S 3375 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING..HLECTRICAL Plitt'[NO
BUILDING DIVISION APPLICATION/PERMIT 1'LUMIING.MECHANICAL 3375
BUILDING PROJECT WENT IF'ICATION
BUILDINGADDRESS: SANITARY NO, APPLICATION SUBM I'1"fAL DATE
19-2 5, /err -�/.
W "9 PIIONI?: CO tACIUR'.'NAMIi: LICNO
N/C CONT ROL#
ADDRE : pp ❑
5- 0—AA-z,) p
CONTACT: PHONE: BUILDING PERMI'1'INPO
�G,WL "y�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECTPLUMB MECII
W ❑ ❑ C� ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FE1i
I hmehy affirm that I um IiamW andar provisions of Chapter 9(commencing JOB DESCRIPTION
peal with Section 7")of Division 3 of the Rosiness and Pmmssiun.s Code,and my license is RESIDENT'IAI:
'C'0 PERMIT 1$Sl1ANCE
af-F iicene Classdeffect ❑SI'DWI. ❑KITCHIiN REMODEL
<-yU License Class Lick APPLIANCES-RESIDES TIAL ❑ADDITION [.}ir MRING RE-PIPE
rFdW Dmc Commctor
ARCHITECT'S DECLARATION ❑MULTIUNIT ❑STRUCTURAL.
F rn PANELS MODIFICATION
C p Z` 1 understand my plans shall be used as public records
CZ—X-+Q UP TO 200 AMPS ❑IN INTERIOR ❑CI{IMNEY REPAt
F'W Licensed professional 201-1(XXI AMPS IMPROVEMENT [DSWIMMING IYbIS
�Y ; OWNER-BUILDER DECLARATION OVER IIXX)AMIlS ❑HATH REMODEL/RF.PAIR El DEMOLITION
6' 6 1 hereby affirm that I am exempt from the Comosc or's License Law for the
X3 4 U following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL GTHER
4f- which requires a permit to construct.alter,improve,demolish,or repair any scommrc
b- 0j prlocto its issuance,akoreyuiresthe applicant nonsuch pentram file.signed statement SPECIAL CIRCUI'1'IMISC. Or
�,`i,'ra2 that he is licensed pursuant the provisioosafthe Contractor's l.icensc Law(Chapmr9
W�ORCIA
0 (commencing with Section Division]ofthe Business and Professions Codo or TEMP MEI OR('OLE(NSI'.
I G o that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW B. GIADDITION ❑D17MOLITION
X�
Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of POWER DEVICES (0 TENANT ❑FOOD SERVICE
not more than five hundred dollars($500).
OTH17RYIihfENT
❑ Las ework,the property,or myemployeeswith wageasthei((Sec.
compensation, SWIMMING IYl01.[,[LYRIC
W -2 will Pr fework,and themmmamis nets License Law does
1. a, warncss ❑OTHIiR
Cao
W ao and Rofessions Code The Commnors License Law date not apply m an miner of OU'1'LFTS-SWITCHES-FIXTURES
6 3 pro ki who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDEN'HAL FLECT R SQ I.T.
role.If,however.the buildin,ormarvemem issold within one famofcompliumn.the SQ.FL FLOOR AREA $`SQ,FT.
o er-builder will have the bu den of proving that he did me build m improve Por Imr-
poseoLvlal.
I,as owner of the progeny,am exclusively contracting with licensed contractors m TOTAL.
construct the project(Sec.RWJ,Business and Professions CWe:)The Contractor's Li-
nmLaw does nor apply manowner ofpropcnywho builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a comracmris)licensed pursuant o the Contmmors
License Law. PERMU'ISSUANCI?
❑I am exempt under Sec. ,R&P C for his reason
Owner Dam AI TER-DRAIN&VI?NT-WATER(IiA) VALUATION
WORKERS COMPENSATION
on DE CLARATION PACK IlOW PRQTIi6T.DEVICE
1 hereby illi rat under penalty of pe jury one of rhe following Workerdivelarration,Compeer-
❑ Ihavc antlwilllforby Section icate37M of theConvert
Laor Code,f mfor Workers eofthe GRAINS-PLWR.R(X)P,AREA.COND. S']'ORIIS 'TYPE CONSTRUCTION
sation,as hick his
for mi Section 3700 of the IsM+r Code,for rhe perfommnce aI the
E] I far and this permit is issued. FIXTURES-PER TRAP t•
❑ I have and will maintain Workers Compensation Insurance,h required by Smlion
l]W of me Labor Code,for the Performance of me work for which this permit is issued. GAS-FLA.SYSTEM-I INC.}OUT LETS DEC.GROUP AI'N
C1ynWnr r Gne a� Wt do me Pand.licYNnyny ,tbsbf ��Q� GAS-EA.SYSTEM OVER 4 IRA)
Of CERTIFICATF.OF EX PILON FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION(PFS _
(Thissedion need not henrmpletW if mepem+it is fonmehundmJ dollars($I00) GREASETRAI'
or less) PLANCIfECK FEE
Lnurify Nat intoe perfommnceofthe work forwhicb'his pnmit is issued.I shall SEWER-SANITARY-STORM F.A.200 FT.
