S 3077 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPRRTINO BUILDING.-ELECT RICAL Pek/`�'M1M'.1IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL V 3077
-'.fIIUILDINGPROJIiC'f IDINIIFICAI'ION � ', °��� if
IIUILDINGAUDRESS, SANITARY NI I. APPLICATION SUBMITTAL.DAT E.
OWNER'S NAME: COMRA }{S AML:
NIC CONTROL or
ARCHITECIYENGINHEIL LIC NO. AUtG�•//))Ity$� /1✓✓l4
0 ❑
CONTACT: `, P�I%{�/� _/ a7•;�','BUILDINCPF:ftMl'f INFO ,
-G!'v ✓/ (� {!/ ❑ Consultant FecS Paid by Applicant(Initial) BLDG FL� I'1 U. N H'H
LICENSED NSED CONTRAC I ORS DI CLARAI)ON Q1Y 1 I�CC9 RIC I RMTP't ) I PE I t(t ❑
I hereby affirm R t 1 licensed ed u d p f Chapter 9(conrnem ng r ° JOB DESCRIPTION
QaZ withs i ]WO) flyvsioninfthe BusnexsandP tsunx Code,rado lieen,es /1 RESIDENTIAL:
Ey p p PIAtMI l ISSUANCE l/
��F in full Ilmr ",r;,
J c/2:1 5 / ❑51'DWL ❑KITCHEN REMODIiI.
QUO Licence Class L/ Lian APPLIANCES-RESIDENTIAL ❑ADDITION [31E.UMBING RE NPH
Z Z W Uate Convmcmr
'nQa ❑hNLTI-UNIT ❑STRUM TURAL
A CIIITECT:S OIiC1.ARA'I'I
p.,p m PANELS MODIFICATION
m Z 1 unJcrsmnA nay e)
VWnhull be used as Vuhlie rcande
O Z`L'-0 UP 102011 Ahf l'S ❑IN'1"IENIOR ❑CIILMNIiS'REPAIR
.y,L�au1 LiccmW l'mGssinnal 201-1000AMPS Ihll'ROVF,MCNT 0SWIMMING POOLS
K J OWNER-BUILDER DEChNt61'EON OVER InuUANfpg ❑BN'II REMODIiVREI'AIR ❑D1'MDL1'EIGN
6 I hereby nllinn that I um uempl from the Cono-mmr's License Law rorlhc
a U folio re-mi.(Seedia.1031 S H d Pr f Code:A Y til, county SIGNS ELECTRICAL Ll 01 HER
R13LLy which l p u t 1. d p J Ln P r t atm
W�� pnort t "I: I ''" pEl tf I
' p II I Ib lea tva.d SPECIALCINCIII'fIMISC, '
Ythath 1 :edp .-u n 0 ! ' ' fm C t ctor law(ChtiVlcr9
E+I�CO (commencing with Section 7001 ofDivision 3 fah Business dP f :inn,CWelor TEMP.MITER OR POLE INST a COMMERCIAL:
L ps o r� Ilut he is exempt thcrefmm ai line basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DC:MOIA LEON
WI Section 9131.5 by any applicant loot apermitsubjsvts l he apilart to u....I pemJlyol' POWER DEVICES 11'17NANT EJ 1700D SERVICE
=S� rebe,mothan five hundred dollars(SSW) MI'ROVRM IiN'I'
❑1.uowner of the progeny.air my enaployres with wages os their sole compensation, SWIMMING POOL ELECTRIC
t
willdo'he k and tl .t t t t J d If II (S 704 B r, -
a3m mdprofession,C 1'Th C I I s l d pplyt of OU)'Il IS SWI I CUES-IINTURES
progeny h 6 Id' r' p th d h l h A h n:If Ih ugh
his own emldyee,taresided that such im,reuvermem,me re imended.a,4fitned for NEW BESIDEN1'IAL ELLCIN SQ 1'I'.
e Ic If II 'Id 6 P t I II y pl Ila the C�FLO RI?A S/SQ PP.
