S 3152 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER•1'INO RU LDING-RLEC1'RICAL PI:1j�FP No
BUILDING DIVISION APPLICATION/1'ERMIT PLUMRwG-MECHANICAL \ 31 52
BUILDING Pytti IDENTIFICATION' �J i
ROILIJING ADDRESS, SANITARY NO. APPI.ICA'I']ON SUBMITTAL DA'I'L
lo33 ( -- 3aso
PILON CONTRARfOR'S IJC NO:
3 Ww�`YJITN SIC CON'IROLK
•ARCIII'I I r1'/ENGINI FIR: 1.11;NO, AI NIiS S: ❑
S oa.sz--
CONTACT: PHONE: BUILDING PERMIT INFO
-7Q 3 .3 ❑ nt Consultant Fees Paid by Applica (Inili IILDG ELECT PLUMB MECH
/ ❑ ❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEC
I herby alHreaohm 1 am licensed under provisions of Chapter 9(noounain6 JOB DESCRIPTION
wOZ with Senion 7")of Ins"w ofthe Pureness and Professions Crde,andmyh,emcis
FVB in full force and effect. I` PERMITISSUANCE RESIDENTIAI:
�VV Liccmc Clua LIc.N 3 d S O / ❑SPUWI. '�El.KffCHEN REMODF.1,
+ til Dntc Conlnetor APPLIANCE S-RP,$IDP.NTIAI. ❑ADDITION )ePLUMBING RE-1'IPii
I„pNCy ARCf{ITECTS DECLARATION PANELS ❑MUUTI-UNIT ❑STRUCTURAL
zOyz funder and mydam,hili sensed aspunlic rewards
MODIFICATION
OZ�M DITTO2W AMCS ❑INI'FR10R ❑CHIMNEY REPAIR
F.N.=W Licensed Professional 201-I000AMPS IMPROVEMENT L]SWIMMING POOLS
m C)2 (JWNP.R-BUILDI?H DECLARATION OVER 1000AMPS ❑13NI 11 REMODEL/REPAIR ❑DI?MOLITION
I hamar arfimt drat 1 nm exenmt Iran the eamhnnm'a Lien,rn Law for ma
5(3 d F following reason.(Section 70315.Business and Professions Code:Any city nr countySIGNS GLGC'IRICAL ❑OTHER
IIii11 u-N which esquire,a permit To construct,aper,improve,demolish,or repair any nmmum
FLLO prior to it,i.ssuance,also ecyuims the applicant for such permit ,,file a signedstmemem SPECIAL CIRCUIT/MISC,
Gthat he is licenced pu„uantmnheprovisionsnflhe Conoanarslicense Law(Clwpter9
O (eumerneing with Section](N111)of Divisinn3utthe Btomess tied ProfeW I,Code)n, 'TEMP.ME 11:It OR W)I,Ii I N S
4 o a That he is exnnpt therefrom and the basis for the alleged exentpdnn.Any vlohnion of ❑ iW D ADDI' {N ❑UV.MOLITION
tv. Section7IUL5by anyapplicunT Pura permit,uhicct,the uPPliannt toncivil pentJly of POWER DEVICES
ANT El FOOD SERVICE
not are thad f vc hundred dollars($500).
❑Las owner of Ne property,or my employees with wages a,their sole compensation. SWIMMING POOL ELECTRIC PROVEMENT
willdothe work, it the,mome,enol iatendednrof rcii hassle(See.2044,Business TI�
LL1 and Prote%sionr Code:The Connector's License Law docs not apply loan owner of OUTLETS-SWI PCHES-FIXTURES
2 properly who builds ur impnvcs thereon,and who dors such work himsell'or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELEC'I'R SQ I-T
sale.If,however,the building nrimpmvenumis xnlJ within one y'arof contpiction.the SQ.IT FLOOR AREA SISQ.IeI'.
owner-hadder will have the burden of pmving that he did not build m improve fur pur-
pore of sole.).
❑ 1,ar owner onbe prnpad,am exewrmaly ootmoia,with licensed womnelors m 'TOTAL
onsnam The more,(Sea.2044,Bmlae,a unit Ii ferinm Codc:)The Codraclar's I-
«mel,awdoesnot apply loan ownerof propcnywhohold.sorimproves domon,and QTY, PLUMBING PERMIT FEF.
