S 3103 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNo,
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.MECIIANICAL S 3103
'BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SAN[I'ARY NO. APPLICATION SUBMITTAL ONE 17.
0 gKO 5"� 4T' v�9- p2. - 2 9�
OWN' 'S N/A�M Ii: 1'I IONE CONS' 'TOYS NAME: LIC NO:
�/G /� /_J NIC CON'I'ROLp
ARCHRIECDIiNGIN`E,,•EJR: LIC NO: YJJ ADD911/ �6� O ❑
CONTACT: PHONE: L/`t BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT 1'LIIAt MECH
ID EJ
LICENSED CONTRACT'OR'S DECI,AkATION QTY. ELECTRIC PERMIT PEE
E hereby OR,.mal 1 ant]focused under powidonx of Chapter 11 numtneneiug J013 DESCRIPTION
WOO with Section 70010)of Division 3 ofthe Business and Professions Code and my license is RESIDENTIAL:
WOO 7 a
In I'T:RMIT ISSf1ANCE
F W full farce unJ effec ❑SI'DWh ❑KITCHEN kIiMODF.I.
Mousse CI s Lic,p
6 V p, APPLIANCES-RESI EN'I'[At, ❑ADDITION 0PLUMBING RE-PIPIT
N6Datc Conlrnc'Inr epL�
Din ARCI II'1'ECI'S DECIA ATI PANIi1S CMU1.9'6UNIT CSTRUCI'HRAI.
z O'n z 1 un round my plans shall be used as public rccnMs MODIFICATION
oz-C UP1'0201 AMPS CD INTERIOR [I CHIMNEY REPAIR
W Llcen.W Pref nssiumal 21.10h0AMPS IMPROVEMENT E]SWIMMING TOOLS
OWNER-BUILDER DECLARA'T'ION
Q 1 heresy anion hat I am exempt lions the Commcmr's License Law for the OVER 1000 AMPS ❑HAT H REMODEUREPAIR ❑UIiM01.1'TION
�a OTHER
following mason.(Section 9031.5,Rusinsx eand Promssinna Cade:Any city or county SIGNS ELECTRICAL
a U —��---
17+ 30 y which requires a permit In enmwcl,cher,improve.drtmoIisb,or repair am awrrrr ,(�
�d prinrm its is,no ct,.aHo myulmelholl,licum mr such venninn]fle m xignrdslatunuu SPECIAL CIRCUIT/MESC. �O
fly"') that he is licem'ed pursuamm the provisions or the C,ntrctor's License Law(Chapter o //.-
1i 00 (commencing with Section7000)of Division Sof the Business and lhnfessinns Code)or 'I ElsIP.METER OR POLE IN5 COMMERCIAL:
It
6 ry,o eG that he is exempt therefrom and the basis for me alleged exemption.Any violation a( 0 NEW BLDG/ADDITION 0 DEMOLITION
u%1 h• Section 9rol5 hyanynpplicanl for u Punm subjects theapplicanto o civil pvnallyof POWER DEVICES E31FNANT CIbODSERVICF.
�' ontmom man five larnreddoll:va($500).
F y Ih11'NOVF.MfiN'I'
d 0 Lothe owner oftbepropeny,o.my isnotm uldcdoilh wages mtheir(Sce. 04zl,B sinen.s, SWIMMINstill P .F.LL iC
will Ao the work,and me smaure is notimendcA uroOcreJ liaxle(Sec.TDW,Business COTlllik
L 3 ao� and Professions Cess ee.The Contractor's License law dos not apply to an owner of O I' x U
property who bonne fir improves thereon,find who docs such work hinnell or thr..gh
his own empinyccs,provided thin such improvcno nts arc not intended or offered liar 'W REQ H AL BC'I'R $Q FT.
sale.If,however,the building or improvement issold within one year ofcnmplmioa, SQ.FP FLOOR ARBA $/SQ.FT
owner will have the hnNen of proving that he did nm build or intpmve
pmearodo.)
El L fie nwnar of the pmpeny,n n,xdusivuly contmedng with heensn fact nra to 'TOTAL:
ennarucl tire project(Sec 7044,lousiness and Professions Code:)The Ct Of -
nscLaw does not apply toanowner ofnapcnywho buildsnruniform s Q PLUMBING PERMIT FEE
who contracts for.such projects with a cantmetor(s)licensed pnrsuanuo the C t an/s
License Law. PERMIT ISSUANCE. -
❑ Iant exempts der Sec. ,B&P C liar this
ALTER-DRAIN&VENT-WATER(EA) VALUATION
owner
Date _
WORKER'S COMPENSATION DECLARATION HACK FLOW 1'ROl£CI'.DEVICE
1 M1land ul'IITnt tier penalty ii,ne of C uryon one of(lie hrdam for dec%tranWorkerHans
C lhave and willfor by eCion 37 to of the Labor
Code,I.. for Worked,Ceanpeu DRAINS-PLAOR,ROOF,ARIIA,GOND. S'fOR113S '1'YPF.CONS'IRIICTEUN
,onion,as provided for by Section 3900 of the IaMr Cantle,fisc the perhmnance of the
(hr which this permit is issued FIXTURES-1'EiR TRAE'
ave and will maintain Worker's Compensation Insurance,as required by Section
Curled the Labor Code,for lhcperI munceoalby N,,k l ou which thispentit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.ril AI'N
My Wor C}W�tIY-'Em...satin w rano f.,kh"and Policy gyn le x:ppe/zLr-.b/ GAS-EA.SYSTiiM OVIiR4(EA) +"�rI�
CIiRAFICA'ITOF EM Pr10N FROM WORKERS'
YI�O `.
