S 3203 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECT TRICAL 1-171911 NO
BUILDING DIVISION APPLICATION/PFRMIT rl.UMIHNC•.MECHANICAL 3203
BUILDING PROJECT IDEN"I'In'IUNTION
BUILDING ADDIt ISS: SANITARY NO. APPLICATION SUBMITTAL DAZE
�d �b I- -?-5
OWT'S NAM?: Vk e PHOS:: •��� CON'IkACIO ' Nr�h1i::� �QO/! IC NO:
V � N/C C(1MIRULM
' "FIECIIIiNGINIiIER: LIC NO' ADD ESS: ❑
U
i ✓6- Lo
ON IAC)': 1•IIONIi: BUILDING PERMIT INIsO
❑ Consullanf Fc es Paid by Applicant(Initlal) BLDG 13LECI' PLUMB MECH
LICENSIL CON'F1tACIUIi'S DI?CLAItATION QTY L'LECkIC PERMIT FEE JOB DESCRIPTION
I hcrcny..trim that 1 am ransed under prm'isiom,,f chapter 9 commencing
�f�Z 3shh Sed6ro 9.10).1 DiAkio.9ot oro.mains.:and PulvtisiomCoca.amt illy l ieclee is RESIDENTIAL:
I+L O PERMIT ISSUANCE
F��� in full lora vnJ eRecl ❑SFDWL ❑KITCIIEN REMODEI,
QUU License 'I Lieu APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMBING RE-1'IPF,
L•Zn! Date Cnnlmctor
`n6d AItCHI'113C1"S UIiCLAV TION ❑h1U1.T1-UNIT ❑STkHCTUHAI.
F,7 w PANELS MODIFICATION
OZ-�JZ 1 .tan my plane shallMus lis publi cordo UP'fO XXIAMI'S
❑INTERIOR ❑ 1NIiY REPAIR
a 'rote....... 201-IE04)AMPS IMPROVEMENT' iSW MING POOLS
�•�F.J
OWNER-BUILDERDEOVER HIM ❑RATHRF,MODILRIl R DEM LITTON
C C Q 1 hereby of inn that 1 am exempt from the Contractor's License Law for the
3�F I,,Ilow'Ipg r..aa.(Section 911.315.Buxincnrand Professions Code:Any city or county SIGNS ELECTRICALLD OFILER
m which requires a permit to construc,cher,unfree,demolish,or repair any slrucmrc
prior it)its Issuance,also requires the applicant for such pcmtit to rile a signed statement SPECIAL CIRCU IT/M ISC.
f la',
,but he rs licensed p...... ,,,he mW,, )rs III the Counci rn Llano.Law tChaprr9
Wap0 (coluil ing With Section 7000)of Div ision3 of the Business and Professions Code)or TEMP.MITER OR I4LE INST.
a a c a That he is exempt Iheref eni and the basis for the a11ugW exemption.Any violation of ❑NI?W R DDITION [I DEMOLITION
Section 7031.5 hyany applicant for a Permit subjects the applicant a civil Penally of POWER DEVICES ❑"2- ANT ❑E'OOD SERVICE
of more than five hundred dollar 1450(8. IMPROVEMENT
FSD ❑I,as owner til the progeny.ar mY employees with wages es their wle compensation. SWIMMING POOL ELECT S: C�
$y�F, sell Jo the utak.aradheavncmm keotlnicudcd orotbrcd bur sale(See.7044,Rumness ❑OTHER
{y 3 and Processors Code:The Cantrnetor'x License law does not apply to an owner of DO ILEI S-SWfFG111E5-IYX'I'UHLS
w
property h III :d I hodoe, rich work h each thn r,h NEW RESIDIEN'I'IAh ELHCFk IT.
F. r pl ye,. p d J that. h P e Iintended almost for
.It file build u,nociesm is soldwithin Y I pl t at the SQ.PC Iill'I asci k YJSQ.Pr.
