S 3002 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
PBU]ILDING
OF CUPER'1'INO Bun.DNG-ELLf7tRICAL PE IT NO �j (�
LDING DIVISION APPLICA'1'ION/1'IiRMfI• I'LUM1tlNc-ME('HANICN. 3 O U 2
i1U11.DING PRO.11?C'r IDFNI'IFICATION
AI)I)IIHH'�5�� SANE TA R,NO. AI'P.ICOA I'If)N K�TA ATE
OWNINER:S 1i: PHONE: CONTRACT'OR'S NAMIi; LIC No: NIC CON'TROLM 9
it,ANCIijT1 C�/li/C7EL./ /.� LIC NO', .DORCSS: ❑ / O
C
ONTACT.tandeffect.
?R' PHONE: BUILDING PERNfTINFO
�t��a6,7� ❑ CnnsBllanf Ptts Pald by Applicant(Initial) UG ET PLUMB MT:C
ENSED CONTRACTORS DECLARATION QTY F[,I3CTRIC PERMIT I'Efi TOB DESCRIPTION
shot Ion,Ilcenlcd undo pmvi sion.of Cha uI,Y Nvmnuencing
CMZ vi..oil the Nusinenp and Prolcspion%Code,v anrylicenuis R D` TI
AL
WOO PERMLTISSUANCE S. Z
F W F .IU L ❑KITCHISN RENIOD.1.
aUU Ldcensr Class hic.N APPLIANCES-RES IDEN'I'IAI. ❑ADIDIHONt ❑PLUMBING RE PIPE
I-ZW Da¢ Cnnons'no ❑MUI.TI-UNIT El STRUM URAI,
h G 1 ARCHIE'ECPS DECLARATION PANELS d0D I:ICAT10N
z 0 oz I underxmnJ To'd in—ball be nsed as gublic tett,N%
OZKUp 10 20()AMT'S
� ❑INTERIOR l]CIEMNI?Y REPAIR
Vit: Li...ad professional 201-H)COAMPS ]IMPROVEMENT �SWIMMING T(H)IS
0.' , OWNER-BUILDER DECLARATION
C , OVHR HXMIAMPS ❑BATfI REiMODF,VItIiPNR DEMOLITION
Q I hereby ulfimn Nm I am exempt from the Cnnnin,na,Uenw Law for Inc
L O a U following•reason.(Section 7033.5,Nusine—ral Professions Crde:Any city.,train, SIGNS ELECTRICAL ❑(YI'l1Ek'r
3 W y which I le rdu t t her. r d Ish , ny spudure
h�0-1 pr on t 'I: d Enlic: It IP not IIsignedkmtcncnt SPICIALCIR'MINE
I$ }
that he I -d,arou It thep ns of the C t tors l' i (Curtner9 COMMERCIAL
W�00 (Como 6 with Sectio 700(. fD Division (if Business and% f.. ns Code)or TEMR ML RPOLh 'ST.
d X e a That be is cnce,a the tine land the hail,far the alleged exemption.Any violmion of ❑NEW BLDG/ADDITION ❑UEMOLI'I'ION
Wim
Section 7031.5 by any applicant Into permu%ubjeIts the applinlno m u civil penally al' POWER UEVR ❑'TENANT ❑Fool)SERVICE.
nu"Cue than Eve hundred dollars 1MBROVEMENT
Sp wsowoar nl the prory'ny,nr myonpinyecs w'nh wages us thcinnle nnnpcnsaion, SWIMMING P(X)1,T:- IC ❑OTHER
F• the work.lnW lhm¢nnur9 i.nm imcndcd orofl'ucA lbr solo(SccJ(144,Bulinus
aim and I'rofnsiom Code:The Contractor's License law does not apply h,an Owner of UU'TLhTfS-tiWITCI 'S-1' RIiS
progeny who builds or improves thereon.and who does such wed.Innsalf ur through
hip own cmployrel,Provided than Inch imp...se is are not Intmnded or entered for NEW RIiSIDi:MC1Af.Iil Ai SQ FR
sale,11.however,the builda,...improvementismld wiffinon.yearof mmpletirn.lhc ` SQ.FI'.IIOUR ART SISQ. e3'.
