S3072 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING,-ELECTRICAL PE ITNO
BUILDING DIVISION ,1 APPLICATIONIPERINUT PLUMBING MECHANICAL 3072
.� BUILDING PROJECT IDENTIFICATION
HUILDING ADORES .���A LN 3 4,,,-t ' SANITARY NO. APPLICATION SUBFITrTAL DATE
t OWNER'S NAM ' PHONH: CON RAM OR'S NAME LIC/[JOYIfCONTROL
Ell- 3N � H SNL 6�ISas NA «
ARCHHECTIENGINEER: LIC NO ADDNISY ❑
L"OWACEPHONEp BUILDING PERMIT INFO
❑ Co..IWnt Fm Paid by Applicant(Initial) BLDG HIAICT PLUMB, MECII
E!r
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEB L—Ja/ LDJS
1 M1neby efhrm mm 1.,it ficcnttd node.prnai,i t,of Owgm 9(mlmtezmg JOB DESCRIPTION
MWZc,o with S0.Ii.m 7*llporDivivion JOHN:B,mi ,wd Pr,fca,ionx/Cralc.anlnry licm,c iN I'I!kF11'I'ISSUANCI! EIAL
1- Ili full fnrce and ell"'. �//�1 WL ❑KaCHEN REMODEL
�UU Littnso Clan hia* D J" APPLLWCES-RISIDIMIAI. ❑ADDITION El PLUMBING RIi-I'IPIi
F 4w Um, CMItMIu
mQa N I ❑MUhTh UNIT ❑STRUCILRAh
],� ARCI{IF.CPS DECLARAT N PANIJS
R'onZ Iuttdcr,und my Plana shall he used as public rtt+odx 310DIIlCATION
ZOONO UPTO 1(MIAMPS ❑INTERIOR ❑CHIMNEY REPAIR
WLianaW Profs mcmal 1,11-l"AMPS IMPRONDIENT 0 SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER111(OAMPS ❑BATH REMODEIIREPAIR Ll DEMOLITION
C Q 1 hereby of irm Ihm I am caem t from the Cmtr,O'n,Liveme law fur the
folktwing tc.,(Section 703 1 5,Bmirv,,anal Pmfcesion,Cock:Any city m comm, SIGNS !CT
ELIR,C Ll fyl'HER
ly 3(y w velli n y Imt'I I her n* d Bth In. err xwrmre
��� prim t I ': uku cy ' II Pram If 'h Pcn itl rl ), detaentcm SI'IiCIAI,CIRCUITTII,
Ihath I d,m, a Ih P nn nhcC tract r I W ,(Capt,9
{i1 00 (oommcncing with Section 9q*Bof Division 3 of he RUNrcw,nW I-nd—ions Cede)or FFAIP.MIU-ER OR IS INS') K�C.GROUP
AAI.
a L e C that he is exempt therefrom am,the basis for the alleged exec mon.Any violation of NEWDC✓ADDHHON ❑DEMOLITION
-vLLi Section 703 I3 by my t rlicant for u permit mbjecu the aploG,aru to a civil prultY N POWER DEVICES ` ❑FOOD SERVICE
nor more than f ate huodrnl"lan(3-s(IOF EMENT
FZQ ❑I.wwxrof Ue pmpeny.mmy emPu hem with w�Ha as theirwk canprncvim. SWIMMING POOL ELECT
will do the work.am themmorm,is not imerdcd m olricd for W (Sm.'/DU.Busivw.
F
13 Do i,, no
CNe:The C 0hemr's License taw id�,tic tot apply , w mmr of (IUTI.ETS-SWITCIIIS-PIXI'L S
his
,in
who build,w impnrva tberton,wd who door,wh work him.wlT,r thnta8h
Iris ion empinyett pnrvldwl Ilwl euc'h inlpmvenenln am nm immrdW nv elTcndfnr NEW HISIUIiNfIAL ELI!CI'k SV I�T.
Lath,lf,Inrrcvcr ted buddin,ornr,nwanmm i,odd wjOj,ion,,.ofcomp1,ln..the IT.Il,r10H AREA SISV�PI'.