her Mulder will nave the huNen ill Is ing that held not I Ad.,'nprove)npar - X
pose of eater). (J
❑ L as—re,of he See 704 am udu,veld convecting with IianseJ conwanrx m TG'rn L:
amvucl Ihep jwt(Sec.911Jy Business mW Ford luvnione
but secomets sr such apply can ownemdpacents )tobuilt) wn.mod 1; !aPLUMBINO PERMI'1'11't
who commas for such projects witnauunracmr(.)licemed pnmunnun nmchais
License Low. PERM 1' S$DAN
❑I am cxmnpt nnJer Sec. ,B tit P re.ua t
ALTER-DRAT N'I'-WATER IIIA) VALUATION
Deaner Date 5710( —
e WORKER'S GQMPI?NSATI(IN❑EChAIIA'1)O H W i' UhVICE
I hereby alarm under penalty at perjury one el Follow in de lemtionc Ik
(have lmd will maintain aCenifcae of Conw:nuo selGinrureh VhyAeh Cnmpem DRAINS-F > ROOR AR .GOND. t 'To..IS '1'YYP.CONSTRUCTION
a tion,ax provided far by Section 3]W of the Labor Cea fm th f7i'/mance ol'the
which this permit is kaasd, FI%'1'111115- :I TRAP
P1.ZC and will maintain Worker's Compensation Insunin an coma,, by Sec
t]W ofthe Lahr CtJa,for the erfonnanceofthewktate, chthislnmaitisixsuCJ. SYS' [AI-I INCJOIJTLIiTS OCC GROUP APN
My Wnrk,''C((npc 'bion mmnm arrit'nod Policory maltt: �rO / CAS-EA.BYS'TEM-OVI?It 4IP.A)
Carrier. Po)cy No.: G(.(J� I
CURTIFICATHOFEXEMITION FROM WORKERS' GRL'ASEIINDUSIRI.W'AS"1'F INI'EKCEPTC)N
COMPENSATION INSURANCEHUILDINGDIV_ISION_FEIS
('Ihissecllnn need not FcaamplemJ iDhepermil is hnnne hendoMdullar.15100) GREASETRAP
air lass.) PLANCIIBCK Il?I?
I mnify that in the perfamaanm of the work for which this permit is issucall.I shall SEWER-SANITARY-S'IORM BA.210 FT.
not employ any person in tiny umoner So as to heroin,subject to the Worker'Compcn- ENERGY FEES
Oz sation Law,of Cohromii.Date WAI ER HEAI'I ill W/VENT/FLEC I'It GRADING I'lili
z Applicant
NOTICE*10 AVPLICANC 11;ido,making this Cenificnte of Exemption,you should WATER SYST,cto.. 1RC,,,NG SOILS ItiE
a hesuhject ,,the Werke,Compensation prnvi.ium of the ,y
LaMn Codeou n est
fonhwith comply wish such pmvi,mr,air this genii hull bedeemedInvoked. WATER SERVICE:
a �
CONS"TKUCI'ION LENDING AGENCY NEW R15101iNT1AL PLMII. SQ.FT PAID
UO 111'emy ld'I1rm Batlhme is aronemnlEoll lc ingngcwy for lhuperfomm"c of Dnte eceiptx
t•+ the wndrorwhichtbispennitinissuul(Sec 3097,Ctv.CJ
O IJ Lender's Name - 'I(ITAL:
Lender's Address TOTAL: /
W - I acoldly ts I have road this opplicminn and seam that the art nlonnmin
ve iun in - BUILDING Plili
W hu
F" H correct.)agree b,comply with all city and county ordidenres and stale laws riming to 'QTY.- MIECHANICAL PERM IT "FF:F,
U ,2 building construction,and haehy amMrize reprcsenmtiven nfthis city menterupm the SIi15MIC FF.Ii
"-I above-nimLomel P,,,peny fm inspection fulfiller.
(We)a use to save, ademnif it harmless the Cit fCemnln9 andnnt PI!ItMI'I'ISSIIANCI / BIICI'KIC PI?I?
S drra p yo I S .
liabilities.judgments,ronsandef,hi,pswhich may in any wey accme against said City ALTI3k OR ADD TO MELCH. /
PLUMBING ITE
in sequence of thegranting Sthinpermit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Allt IIANDLINC UNIT(T(I 10,[NNI CIM)
SOURCE kEC -ATIO h11iCIlANICAI.I E
7171 7171 AIR I IANDLINGUNIT(OVER 1),(NN)CFM) CONSTRUCTION TAX
Sij,onj�AAqEj1hcmjACommcmr ! `l ate EXI MUST 11001)(W/DUCT) Hot SING MEI GA'I'ION FIEF '
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hafatdous mmedel HEATING LEN]'1'(10100.01)BTU) s
ns drained by the Cupertino Mew Cade,Clove,9.12,end the I Eculm and Sefoty -
Code.Section 25532(ti)9 HEAPING UNI'I'(OVER 1X1,00)It'1'G)
E]Yes VENTILATION PAN(SINGLE RESID) PAID --
$)ate Receipt It
Will the uppli,nd or I'umre buiAng accupam use equipment or devices which a�
emit hvandnus at, mbaoname,as defined by the Bay Area Air Quality Managmnent B(111.1?K-COMP(3HP OI111NI,pfNl lfflp 'TOTAL
District^ I_ / BOILER-COME'(OVER 100,00011TO)
F Yes IYXJ
I have maid the haeunlnus materials(equinnmms under Chapter 095 of the Cali- Al to CONDITION ER / ISSUANCE(JUTE n
fomia llenith k. fay Code.Sections 25505,25533 and 25534,1 ameestand that if the NEN'RESIDENTIAL MECH SP IT. / Na(m/-] i� 1
huildingdaws mlyhuveu tenan''hxt it ismy renpmodultry,¢a otifyl crop t le re rel s 'eh man he net prior to issmance of u Ceni lc I'(
0 ht Ger agent Dale 'f('ITAL SSUED BY:
OFFICE