COMI'IINSATION INSURANCE GREASUINDUSTRL WAST'II INTERCEPTOR
BU_ILOIN I 'ION PEH_5
(This sermon need an(he completed i f l hcpenmit 1,bu enc madreldollors($100) ORHASP.TRAI'
PLANCE
or less,) ' P . 9
Icenifythal in the perfonicaml.flia.ml,fnrwbich this permit is issued.],hall SHWER-SANITARY-STORM IA.200 Ie1'. 'J
not employ any prows in anynwnnerso as ,,became .hj.Ru me Workers'Creation- u O PT:E
Z
,:tion Lawsaf Cnliforma.Date WATER HENI'IIR W/VHN'I/ELHCTR
O Apprraat GRADING PI:E
.N.a NOI'ICH TO APPLICANT:If,after making this Cenifcam of Exemption,you should WATER SYSTPM/TREA'I INC,
F� > became subject to the Worker's Compensation provisions of the Labor Code,you must pst SOILS Ill
Wfnnhwith comply with.such provisions or this permit shall be deemed revaked. WATER SF,RVICIi 8]
Q PAID
.7z CONS'T,is.
LENDING AGENCY NIIW RESIDI:N'1'IALPI YIIi, SQ.FC Date ireiptp
L)0 1 hereby is hzhi ma.it I is s ed(Sec.u lending agency for tlm performance of
the work for which his permit Ir issued(See.3119',Civ.C.)
Leede/s Name TOTAL:
Lenders Address 'TOTAL:
1 fenny thus I In ve rend This appl'mutlon and stem thin the bill.infomtetion is BUILDING PEE
correct.l agree hr comply with all city and county ordinances and slam laws remring to QTY. MSCI IANICAL PERMIT FEE
L) z building conshuction,and hereby authorize representativenofflik city menterupon the SEISMIC FEE
above-mentioned progeny for inspection purposes. PFRMIT ISSUANCE
(We)amo
gree fir save,inde nnify and keep nde,,To hCity of Cupertino mgaiusl ELEC"I'NIC FBE
liabilities,judgments,cnmsuaWexpenses which may in any way accrue aguinusaid City ALTER OR ADD TO MECIL '7O
in consequence of the grunting of this pcount. PLUMIIING PEE ((
APPI.IC 'T NDF,RSI\NDS AND WILL COMPLY WITH AI. NON- DINT AIR HANDLING UNIT('TO 10,fXX)CI'hf) MECHANICAL FEE
SOU .B/yR1�i(//yu/(1gp1�PIO^N.. �/P[�
��6 I� 13 ! O AIR HANDLING UNIT(OVIIH111,00)CFM1 CONSTRUCTION TAX
Signaureof pplicanVCnatramnr D to EXHAUST HOOD DVTDUC I HOUSING MITIGATION FF,E
HAZ RDOIJS MATERIALS DISCLOSURE
W III the upplmont ser funic,building oecupent smm...handl,hamtdnus mob ricl I IHAI ING UNI'i'('I'O 100,000 BTU)
seas defined by the Cupenino Municipal Code,Chapter 9.12,and the Helm ami Safely
Cale,Section 25532m)9 IIIIAI'ING UNIT(OVER 100,000131T)
❑Yes I(] VENTILATION FAN(SING.II RESIDE PAID
Will their fi,nl or funme buldin'soca .ml use ami i n de,Tic,which Uma Reccipl p
II b P' 1 PrQu BOILER-COMP(3HPORI00,000BTU)
09 emit hazardous air comaminunhned by the Bay Arca Air Quality Management 1
DinnmT
(]Yes BOILER-COME'(OVER 100,000 BTU)
x I have mad the hazanmms material,mop/u'ememr an lcr Cha:pm,to 9.1 of the Cali- Alit CONDITIONER ISSUANCE DATE
fnmia Health&Safety Code,Sections 25505,25533 and 255341 undenmnd Ihal if the NEW RESIDENTIAL MECIL SQ.IT.
handing docs not cum fy� Ihm it is my msrymsmility mnullttfythc r}}}'cupanl Ye
of the requirements yon nht issnancoofv Ceti a (kv160yagY.,
Owner gent // ate IOTA L: ISSUED BY:
OFFICE