S 3873 (2) APPLIC♦ANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ��;/1 � U LU�— C.// / G,
CITY O'M CUPERTINED BUILDING-ELECTRICAL PI7RMIT NO.
BUILDING DIVISION APPLICKFIONIPFRMIT PLUMB NG S 3873
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITIAL DATE
1 obZ 0 , T rZ -,?
OWNIiRf N m1' � PHONE: CONTRACTOR'S NAME: LIC NO
N/C CONTROL p
1 , io, e
ITI'ECDEN INE`,R: /LJIC + ADDRESS: ( ❑ /�
ar
61
CONTACT. PHONE: BUILDIN PERMITINFO
- �Q�I I&6 ❑ Consultant Fees Paid by Applicant(Initial) RLUG ELECT PLUMB MECN
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S D17CLARATION QTY ELECTRIC PERMIT FEE
I hereby afm,n that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
OW CC) in crti avdeRec Division 3ml'the 11-mrssnnd Pbd,,,iar Ccdaaed my license is ^ ^ RESIDENTIAL:
O O PERMIT ISSUANCE
Fy— ❑SFDWL ❑KITCHENREMODEL
C U F- License ClassLic.p
¢Z V APPLIANCES-RESIDIiNT1AL ❑ADDITION ❑PLUMBING RE-PIPE
yQi Dom Camraen(
ANCHI'TECT'S UECIARAI'ION ❑MULThUNR El STRUCTURAL
p.,O to PANELS MODIFICATION
Z O H m
Z 1 undersnJ my plans shall hr used us public records "
JZ—O UIf0280 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
yyFY1 Licensed Professional 201-1000AMPS IMPROVEMENT DSWIMMING POOLS
YF OWN[R-HUILDER DECLARATION OVER IM0A ❑BATH REMODF,L/REPAIR ❑DEMOLITION
x ¢ 1 herehy affirm thin 1 am esempt from the Cmita s License Law I'or the
y 3 LL F following reason.(Section]1131 5.Business and Professions Coda Any city or county SIGNS ELECTRICAL ❑OTHER
y which namres a permit m convect,altaq improve,demolish,or repair any stmcfmrc
F't=-�Q prior In its issuance.alto reyuirea the applicom lar such perminu flcanigneA.aatemem SPECIAL CIRCUI I'
ug Icomenclic,ns pmrwam tofisc ofDhviowof the Business
Lie emu LawlChapmr9
�y0� (commencing withSeetion]g10)of Divizion3 afthe Business and Profession Care)or TIiMP.METER GR POLE bNST COMMERCIAL'
EL Lx e c that he is cacmpt thereftom and the hu,1 ka the alleged exemption.Any violation of ❑NEW BLDG/AUDITION ❑DEMOLITION
W^m Scrota,]1uL,hyany applicant for.perhatsuhjcetsthe applicant a civil penalty of Pc iR DEVICESB [3 TENANT ❑FOOD SERVICE
t more than five hundrerf dollars($50l IMPROVEMENT
F.
n1.as owner of the property,or my etnployees with wages as their sole compensation. SWIMMING POOL ELECTRIC []OTHER
E'Oo will dome work.molds,%tructuri intended material for sale(Sea A044,Bushmss
L 3 err and 1'raresoons Code:The Contractors License Law does not apply m un owner uI OUTLETS-SWRCHPS-FI%TURFS
proprny who builds or improves thereon,and who does such work himself,r through
his we employees.provided that wch impmv,m,m,am not intended m offered for NEW RES[DF-NTIAL ELECTR SQ
sale.IL howeve%the building or haprovenent is sold within one yeurofcantplUinn,the SQ.IT..FLOOR AREA $/SQ.E..
mer-builder will have the burden nfpmving that he did nm build or impmvc forpur-
pase of sa1cJ.
