S 3083 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL PERS[f NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL �J 3083 -
BUILDING PROJBCf IDRXI'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'TT'AL DAII
OWNE "NA PHONE. CON'IFACTOR'S NAME: LIC NU:
NIC CONTROL#
\� ARCHI9' T/HNG EC LIC NO'. A)DRESS: ❑
\
CONTACT': PHONE: L' BUILDING PEIRMIT INFO .
t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ S�
LICENSIUCt IRAC RS DI CIARATION QIY.� - f:LIiCTRIC PERMIT 'el` IF.P
In ny n uhtl r w J p rrl 1pta9(e11tn "g ,/ JOB DESCRIPTION
Q=z lh5 i ]INX11 f6 hdlhe Rua dP f 'si ms Axle unJ mylic nwu REST DIiNTIAI.:
W 00 1'1 RMIIISSUANCF.
F W n W f R I n J t ❑SIDWL ]KITCHEN REMODEL.
aUF L; Class
QLic p � Ob101S
UAI PLIANCi,S-RESIDEN9'IAL - ❑ADDITION ElPLUMBINGall PIPE
FZW Date—,- Con _
NQm' ARCHITECTDECL
S DEChARWN N ^� ❑MULTI-UNIT [I STRUCTURAL
Z pr7/)Z I wedentami my plans shall be used as ptibbencOmda
PANELS MODIITCATION
OZ=O UP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Na,4tW Licensed Professional 201-1000AMFS IMPROVEMENT ❑SWIMMING POOLS
Cu J OWNER-BUILDER DECLARATION OVER 1000AMPS ❑PATI I REMODEIIREI'AIR ❑DEMOLITION
CLWQ I harch,iffiner that at esermlf the Comint L law fir the
3 L U fall g t.(Sref,,an 7031.5,11to.two,a I P s C 1 A y city m county SIGNS ELECTRICAL ❑ HER 1
ra. xh b q pe mtt construct. It nEn J loo P' day structure ]. pr P
LLOat p.li t '1 I ' ch ppl' tf Ip ott 11 ig Jamenient SPECIAL CIRCUIT/MISC. `
T.•77 m 1 licensedpursuant fi p nfth Contractors I Law(Chapler9 �`�,��
W
W �p (ennmrtc'n6wlb SWon]OXbof D'v'i n3 flh H . text dP 1ssions Coch,)Or TEMP.MITIMR OR POLE COMMERCIAL
a a c tG that he is exempt therefrom and the basin for the alleged exemption.Any violation of ❑NIiW BLDG/ADDII'I(1N ❑DEMOhI'I'ION
m Section 911315 byanya,lirnnfin ra peonI,objees theappliecun m a civil prauhy of POWER DEV]CELS ❑1'17NAM ❑FOOD SERVICE
no,me than five hundred dollar.(b($500fIMPROVEMENT
C
E] 1.xs orowner of the property,or my employees with wages as their sole wmpenmltinn, SWIMMING POOh EI IC
P. will do the work,and theouumure is not intended or offered bat(See.lnLJ.Business - ❑ITIIIiR
ua]13'm and PrifeW I,Code:'rhe Centruclur'x Licelvae Low dopa Bol apply to an owner of OUTLE S-SWI'( IES-FI%TURES
G pmpeny who builds or impmva thereon,and who does such work himself of through ffAY Ills Own employees,prvided that such i"yuovenremts six not incanted nr offered lar NEW RESIDE 'IAL EIMCIR SQ PT.sale If 1 lh build g p t t Id ith' y f pl Yon theSSISQ
w Id llIhav t h I fp gtnl 1I 1M1 IJ Iopurf 1 ) 99
I] 1 ftl p ,er 1 ly I6 'lI' t t lorea ((ITN.:Ont l th prps(S 91DJ Ba' e. J P f CLI 1'Ih C t l rs L Il l Ewa Ilol appgl snow cr ofpn ps ly sum nn idlrr mpr a nlare�l and QTy- ;� PIUMBINC PERMIT, l ' IfHF
who contmets mr.such projects with o cavmeuu(s)licenwN punuant to the Conlmul "' � -I Ej [,amLuw. PERMIT ISSUANCE!❑ lam exempt under See ,B&PC larthis reason
AUH7 -IIRAIN&VENT'-WAFER(BA) VALl1Al'ION
Owner Lie
WORKER'S COMPHNSA'I'ION DECLARATION_ BACK FLOW I'NO]'HC'r.DEVICE
• ❑ Ihereby affirm under perthy Of Perjury ane Of the fallowing Jeclaraions:
I hn �--'
vOandwillmaimaina Cenlficamof Conal In on-inalle fur Wmkcrs Corpen" DRAINS-FLOOR,ROOT,AREA,COND.