insulter builder will have the hu,den of playing that he did not loud or improve for per- �r . 0 $ O /Qfi
pine nrs:dcy 'I OTAL I
(DLas owner ol',he Proliany.am exclusively contending will,licensed colnracua.It, � S ^ Z 3 3 „/
construct the project(Sec 70,14.Business and Profession Code)The Contractor's Li-
cause leave does not:,,,Iy lr un Ownerofprogcnywho M1uilds orimprove%Thereon,cell QTY. PLUMBING PERMIT FEE
who ounvaCls lin such Projects will,a Conimcmr(k)licen¢d pndwllh n,the Contmemrs _ -T
License Law. PERMIT ISSUANCE 5 A,
Literatiima8e�/n
L]I al aa apt ander Sec B k P C for this reason ,2- /-/
J
N:I'lill-DRAIN k VIiNT-N'AB'ER(IiAI VALUATION
ZOV
Data 12 -1—
W(➢ H!RSCOMPFSNSATIONDECL RAIION BACK FLOW PRO EC..DEVICEO ] , \ !lnerenyatium under pentllty nr Friary ora crone fl,urwlTng deemr:nmw. [p VVI have and wll l mainnuin a Cerinicate ofCanlenrao%elr-inwnc fr Workers Compen- DRAINS-IIAOR,ROOILAREA.CONU. �]'r'YY.IIJF( NSTRUCHONkation,as provided fur by Section 3700 of the Lbr Code,for the gerfonin nce of the e /P�work lo,which thi.,pemnit is issued. FLXI'URES-Plik TRAPhave and willn,in cin Workcl'p ConTpcnlotlon Insurance uv revolted by Section3700of the LabsrClde.ILriheperiturreceofthe work far which this permit is i...ad, GAS-EA.SYSTEM-I INCA OIfiLFLS APN ooMyWodcrs Cumpeosation lnsumnae carver and Policy number art: GAS-Ti A.SYSTEM OVER 4 HA) S7_�L� r�CCartier lalicy No.:CERTIFICATE OF HXHMVI ION FROM WORKERS' GRIiASFJINDUS'rRL WASTE INTERCEPD)RCOMPENSATION INSURANCE SIUN FERS('this necllon need not he completed i U he gentiO,forrme hundred doll..($10d) GREASE TRAPofle".) / .��I cenifytw int he perf...recof the work for which this permit is issued.111, SEWER-SANITARY-STORM IiA.21X1 PL
for employ any ,on in any manner sn in;to become iubjed n,the Workers'Culligan-
Z ratio.Lows of Culilmnin.Date WA'll?It f{EATERWIVIINI'IELI!CTR GRADING FIiIi
Q O Applicant
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WA'D!R SYSI EM/TREATING -SOILSFEE
hwnnw snn'Icc,n,the Wrdars Con.'ensnion provl%inns of tilt Labor Code,you nwst I\ m
forthwith comply with inch provision%or ihi.%proud diall be deenned revoked WIG 17R SERVICElnl /] \\ U
OWi Q I If PAIL[) IJ.
CONSTRUCTION LENDING AGENCY NEW RESITNWIFIAL PL.MU SQ.ITT Dam eccipt p
U O 1 herchyoffion ihaunere is a conamdion lending agency nor tneperh,mlance of C/1
{1n P the work for which this permn is issued(See.3097,Civ.C.) C Q 'TOTAL:
O
U Lendcrp Nane 'TOT4/ 3, S
r UJ ltndcl'a Address, BUILDING dill �I Erb
6. I cent,that I have read this app[icalion and state that the abuse infunnition is
F' N crtcd.lagreemcomplywinallcityandvounryoNinancc%andpratlawsrelaGngm QTY. MECHANICAL PERMIT eyI'EE SF,ISNIC 'I. 11,'
(.) 'Z haildurgmnatmdinn.Tln I hereby out hori'rclepm,"'Inivcl olod,eitym enmeupon 0e —r"�
above-mntinn
eed Prnpeny rnr lnnpletwo yunnP
lak. ERMTr ISSUANCE 5 • ��(- ELPC"TRI
m
(We)agree to save,indemnify and keep armless the City of Cugcnino against
Iiabilitick.ludgmc.ds,cowsand1 expenseswhich%nay in Tiny wryaocrue again.a said City AI:rEROR ADD TO MI!CH, PLL .0 lilt
of rmryuenae of the graining of this permit. n
APPLICANT UNDERSTANDS AND WILL COMPLY W EI IT ALL NON-POINT AIR HANDLING UNIT(TO EkdEd CFM) MUCHA [CAI.ITE
SOURCE REGULATIONS. r
AIR HANDLING UNIT OVER I0.0011 ChM) CON 'NUC'IION'I'AX
Inure pphcanV trach Date EXIIAUSTHOOD(W/DUCD HOLES GNITIGATIONFEE
II %ARIOUS. A'I'ERIALSDISCLOSURE
Will lbeapplicant orfutun lwlldou,neaupurtm,re or handlchum,Jous matcnd BEAT INC,UNIT(TO lolkom Hit))
a%defined by the Cupertino Municipal Calc,Chapter 9.12,and the Health and Safety HEI0ING UNIT(OVER I(l(TWO BTID
Cale,Section 25532(u)I r
❑Yes ❑No VENTILATION[TAN(SINGLE RESID) PAID
Dutc Receipts
Will lie applicant or future building occupant use equipment or device%which BOILER-COMP(3111.OR IIX4n(X1 13 ED)
error hamrdw
nul air cnnnninams us dc0ned by Inc Bay Area Air Quickly Manxgcncnt 'I O A,
District! BOILER-COMP EWER 100,MX)B'I TH r�
Yes F7 No V
AIR CONUI'I'IONEIt INSET CE DATE
have rad the h ode, ma255 equ5,15533 an mdcr .1 and rsta nl the Cdi-
fomla Health Fs Safety Code,Sections,find1 21 ony and 25534.I I ndeomnh (W if the NEW RISIUIiNTIAI.NIECE]. SQ.19'.
huihlingdle%ern curtenlly havca tend t,ihal'n ilnly rclpominility to notify the(Weapon
if he reyui n%xmtn troll rte ly grionoiasnance of T,cenintwt afoaupa
n' ar lo,nd,o r0 owe Torn 33•S ISSUED BY. ��1 ���� �G•
OFFICE