who canteens for such projects with a communist licensed pursuant o the Commcnrs
Licemc Law. PERMIT ISSUANCEElI nm eaampt under Sec. R&P C for This.,,,a
Owner Date AT:[FR-DRAIN Nr VENT'-WA'I HR(EA) VALUATION
WORKFWS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby atTrm under Penalty of perjury one of the following declamtinme
❑Ihave and will mainminaCenihcate of Current mself-inwmfor Workers Cnmpen- DRAINS-FLOOR,ROOF,AREA.COND. $TORIES TYPE CONS'1'It ION
sation,as provided for by Section 3700 of the Lubar Code,her the performance of the
work Ba which nbls pn....(N—tied. I'IX'rURE$-PER TRAP
•�vc and will muialmin Workers Cnmpennnion Insunurce,as required by Sortie
37W in the bear Cade,for the peRonmance of the work for which this Permit is issued GAS-EA.SI'S'FF,M-I INC.4 OUTLETS OCC.GROUT' APN
MyWarka's ompensahn mane carrier and Policy num GAS-EA.SVSTF.M-OVF.RY(IiA)
Carrier: nzu Policy No.: r
C RTIFICATE OF EXEMPTION FROM W OI2KF.R
COMPENSATION INSURANCE GREASEANDUS'I RL WAS'117 IN'FIINCEPTOR
•BUILDING DIVISION ITIF,S
(Thls,cction ncaA not hca:mple4W ifthc permil isfnrcmohundred dollum[$IIXI) GREASETRAI'
or IcssJ PLANCIiT:CK FEE
Loy any that inthe anymmanceof he work for as
subject
jectto Perthe it Wrkers'Corser- SIiN'ER-SANITARY-STONM ISA.2IXI FT.
not employ any person in any manner sous na herontc subjen to the Workers'Gnnpen- GNERCY FEE
z cation Laws orcelifemia.Omc
�Q Atodenil WATER HRAI'I?N WIVEMI'l1il,IlCf12 GRADING FILE
r~N. NOTICE FO APPLICANT':If,after making this Cenifcme of Esemnion,you 0muldWgTF.R SYST`I3MlI'RF.ATINO
a > Mne
enobject to the Worker's Compensation provisions of Theh
Lar Coale,youm
n ,a SOILS hili
[t1 forthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE
az CONST RUCTION LENDING AC17NCY NEW RESIDENTIAL PLMR SQ.TO PAID
VO 1looeby ofGrmthat Ihere isoconstruct...I lending agmmy fur the perfomnmmof me I2uwiptN
Hs F~'T the work for which on,permit is issued(Sec 9092,CN,C.)
O Lenders Name 'TOTAL:
Lendse,Address Fiyl.:
f..,t 1 certify,that I have mad this vpplicutlon and state that the above infonmmion is BUILDI
fir h correct.I agree to comply with all city and county ordinances and state laws ralaning to QTY. MECHANICAL PERMIT � FEE _
V building nntnmclion,mol booby nuthorl'ec mpmaenlanivwA of lltia city In enter upon the SEISMICP -
above-mentioned property Ibr inspection purposes. PERMIT'I$SIJANCIi
(We)agree to save,in I;Iy and keep hmmle,e the City of Cupertino against ELFCTRIC ':E
liabilities,judgments,roes: expense,which ma yin anyway awemeagaina said City AI TF.R OR ADD TO MECH.
in nseyuenccoft a gran of do, not,, PLUMBINGF F:
APPL CANT offs'. ND AND WILL COMPLY WITH ALi,NON-POINT AIR HANDLIN"Illli-Ft 1 1
MECI IANICAL FEE
SO LA'T S.
AIR HANDLI U GGV: CPM) CONSI RUCTION TAX
Signnm Apith .'Contmnar HA"LARIX)US MATIiRIAI,S DISCLOSUREone EXHAUST 110 /DUCT) HOUSING MITIGATION IFF.
Will T heapplicunt nIt'u1 huildingwc inure nr handle haneolnux mtinned HEATING UNI' 100v10 I)
as deflncd by the Cupen,nn b unleipnl ' • per 9.12,nu l the Health nn I Safety
Code,Section 25532(aV HEATING UNI' VCR 100,000 IT I U)
❑Yes PAID
VCNITLATION 'A ' $INGIIi NGS IDI pate ReceiptN
Will the app to se, llding:weupont use cyuipmam or deviser which I{OILER-COM 3H 1 N'1'U
emit trinkets air mmmnl ants as defined by the Bay Arco Air Quality Mnnagenrent Pn , ) )
District' TOTAL:
❑Yea ( BOILER-COM P(OVER I TOO)()BTU)
I have re. the natant materials ...I,ands,Chapter 6.95 of the Cul,- AIR CONDITIONER
reyui p ISSUANCE DATE
forma health&S Poly Code,Sections 255(1.5,25533 and 25534.1 understand the,if the NEW RESIDI?N'1'IAL MECI I. SQ.fir 9
buildingdoesno ,mentlyhoves¢nnnT,phut it ismy resmmsibility n:Nati fythe,a,opont /
of the reyu' •nt II,, M1metpsia In i,nuntuc ofa CcniBeum tnmcy. 'G� 1
Owner ory t eJ a6cntn ala TOTAL: ISSUED BY: —f—x?
OFFICE