0
�I ,k
1,as owner of the papery,atm exclusively contracting with licensed comnnohs to TOTAL: 79, oC •�,1'./ �Y 32,0�7/r
construct the parapet,(Sec.]BWI'm
,Business uad feainn CW,I are Conmxmr's I.i- G�IP
rim,alaw does not apply Earn owner of property who on Ids or unproves thereon,and QTY. PLUMBING PERMIT FEE p
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor's �• 1 - OQ 6,
License Law. PERMIT ISSUANCE 7 f
I am esempt under Sec. .B&P C far this rearm
ALTER-DRAIN&VIJJ'1'-WATER(EA) VALUATION
Owner Umc
W' 3`5 r,�.{^
J
WORKERS COMPENSATION DECLARATION BACK FLAW PROTECT.DEVICE. / P— O 4D
1 herehy,from uMe,penalty of perjury one of the following declaratinnc J
I have and will maintain a Certificmc of Consennn wif insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONS'1'RUCTION
.Sion,as provided for by Searm.3400 of the Labor Gde,for the Pormar ante of the
work for which this P am t is issued. FIXTURES-PER TRAP -
❑ 1 have and will mulumin Worker's Coorpcnsetien Insurance,as required by Section
37IXl ofthe Labor Cnk,for the perfourance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Worker's Cnnhtamer pensatimt murmac mer and Policy oundeaF aM
Carrico Policy Na.: GAS-IA.SYSTEM-OVER 4 TA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASF/INDUSTRI.WASTE INTERCEPTORC'OMP12NSKI ION INSURANCE BUILDING DIVISION M-ES
TRtis union cited nm be ronoplihod ifthe permit is furore hundred dollars(SIM) GREASETRAP
or lea.) PLANCHE 'E Q
Isenify that in the perfompancc of the work far which thi>permit is issued,)shall SEWER-SANITARY-STORM EA.200 FE "E
not employ any person in any manner%a as to became wbject Io the Workers'Compen- F.NERG < O
zcation Law—If California Date WATER({HATER WNENf/ELEGTR
ZO Applicant GRAYM
to NOTICE TO APPLICANT:If.after making thio Certificate of 17-caprin.you should WATER SYS I EM/IREATING
?
heroine subject m the Worker's Coavpensatian provisions of the lana Cade,you must 7PAID
forthwith comply with such provision or this permit shalt be deemed revoke. WATER SERVICE:
CONSTRUCTION LENDING AGENCY NEW RGSIUIiNf1A1.1'LNB. SQ.FT.V O l herebyaffirm te there is a cm.muction lending agency for the performance of ate R«cipt#
the work for which this ermit n msu rd(See.309],Cie C.) �7ULenders Name LI<ndrTs Address TOTAL:I codify that I have need this application and state that the above information isF, •O
Er H rather.lagmen,comply with all city and county madiramers and stare laws relating mI QTy.. MECHANICALPERMIT FTE EE
O Z buddingmte
csstruution.and hereby amhmi/e mprewahrlves afthiscay to enrupen SEISMIC the �G • t5
ahovcmcntioned property for inspection purposes. PERMIT ISSUANCE. ELHCTRI IEE •
(Ve)agree m save.indemnify and keep hameless rhe City of Cupenitm against
IiabiliAcs,julpinents.aanm;md expcnux which may in any way Seem,against said Cip ALT ER OR ADD TO MECN. GFEE �,
in ,sequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 0.M0CFM) MF.CHANI ALIKE d'-
SOURCE REGULATIONS,
AIR HANDLING ONETIOVER 111,880 CFM) CONSTR CTION TA% g� 3
Signature n(PpplicanUCommctor Data E%HAUSI'IIOOO(W/DUCT} HOUSIN MITIGATION IEE 'O,OO
HA%ARDOUS MATERIALS DISCLOSURE
Will thnaDth,anor fare.lamidingacrupsmxmmorhundle haznrdoox material HEATING UNIT EEO IBH.B00 BTU)
as define by the Cupertino Municipal Code.Chapter 9.12,and the Health end Safety
Cute.section 255321S0! HEATING UNIT(OVER 1110,0110 BTU)
❑Yee ❑No VENTILATION PAN(SINGLE RESIDE PAID Dam Receipt#
4 Will the applicant or future building occupant use equipment or devices which BOILER CEHP OR 100,000 B'N)
nit hazardous air contaminants as defined by the Bay Area Air Quality Management 'TOTAL.
Inricn.. BOILER-COME IW,000 BI IL / �r
Is 71 yes C)No #T / ��♦ /
1 have read the hamrdous mmeriWs rryuircmcros uoArr Chapter fi95 ofnhe Cali- AIR CONDITIONER ISSUANCE DATE
biota Hcalth&Safety Code Sections 25505.25533 and 25534.1 understand that if the ,NEW RESIDENTIAL MECIL SQ.EL
Wilding does not correctly have a tenant,that in is my re,sperema ity m notify the trecupant
of tire reyuiremem.v which must be act prior to issuance of a Cenificam of Occupancy
Owner or uahorize t car Doe TOTAL: ISSUED BY:
OFFICE
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