STORIES TVPIi CONSTRUCI'IOD
amino,as provided for by Saloon 390)of the Labor CoWe,for tM1O peRommncc of the
work for which this pennil is issued. I11X'I'I1RIiS-PER TRAP
1 have vol will maintain W'orker's Compensation lownews,as require)by Section
.] ofthe Labor Cade,for perl'nnn:mce Ill the work tow wh,hit isp �lis isweI GAS-F"A.SYSTEM-1 INC.4 OUTI.E�' OCC.GROUP ANN
an da br and Policy our arc: WC!
My WykFrk Coln GAS-EA.SYSfEM-0VIiR4(E
Camel ��1 e •m ('ION Na:
ChRTII'ICAI'F.GI1 EXI!MPl'ION FROM WM IM�� GRIiASEIINDUSTRh WAST' N'FERCEPTOR
COMPENSM ION INSURANCE BUILDING DIVISION FE _
(This section need or he completed if the permit is for one hundred dollars($100) GREASETRAI'
or lever)(This
IYH!"
I cenlfy'flat in the performance of the walk for which this permit is issued,Ishot] SEWER-SANITAR -STORM EA.201 FE -
notemployanyperson inany man,,, Ias to hecone,chw, ,,Ne Workers'Compcn- ENERGY FEEE,
C) ZIfornio.DUIa WATER IIIA'H /VENI'IELFCIR GRADING FEE
2 Applicant
NM ICETO APPI.ICANT:IC altar making his Certlficum Ill Escmplinn,you should WATER SYS :Mn REM ING
become suhjca m the Workers Contpen.sation pmvisionc mf the Labor Code,you mum SOILS FEE
W finhwilhenmply with such pnrvi'iomor his permit shall Ndeemed revoked WATFR.':RVICE
W Q
z CONS'IRIICTION LGNDINC AGENCY NEW ESIDI!NTIAL PLMIi. SQ.1.7. PAID Dote Receipt#
U Q (hereby affirm that then in a construction lending agency forth#perfommna:of
'lie seats r..rwn]1h lhls pmmif ix Isaual(Sec,3097,Civ.C)
V" Lenders Name IOTA 1.
U Lento's Address TOTAL
'��y'• 6Wi l certify that l have read this application and state Nat the lithos,imorrommn is -(;. Bl11LDIN0IIiE
F. zf correct I egress to coolly with all city" d counly ordinances andot laws odaengto QTY '. . M17CHANICAL PERMIT j FFI
U ,�Z. bolding construction, dh by um representatives ll Of this city to enter alar tiro SI!ISMIC FCh
davr me inumd pr 1pv ly 1.11 i ,legit l p umrsca, PCI3MIJ'ISSUANCE
(Wed agree to save,indemnify and keep harmless the City of CupertinO against ELECTRIC FEE
habilllics,judgumnts,111115 and cxpcases which ones or any wayicena'agalnm'aid City ALI17R OR ADD TO MUCH.
PLUMPING FEE
in consequence of the Rnoting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR EANDLINO UNIT 1101(1,1X%1 CFM)
S�REGULATIONS. CONST MECHANICAL TONT t
P b % ^1A AIR HANDLING UNITµ)VI!R 10,(X CPM) CONS"rltUCl'ION'1A%
Signalare NAp�r�antms'r ` Duo EXHAIJSTHOOD(W/DUCT7
DOUSING MITIGATION PP.Ii
I IAZARDOUS MATERIALS DISCLOSURE
Will lhempplicurd furore building rwcupual"I'm-1 handle haeurd9us mmerill E I EAT]NO U N IT ILO 1 W,000 B'FU)
is defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety _
Code,Section 11532(a)9 HATING UNI"T(OVER 101,000 Ill U)
C3 Yes `y- VENTILATION FAN PSI NGLH RE.SID) PAID
Date Receipt
WIII the applicant nr from building owcupam ase equipment m devices which
con,homMOus air canaminam.as defined by the day Arca Air Quality Management BOILER-COMP(3HP OR 100,000 BTU) 'TOTAL:
D11111119vid^ BOILER-COMP(OVE!R 100.0011TU)
❑Yes ❑ryw
I have rad the limandom.s mucria6quire
rements under Chapter 695 of the Cali- At It CONDI I'IONI!R ISSUANCE DATE.
fornin Health&Safety Code,Bruton,25505.25533 and 25534.1 undemmnd men if the NEW RESIDENTIAL MECH. SQ.FT. cp
building docs not currently hav#a remain,111,11 it is Illy responsibility to notify the megnml J / V"
1 ,rapd r 0111,11¢which Breathe met prior In issuance Oda Certificate of Occupancy.
, TOTALOw' nuar alug ISSUED Hy. 7t--lm
OFFICE