S 3052 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IBUILDING-ELECTRICAL. rE rr NO,
BUILDING.DIVISION APPLICATION/PERMIT PLUMBING.-MECHANICAL 3052
BUILDING PROJEM'ID6N1'IF'ICA1 ON
fl�ILDi�A�DRESS: �Q ��Q SANITARY NO AI'I'LICAI'[ON SIII�I'IA�AI'F.
O09
WN " AAQPHONE: CONTRACT.IR'S NAME'. LIC NO:
L o -3 -�� 85 NIC CON ROLA
�C IT1!CT/BNGINFER: LIC NO: ADDRESS: - ❑
CONTACT: PUON17i&Sp BUILDING PERMIT INFO
�.�p
El Consultant Fees Paid by Applicant(Initial) BLDO ELECT PLUMB vl
1�4 N ucE rf�t/�71� 5284O 5�-- ER ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
I tottery of irn tml I aro li,ounned and,prolllmaas nfCbaplhi 9(catamemmg JOB DESCRIPTION
O a'Z wise Sectien]W8)of DlvisionJonhc Buanosx ata Pmfessiulu code.atm my licenre in f-`� RESIDENTIAL:
Won PERMIT ISSUANCE //
FSO in full force ail cry"'. 0yFDWL CHEN REMODEL
aVZV License Class Lim.or APPLIANCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE Pilot!
i-¢kc Dae Cmnmcmr
ARCHTI'1!CI"SDECLARATION OMUI.I[.UNIT OSTRUCIURAL
h.O o PANELS MODIFICATION
z O m Z I understand my planuhall be usN as puhlic recnNs
OZ4O UP TO 208 AMPS El INTERIOR ❑CHIMNEY REPAIR
.Fn Liceroed Professional 201-❑x18 M1P5 IMI'ItONEMENT ❑SWIMMING I'UOLS
Q 7� OWNER-BUILDER DECLARATION OVER IgN1AMP5 ❑BATII kEMODE1lREPAIk E3 DEMOLITION
I hereby affirin that I ane excerpt Eon,do,Comraelor',License Law fur the
G O a U followin Soainn]031.5,Itusinect and Pndessions Cnde:An emnl OOTIRIZ
W 3 LL Fm g reason ( y ci y nr y SIGNS ELISCTRICAI.
Fm which it'soa a permit m ainstrum,al¢r,improve.,f... demolish,or muni,any structure
E'�OQ you he isl cense tv, s .for such permitm Oleo signed(Chapter
SPECIAL CIItCUI'I'IMISC.
Ihahe inria,,,rh r ornate000) icense Law(Chap¢r9
�G� (cat he is ingwlt I r ]I1fa1) first or
cis
of B st ens,vnJ r IAny si Cfir..1 T13M1P.ME'I'ILR.112 POLE INS'1'. R L'
L d e C
that he is exemul I � m un cr,the n e eJ ext pl n.Any violation of EW 13LD(i/ADDI'T']ON ❑DP_MOL1 TION
s
iC^It tion 703 1.1 by dicam for a pemoapu
rn bjects ct a on civil penalty of POWER DEVICES OTFNANT ❑FOODSERVICE
but LLl mine than five oil 5
�z'Q ❑1,as owner of pmpe r e {p� qlt�@'I�'sa ole compenswinn, SWIMMING POTHER
OOL EL[LTRIC IMI'RUVIiMI!N'1'
�� willdotbewotk,: 16e slruetutcixnol lnmtMW A,7,IUQIf11 a ecA(144.BasBasin,,L 3 m unit Profession, ode:"Me Consorters License Law does ply m an owner of OU'I'LGTS-SW I'I CIES-PI%'I URIiS
.. Prouerly who hu d In thereon,and who does sic himself or through
his
n wn employ es Yeo ed that such intpmvemcros am not In hided or offered for NEW RESIDENTIAL RLIiCTR SQ rT-
sale.If.however,libllilb Wot issold within one, arofcnmplecion•the SQ.IT MOON ARBA SISQ.Fit
Proowner builder will have the Burdon,'tl pro) gM u d or hnpmve for for-
of sale.).
