S 3006 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 4U�pCTRICAL PE IT NO.
BUIL141NG DIVISION APPLICATION/PERMIT Ul 'CAI. V 3006
F.NT14'll'ATION
BUILDING ADDRESS: SANITARY NO. APPLICATIONSURMI1"IALDATEPHONE: CONTRAC'TOLIC NO:
99 / _ 0I/ N/C CONTROh#
A CHITECT/ENGINEER: b LIC NO:O ADDRESS: // ��1 ❑
era, [NNS C AYI
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LIC17NSED CONTRACT'OR'S 1)ECLARAT1ON QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby,from that I am liecnsud under provisions of Chalon 9(commencing
MWZ witb Seniors]tgOtnfDivisionJoftbenosiness and Rolesxions Cole.andmylicensik RESIDENTIAL;
M O p PERMITISSUANCE
aF lyU infullforcevvd-eTl�Y'f� '-'�,^ 677 'T02 0ADDIEl I ❑PLUMBINREMODEL
UV Liemrsn Clgss l l.lc'N pPPL1ANCE$-RESIDENTIAI. ❑ADDITION ❑PLUMBIYRALRE-PIPE
�W Date Coma,' [I MULTI-UNIT ❑MODIFI URAO
ARCHIt[C'1'S DECLARATION MODIFICATION
F.,7 y PANELS
'Z O y�
w IZ I undcamnJ at,plans shall be moas public records
UP TO 2(NI AMT'S
O rZ�F+� E3 INTERIOR [I CHIMNEY REPAIR
W Licensed Professional 201-100MAMPS IMPROVEMENT SWIMMING POOLS
C4Y J OWNER-BUILDER DECIARATION OVER IW)AMPS C1 BATH REMODEUREPAIR ❑DEMOLITION
ceC Q 1 hereby affirm that 1 am exnnpt from the Contranar's License law far the
O 6 U following reason.(Section)031.5.Business and Professions Code:An r count El OTHER
�y( Y city o Y SIGNS F.LI?CI'RICAL e'
LL1�+LL y which requires n permit re cores the,ppee improve,for such
demolish,or repair any swmnre
that hoits slcense pursuant in
thevisrookntfor such Permit Licensle ae Law
(Chastatepter
SPECIAL CIRCUI'T/MISC.
}J thatheislicensed pursuant A the provisionsof the the Business
License LawsCode) 9
(hot he is ng withmiliion]INNo ofDivision 3 of nal alleged
a.sand mfinn.Any
vii Code)or TEMP.METER OR POLF.INST. OMM'LI JA
that he Is exempt therefrom no the basis for the alleged applicant
to Any viPen ion of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y nSection ot mom than
any hundred
dollars($5Wmit subjce¢the uPPlicam toacivil penalty of POWER DEVICES ❑TENANT [I FOOD SERVICE
y not mare then roe hundred dollars($SW). IMPROVEMENT
fa0 ❑I,as ownendthe propeny,onny employees witM1 wnget as their sole cnmpenwrioq SWIMMING Iq>nI.ELECTRIC
will do the work,and the nmcore isnot intended oroRered forsale(Sm.70TL Business [:)OTHER
{ay�m and Professions Code:The Contracmfs License law does not apply to un owner of OUFLUTS-
SWITCHES-FI%TURES
6'3^ progeny who builds or imprnves(hereon,and whit cows such work hi muff or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL EL17M R SQ FT.
mle.If,M1awever,thehuilding or imrove
pment issold wiminone yarordeompletim.the SQ,1-7.FLOOR ARG
marombuilder will have the batden of proving that he did not build or improve for for.
'we of sale.).