owner—builder willh the burden f provingthth JV notWld or improve lot par- -i"'
posyII sale). L: �J,0
❑I,as owner of the pmpeny,it,,,exclusively convaning with licensed nmvaanr m
a.lrncl Bre project(Sec.91H4,Busitel and Prorcxs ons CoI The Contractor's Li-
clow Law does not apply to an owner til property who bailds or improves thereon.and QTY. PLUMBING PEI 'I'
Who contracts bar such projecw wldi a cunnactmi licensed puruanf ,,the Cnntraemtx
License Ww. PERMIT'ISSUANCH
❑ I am cxempl under Sec. .11111 E'C for this mason
AI:I'ER-DRAIN d:V ENI-WAFER(IIA) VALUATION
Owner Date
WORKER'S COMPENSAI[ON DECLARATION ' BACK PLOW PROI'ECI'.DEVICE
I hereby affirm under Penalty of perjury one of fl a following declamlbns:
I exermrdwill...matin a Ccr(ilieldrol Conscm,a Wi Glnvuru lin Worker's Onrpcn- DRAINS-FLOOR,ROOF.AREA,CONDI S'HTRI TYPE CONSTRUCTION
jinn,m pmvidcd for by Seen..7701 d the Lubo,Cole,for the permrromwe of the
dalmk for which Ibis permh Lx i....d. FIXTURES-PER TRAP Z 5 Fowl
❑I have and will..rural.W,,kI Cum,mvdion Inmmn¢,as co uimd by Section ){
E910of lire Labor Code.for We p,It'onnunreoflhe work lir which this permit is i.oucd. 1 GA.S-IEA.SYSTEM-E INC.4 OUTLETS k U OCC.GROUP AI•N ,7
My Worker's Compen..mion 1 .umnce cam'1r and I'nlic$ Mr are: /�
carrier. Cyr ur -/'XI�a W n'd No/.LQ6V2 q7--?o4= GAS-IiA.SYSTEM-OVER
CERI'IPICA'TE017EXEMIII///ION FROM WORKERS' GREASEINDUSTRL WASTE INTERCEPTOR
COMPTINSAI'ION INSURANCE BUILDING DIVISION FLEES
(TTis ttntion neainottevorri it lhepermit i,b),onchundreddell...(SIRn GREASETRAI'
ur Ica.) gA
HECK FIEIi y
I cenily lha ivhe lnrfnnnana ni me work fnr which this pamnil is issued,aluall SEWER-SANITARY-S'FORM EA.21X1 FI.
naI enfloyany paam inmymanner.,,asm We to-hjcetmthe Workers'Compen- YI'I?li
Z satin.Lew,til California,Dam WAFER HIIAI'17R WIV1iN'I'/i?LECL'H
Z
Appllcunl GRADING I'I?E
NOTICE O APPUCAN'1':IL afmr making this Cer ificae of Exculdion.You should WA'1'I?IX SYS'FI?M/TREATING PIiH
I ? hccomc-Fleet to the Worker's Compensation provisions of the Labor Code,you nmst .
G ~n' Lmhwilhcomply with
CONSi8UCI1 nhlxlnnnh snot.he JcunsA revuAJ. ! WATBH SEIiVICI? I
7 Z ON LENDING AGENCY NI?W RESIDENTIAL PI.MW SQ.FF. /� _
I hereby affirm that them is a Construction lending agency for the performance of De v
Oflue ware Fur which Brix pennil is issu¢A(sec San.Cie C.1 VaX TOTAL:UIsnJcr's Name, TOTAL:
Lt7 LcnJer's AJJreas ING IFC •tJI eendythvl 1 base read Ibis application and stam ihel the aMwc infomrs,I) in"Im".lagreca";.... ywnh all cifY•mJ county ordinunccn surd.ulna laws relating tv Q'I'Y. MECHANICAL PEkMIT I; � IJ -` Dp
U Z building eonxlmetion.and hereby authorlurrepresentatives of this edym enter upon the IG TE ✓�Imavc-mmriiuncd pmpurty for ins"fion pr"wes. PERMl'I'ISSUANCE rl RIC Ila? ��s(We)agree..ave,indemnify and keep harmless the City of Cal eninn against LmrdifBev,reguaran,c,,ala and expenses which may i.a.y way occere against said City AFTER OR ADD TO MECH. - no
ING FECinconsequenceofthegrantingofthispermit.
APPLICANT'UNDERSTANDS AND WILL COMPLY WITH ALL NON.VDINT AIR HANDLINGUNIT(TO 10.000CFM) ANICAL FEE
SOO C,''RIEGUI,A'FIUN}'. //
AIR HANDLING UNIT'IOVER 141X0 CFM) CONSTRUCTION TAX
Sigel cut Applicarea2urmcmr Dar— PIX HAUST HOOD(W/DUCT) HOUSING MII'IGAI'[ON hili
I iALARDOUS MAI 11 R IAL S DISCLOSURE
Will the applicant or future building rncupam slom or handle hizardnus material 11HA'I'ING UNIT('1'0 IIXL(XX)Ei'IU) fl
as derined by the Cupetinn Mtmicyy''uI Crvlq Cha,aa 9.12,and the health and Safety Y
Crile,Section 255R(a)9 / ))EALING UNIT IOfLEREID)
Dye, ^ VEN'I'lIA'IIQN PAN(SINGI.Ii RFS1DJ pAl s
f al Rn'dplM
Will flue unbind ,,Faure huddingocc',surd ase quipmcnl nn desk..which BOILPR-COMP(31 IPPR IM01)BTU)
I
mit baaallous air contaminants as defined by the Bay Arca Air Quality Management 'I OITI.: z.3
LnoO BOILER-COMP(OVER 100iHX111"FU) CSI Wit VU, X-:••
❑Yea G�4a
1 have real the harnNous nramdaln rtyuirements uoder Chapter,6.95 01 Ibc Cab-
nIR CONDI'I'IONI?k ISSUANCE DAR:
for uin Frahh k Se1ily Code Sections 25505.25133 roil 25574.1 undersatnJ that if the NEW RESIDIENTIAL.MECIL SQ,FT.
Oy eamnant.Nutitia,nymrDmx+dhymnmiythe pwn
fN imtre whnich ut Ml Pit ceof: �'cnifiamc n(( y.
Uwt r uvnlhnrimdagent t � TOTAL
OFFICE