH. SQ, FI.��hr'di
a calth & Safely Code. Sections 25505.25533 and 25534.1 understand that it the
Aoc,mu .,armnunr, tel it ism resPmsiIII ton tifYN cacupant
2a
elp (•am doe pawneror
BY: s'
OTAUISSUIiU
authorized ab re Data/1
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