1,as owner of the properly, im exclusively contracting with licensed convectors In O I.: O
'ablrucl me project(Sec 7044.Boom,had Prou"ianx Cadc:)'I be Conumalnr9 LI-
nxl.uw arts.Sol applym an owneraf pmpcny who malas or improves mereon,ata QTY. PLUMBING PERMIT FEE
ono 1olum 1,nor orb Pmjoms wim a carhh"'ogs)licensed Paroum m Bre Cournwr's I^t
License Lax'. PERMIT ISSUANCE r W
T oro exempt ander 'u )D uy' B k P C radius reason
_,net J1.LL� D Z AI:II!li-DkA1NMVEN'f-WATER(EN VALUATION
F.IIS COMPENSATION DECLARATIO BACK FLOW PROTECT,DEVICE
Ih to nm under Penalty of,,ja,oneof the following declaration., 3 Q CJ
L I have and will mninmin a Certificate of Consent to self-insure,for Workers Compcn. DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONS'I'RUCIION
lotion,as provided far by Section 3]00 of the L.borCo ir.for the perlirnnnncc of Oat
work for which this permit is issued. FIXTURES-PER TRAP
❑ I hive and will nnurl-c Worker,Cnatrpensmion lo,un,r,us required by scon 0
37Wofthe Labor Gyle,for pmirmance of the work lir which this permit is'issued, GAS-EA.SYSHTM-1 INC.40Ui'I.I IS OCC,GROUP AI:N
My Worker's Compensation Insurance carrier and Policy number arc:
Carica Policy Shut GAS-EA.SYSI'I!M-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEHNDUS'BL WASTE INTERC MOR
OUILDING DIVISION IliliS
(This section need no,Is,cnmpleled if the permit is for one hundred dollars ISIOb) GREASH'I'RAI'
nr lex,,) PLANCBECK P[E
Icertlfylhal In do, rformunceo(Ibe work it,,which l r,,rac,is issued,Ishall SI!WBR-SANI'T'ARY-STORM EA.2W P1'.
net employ any peien in any manner so as m tnarme subject to the Workers'Connah, ENERGY FEE
Qz ,.tion Lnw,nf California.Date WRIER HEATER W/VENT/EI.IiCTR GItADI < '
z Q Applicant
NOTICE TO APPLICANT:If,aper making this Certificate of Exemption.you should WATER SYSTEM/IREATLNG SOIhS
a , hearme subject m the Worker's Grmpensa0on pnrvision,of the tabor Cub,you muss
P-1 forthwith comply wish such Proninvs or this permit shall bedeaned revoked WATER SERVICE
a 0
U O CONSTRUCTION LENDING AGENCY NEW REtiIUF.Ni'IAL I'LMB. SQ.FI'. hA Date Recti"is
I tour which roc then lhom i,uued(See.30 lending ugenvy for the perfnnnancud c
ILFthe work for which thispennil is issued lsa.3(19],Co.C.) 'TOTAL:
Leader's Name,
U henJcrAdkins,
ify then v
cert1 have mad this application end stale Nat the above innmio
fann is T null )TNG PI!li 3 3 (}
nF.t [A correct.I agree to comply with all city and county cool and shite laws relating in QTY. MECHANICAL.PERMIT FEE
V z building conarucllon.and hereby aulhorize ropresunlmives oftlokcily nr enter upon the SIT14A IC FEB 0
abovcmentin led r,,,.y for inspection p hooves. PERMIT ISSUANCEO
(We).,mo lot save,indurody and keep c,ualexs the City of Cupertino agnow I!LECL IC PI:E e
liahilitie,.judgmems,cosmand expense,which may in any waynrerue.gninsl aid City ALTER OR ADDLO MI!CH.
in cml.tequence of lire gmnfr,of this K....1. I'LU\1131 FEE 3 ,
APPLICANT UNDP 'ANDS AND WILL COMPLY WITH ALL.NON-POINT AIR HANDLING ON['I'(TO Ito,X,CFM)
MECItANICAh FEIi
S)URC TO'. LION .