not employ any person in any manner m refor become subject subject ns the Wnrm,s Compen- ENERGY IPE
Z
sation laws of California.Date WATER 11HA'IPR W/VENIVELECI R 7� GRADING FEE O Applicant
q N NOTICE TO APPLICANT:If, her making or,Cmifteam of Exemption,you should WATER SYSTEMOREATING
a ; become subject ,,the Worker's Compensation provisions of the LaMn Code,you must SOILS IPE
W barroom comply with such provisions or this permit shall he deemed revoked WA'IPR SERVICE
Q
zCONSTRUCTION LENDING1?tJCY NEW RLSIULNTIAI.PLM({, tiU.Er PAID Receipt k
I lombyalirm met there is acnnonara nlendi ngagncy[nr nm
U 1„10 me work for which this
pemdt.a ixnued(See.3o9].L'ic' m
0 1--' Lenders Name 1 ` 'TOTAL:
V Lenders Address 1- T
04 I certify that 1 have read this application mi rn'mtof i n-t'j- Gfurt9:niq999��x BUILT ANG
y mnem.iagmemcomply with all city and county and swmlSds rMmi.t.al�l, T MECHANICAL PERMIT Il?I?
U buildingconuresumn,and herebyamhnrixc repres orowesafthi.scitymenmr.l inTMh�/ SEISMIC
r-1 abnve-memionetl progeny for inspection purlx+se D RMI'I'ISSUANCI?
(We)agrcemsave,indemnify anA keep ;lay,the Cimal Cupcninn against 1:1.1?C]'RI EI
liabilicia,judgmems.casts andexpenses whicnmey In ain.stmid City ITER OR ADD TO MI?CII.
in cnnsequcare of,he gmanager thi,,m u. "-+ PLUMNINGFIi O s
APPLICANT UNDERSTANDS AND WILL COMPLY WOII ALL NONROI IR HANDLING UNII'GO 111.000 CFM(
SOURCE REGULATIONS. MECHANIC IPE
AIR HANDLING UNIT(OVER 10.001 CEM) CONS'I'RUCTI( TAX
Signamreol'ApplicardContmcmr Dam EXHAUST HOOD(WIDUC'1') HOUSING MITIGATION Pini
HAPARDOUS MATERIALS DISCLOSURE
Will the applicant or fuwre building neeupam smreor handle hisomlons material IIHAINC.UNIT(I'0 101,0X0 BTU)
as dcfned by the Crisman Municipal Code,Charter 9.12,and rho Health and Safety
Code,Seclir 25552m)F IIEAI'ING UNI'I'(OVI?R 110,000 If OD
E]Yes 0 N VEN'IT[.AtION I'AN(S I vi ICES I D) PAI(]
Dunt Itecelptk
WIBotic applicantornt,froua dere nim]occupancy Aof cywir Quent ality
Main. W1116h BOILER-COMPOHPOR 00,0X)BTU)
emir hnrunlous air cnnmminuntx as definnl by the Puy Area Air Qunfuy Munagenanl Y
Disairt't BORER-C(1MP(OVER IOgq)n I'I'(1)
❑Ye, ❑No
AIR CONDI]'ION RIX
I h�v Ithe h I 1 I y t. Ic Chapter695 IJtc Car- ISSUANCE DATE,
fon' H Id &Sarh'Cd f . 1525533 155341 J l dth�n'flhe N11WRESIDI:NTIALMECIL SQ lel'.
nhlAyl arse ] a Jt Ia is t. p :in l'tyl notify[,a.cpm -z_. ZZ...._ .
yr m ala Jununl a tpn moat erE Canrfrnu'doleury ney.
Ow am r e .gent _ Dam T(YI'A h: 1551111]BY:
OFFICE