❑1,as owner of me progeny,am exclusively contracting with licensed contractors w TOTAL:
came uct Law mpmje«(Sec.nan owner Businesof
and Professions builds
or in1'he Com marine,Li-
came
i- -
c xel.uwdeesnwupplyman with
se(popny who buildsoruns it)
Contra.anJ QTY. PLUMBING PERMIT FCB
who nnlracts❑nsncM1 pattens wim a commcmrts)liansd pursuant m the Commctors
License Law. PERMIT ISSUANCE
I am exnnpt wader Sec. ,B&P C for this leaven
ALTCk-DRAIN&VENT-WATER(FA) �-VALUAI[
Owner Date
WORKER'S COM PF.NSATION IofduefRATION BACK ROTECT. ;,VICE
have
and will
under Penalty of ofCoyenenfinefnllowinr decWrks,I u
❑(have and willmaintain sCeni 37M of GenomeCode.orere Worker's Compem )RAI .NOG RG, STORIES TYPE GQN$TRDCIIGN
` soba,,as provided for
pe by Ss issu 3]W of the Lobar Crede,for the perfnrmunw of the
work have
and
this permit is issued PI -P N AP
❑1 have and will maintain
m WmCompensation Insurance,as by Section
3]qofme LtnrCadle.for the performnnce of the work fm which
this
permitisissued,
GA.- -A.S -I OCC CROUP AI'N
My Werker'a Compensation Imumnce carrier and Policy number are:
Cartier: Policy No.: OAS-IIA.SYSTEM-OVER 4(EA
CERTIIICATTi OF M- EVI TION FROM WORKERSDUSTRI.WAS'T'E INTERC NOR
COMPENSATION INSURANCE BUILDING DIVISION ISIS
(Ihitsectien need ambecompletnd iftbepermit is foronehundreddollon( K(y) GREASETRAP
PGNCIfECK PEE
or last,)
I certify that in the ped Promise ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.2W FT.
ENERGY FEEnot employ any person in tiny nnnnersYeo`u' ` «to the Workers:Compcn-
O Z sation laws piCalifomia.Dare 1__� WATER HEATER WNPNVELECTR
0 Applicant IS. GRADING FEE
q NOTICE T PPI.ICANmf1': t Cenificuns of Exemption,you should WATER SYSTENU TREATING SOILS IEE
F became subjeci tii kers Compensation provisions of the Labor Cede,you must
IX � tnnhwim comply with such provisions or this permit shall he declared revoked WATLR SERVICE
WD
CONSTRUCTION LENDING AGENCY NEW RESIDENT'IAL PLMB. SQ IT. PAID
U0 1 hembyvltirm that mem co
is. lcndingagency I-,the penfmmoncu of D Neceiptp
Uthe work for whlah mit prmb is issued(Sm.3097,Civ.C.) TOTAL:
O Lenders Name TOTAL:
U Lenders Address BUILDING cH
'> W I cenify that I have read this nPlEletien and tote mat the shave information is
r�. N7 nmecLl agree tit comply witholl city and county onli Panes and state laws relining to QTY, MECHANICAL PERMIT FEE SEISMIC EtcE
U G building consrmetion.and hereby aumerize representatives of this city to enter upon the
dausemmnioned progeny for inspection purposes. PERM[T'ISSUANCIi O ELECTRIC
(We)ago=to save,PoEmPify and keep hamdess the City of Cupenine against
liabilities,judgments,corm and expenses which may in any way acerae ugnnsr said Cry ALTER OR ADD TO MECH. PLUMBING FE.
I.consequence of the granting of this permit.
APPLICANT UN DE RSTANDS AND WILT.COMPLY WI'III ALL NON-POINT AI R HANDLING UNIT(TO 10,000 CFM) MECHANICAL FIi
141
SOURCE REGULATIONS,
AIR HANDLING UNIT(OVER 10,(W CFM) CONSTRUCTION TAX
Signature of AppllcanVContractur Date EXHAUST'HOOD(W/DULT) HOUSINGNIHIGATIONIEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant storeor hunJle humrdoos material HEATING UNIT(TO I W."BTU)
at defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cain,Sectio 25532(,)' HI?ATING UNIT(OVER I(Xi(W BTU)
❑Yes FIN. VE- TILATION FAN(SINGLE RISID) PAID
Data Receiry#
•
Will the applicant eco future building occuparn use equipment or devices which BOILER-COMP(3HP OR 100i"BTU) / O
emit hazardous air contaminantsgem
as defined by the Bay Area Air Quality Manaent L:
District' BOILER-COMP(OVER I04I.N.1 BTU)
E]yet, ❑Nn
I havenead thehamckma materials rcyuircmans under Chapsr 6.95 olthe Cali- AIR CONDII'IONEk O ISSUANCE DATE:
fomia llealth&Safety Cade,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,FF.
buildingdrcsnm currently havca MnanO that it is myrespuhsihilitym oaf D
ytheoccupam /
ofuiremenu which atusi tro met priono issuaace of a C Miami ( cy.
m5
Owner or emharizeJ agent Dare AL: ISSUED BY:
OFFICE