/b/Zpl�q AIR IIANDLING UNIT(OVER IB,fXN)CFM) CONS'I'RUC'I'ION TAX
Signmuret Ap r'r RYinta&T Omc G EXHAUST 11001)(W/DUCT) IIOUSING MITIGATION PEIi
I IAZARDOUS MA'I'17R IAIS DISCLOSURE
Will the applicant or future building occupant store or handle haaafdous naterial HEATING UNIT IT(a) ,,W) ,U)
.s diehard by the Cuperonn Mnmicipal Cite.Clo,m,9,12,and the Headband Safely
Cade,Section 25532hd! 1 HEATING UNIT(OVEN 100,food R'111l)
F7 Yes 0 N PAID
VENTILATION FAN SINGLERP_SIU) Uwe Itwciplp
Will the applicant or future building occupant use equipment or toeless,which
if
havallow air cnmmnliners ns defined bythe Bay Area Air Latin,Management BOILER-COMP LRIPOR IDI,(IBORTIR
utnet?
❑Vex L3 No IIOLLER-COMPIOVF.R IINI,INp ItTU)
Alli CONDITIONER
1 have read the od,Shazardous materials requirements under255 .1 tuns 695 of the Cali" / ISSUANCE DATE
fnnJu Health&Safely CWe,Beeline 255114255JJ.nit 25534.1 undccrhinA than if the NEW RESIDNN'I'IAI.MIeCIi. SQ.FI'. C 2
handing doer not cunmmly have n tanant.Iha it is my rexrymsihilily In notify Ire rvcurynl
of the requirements which mal be rem prior to isxnunce oft Cenlfiwmnf Occupancy.
0%acr or uulhs razed agent Dam TOTAL: ISSUED BY�
OFFICE
-••v^ - - --'•_--.•.+:_+.._vim=�zs-,. >;••�-:�^••x.�-"--"'�"�
'ADDITIONAL PERMIT FEESg
BUILDING PROJECT IDENTIFICATION rVALUATION' .
BURLDI
ALONE
ss
OAMEHS
{� FEE SUMMARY
PONE
NOMrnncrons BUILDING j
\IC R. PLAN CHECK
_ .ONTRAcrons. - FEE
'.....ss
PHONE SEISMIC FEE
QTY, ' •ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC . T1 1 2�
LIGHTING FIXTURES
PPLIANCES-RESIDENTIAL' PLUMBING
PANELS 'MECHANICAL
SIGNS.
SIG NS TRANS., - - 'TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS.' PERMIT VALIDATION
I
MOTORS SEE FEE SCH, - -
' ' .SERVICE CHANGE
z 2 . C . . .
• F 0 TOTAL
ISSUANCE OATE
- LU �' OTY. PLUMBING PERMIT 'FEE'CL 0 acct. ELECT. PLG. MBCN.
2 ALTER-DRAIN&VENT-WATER IEA.) ❑ ❑ : ❑ '❑
U O . BACK FLOW PROTECT.DEVICE -
U DRAINS-FLOOR,ROOF,AREA,COND.UU
} y' FIXTURES-PER.TRAP
�- ?- GAS-'EA.SYSTEM-1 INC.40UTLETS
• L) GAS-EA.SYSTEM-OVER 4(EA.) -
INDUSTRIALWASTEINTER.
LAWN SPRINKLERS-1 INC 5 V.B.
5 LAWN SPRINKLERS-OVERS(EA.)
SEWER!SANITARY-STORM EA.2001[/ ,
WATER HEATER W(VENT
WATER SYSTEM '
" . WATER TREATING EQUIP, _ I
QTY, MECHANICAL PERMIT- FEE
ALTER OR ADD TO MECH.
APPLIANCE
I
AIR HANDLING UNIT TO 10,W C.F.M.)
AIR HANDLING UNIT(OVER 16WOC.F.M.) -
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.)'
r HEATING UNIT(OVER100,000B.T.U.)
VENTILATION FAN(SINGLE)
BOILER-OOMP(3 H,P,or 100,000 B.T.U.) -
BOILER-6 OMP IO IP,10O OOD BTEA 6EB FEE SCH.
_._
.TOTAL
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