1�"er-baider will hmc Ihu Wrdcn of povm t ,he did no,build,v Intl"^vu Fortin, U l D
e,I(led, //Trf.�.�
I,a, the of 1 Sm 71neaclu,ivmy cowxwors with:)The d ctrurnctox to T4- .J I 6z) XF
moveLao the proy:ct(Sm.2D+L Bmir.l. am Pmfc„i,m CWc:1 The Cmtrami Li
batt Lew dies trot applymwnoarer of ptgenYwM built4mimpmvec thtvmn.md QTY. PLUMBING PERMIT
who cmtrrN far such Fu*m with a c000xrar O limmac,d Nnuwi to the Cwtnchtr,
Lion¢law. PERMIT ISSUANCE
Ej 1 wt c,empt order Sec. .B R P C for this nvwn
ALTER-DRAIN&VIWI-WA'IT:R(EA) VALUATION
Owlter Owe
WORKER'S COMILNSATION DECI.ARA'1'ION RACK 11-OW PROTECT.UINICH DpI hetehy aRnn under l Othy0 perury one of the loll—ing dvcly Boni:Iluve and will maintnna CeniOcate ol'Gmvert in ttlf-inruee fmWorkersCompeer- DRAINS-FLOOR.ROOInARHA.COND. ORIES 111T.CONSIRUC-HON
.tion,os ovded for by Secdim 3E1of the tabor Cede,for Ihe Pfmutice.of thework for uldch Ni,permit ix ii.,led. M%TURES-PER TRAITL❑I have aril will maintain Wmr e,C.,,criation Imurw,c,u reuited bySectio3'7W of the labor Cede.fothe pefo i,cifthe wvrk fo which thi,pennia L,i,w GAS-EA.SYSTEM-I INC.J OUfLITS .GROUP APN
C Wada', an ttxvrion sura cudcr wd Policy nu bcr wc�— GAS-I!A.SYSTGN OVIiRJ(P.A)
Carlen PMicy No.:
CERTI" Ili OF %EMPTION FR OM WORKI! $' GRE.ASF/INUUSfRI.WASI'I!INI'ERCF.PIT)R
COMPENSATION INSURANCEUILDING DIVISION FEES
('Ihl,m:tio i nced con Mcm.id"Mirmi,'.oil'd lir moblmdad&11—(51 W1 GREASETRAP
m Icva.) PLANEI! D
lornNd
ify in the ptrfonuttccoflM:wmk fmwhich lhizpemtit ix is,m .-,Llahvll SEWER-SANITARY-STORM EA.2011 FT.
no employ very parsec in any manner uo ti to ccom sobjeo to the Worker,,Comr,co- ENERG LTL'
Z ,tm.lave'.(Celifoniv.law W'ALER HUTER WAIENWELEC R
ZO Applicant G 'G
h NOTICETO APPLICANT:If.after rtbkotp this Cenifcarc of Exemption.you,hold W'ATE'R SYS NIMRE.ATING
F' ? Femme o ma
object to the iwmvLd
WMef,Com,rno pos of the laNe.hnr Cyst stills
Wform.ith comply withNlwh proviiin.,I Nis pe.it,[mll he derm,d]my^ked. WATER SERVICE
Q
7Z CONS I'RUCI'[ON LENDING AGENCY NEW RLSIUENTIAI.1'1,1,11. SQ.EI
SQ,
U p I beorbydEml toil lhcm lc
ixvumzlmclmn m1ingagc1wv tir m
the Ndowoeo of Doc kmcigM
L. tow wok Towhich Ibis pt:nN na i,IawIre,3N7,Civ.C.) nV
b" Iatdcr,Narte
U Lack?',Anlbc,x TOTAL
} IT] BUILD 'G PER
6. L atm that 1 lave trail thin appliceriun and,tate that the,hive in real im u
F- N Nildrigivomewcor,and w,,chyaityatd c^wtyonivat eattdwatelawordminem QTY. MECHANICAL,PERMIT PEE
U Z buildin8mwmctio.aM Mehy wthwriu rege,entati,v of this city l^mter upm theSEISMIC �:E
ko
Wove-mmimmed M'M'led impaction purpose,. PF,RMIT ISSUANCE.
(We) me m dmtmnil karm
cove,iify eep hlw the City of Culemmw again, ELF.CIRIC �ili
agr
Iiubilitic,jtWBmmmv.cosl,atdva,r,cxwhkhmay in wywuya<cmc again,old Cil, ALTER OR ADO TO MECIL
P UMHING
9on. ucwc the INP
AI 'LICAN9UNDERSTANDS AND WILL COMPLY WI HI AL1,NON-POINT AIR HANDLING UNIT('1)III,(r)(1 CFM)
SOURCE REGULATIONS,
MI?CTIA N 1414. f
�(' / � ��� AIR HANDLING UNIT(OVER 1(1,(x*)CITU CONS U IIN'LAX
Si�nuurt pplicarp/Cmlt/mct✓rc Ihte EXHAU.STHOOD(W/DUCT) HOU. G UTIGATIONFEE
HAZARDOUS MATERIALS DISCLOSURE
will Neapplicvu o future wiMtitt6 ocedrwor,rore or hemlle b .'material HFI.TING UNIT(TO HIC.UI()BTU)
aN&fIn,,l by the,Cu,,mm)Municilml Code Chvptcr 9.12,mid the health wtd Safely
Code,Section 2553201? MUTING UNIT OVER IWjffl RTU)
Cl Ye No
VESHD ATION FAN SINGLE RPSID) PAID
Dmc Raeiq#
e WIII the rytpllrvm a forum building ucenPam um ryuipnuml or tkvices wM1ich
mil haesrdous air mnL,ninams as dcOrcd by led:Hay Area Ar Uuultly Mwagcmm�l IfUILI!R-EOMI'OIII'Ok I(XI,(XX)If TU)
Dixtrin? HOILIBf-COMP(OV ER HQ(HIO BTU)
❑Yes ❑Nn
Lluve tem de luuvnbam nwu*iWF requbeocrv.utaler CTupter695 ofthe CWi- AIR CONDITIONER ISSUANCE DATE
forria Health&Saluy Cade.Secdmn 25505.25533 am 23311.1 m alm,m d dor if the NEW RESIDENTIAL FIECIL SQ.EC !Y:—dov rotc.11 have-led .tim it bmyt PamiHlit)'tat nt-fy thea Pemrofthe reyuimatrnn which mm,be metrim to iv,t of a Cmificme ofOu,mc,. (((O,mr m aathn i,,d]"ern Da¢ TO AL: ISSUF-D
OFFICE