S 3038 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEITNO
BUILDING PROJECT IDENTIFIES]'ION
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.-aD:cunNlcnl. 3038
BUILDINGADDRESS: - SANITARY NO. APPI.IGAI'1GN SURMITI'AL DAM.
ry//{y/53 � )O�Z,� N 2E_ b /J,�� /�,�� f0
OW/ rF�OSNAME: A PHONE: /'/ EAVI NAME
O1+14 ✓�—Jw_AI I.IC NOy53S
C f_ NIC CONTROLp
h' . 1IfECl/ENGINEER: LIG NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INPO
3 E] Consultant Fees Paid by Applicant(Initial) ELDG i ELPLUMB MECCH
LICENSED CONTRACTOR'S DECLARA'HON QTY. BLECTRIC PF:RMrr I°Illi ®/
ncieby affirm that F am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,Os�O with Section]000)of Division 3 of the Business and Professions Code.and my license is PERMIT ISSUANCE f3 Y7 RESIDENTIAL
���.. Lcenfail eCl... eBecr/1 ❑SPDWL ❑KITCHEN REMODEL
�UU
License !:J Lic., AYI'LIANCEg—RESIDCNTIAI. ❑ADDITION C3 PLUMBING RE-PIPE
F`�LL1 DaM 7"—Z/�7MNr Conlra[I:
F,N ARCIII' FCI"SDFCLARATION PANELS ❑MULTI-UNIT ❑STRUCq'URAL
z O`n unJcmwunJ my plans shall he used as public rcaxds MOU119CATION
Oz-0 UPT0200AMPS El INTERIOR El CHIMNEY REPAIR
[=.SFJW Licensed l'miessinnal phRMx1AMP5 IMPROVEMENT E]SWIMMING POOLS
.�.C 5 Q hereby alfirrn thmN uua BUILDER
nnnaDe,Ms Licence Law for the OVER IFOLAMPS L14%ATH RENiODI:TJRIiPAIR ❑DEMOLITION
iqy O y U fallowing rcoson.(Section 7031.5,Business and Prefessinns Code:Any dryer county SIGNS I?I.IiC RICAL Ats
❑OTIfLR
W'3 W,o which ne,u...a Perini,o cnmcuvet,otter,impnwe.demolish,or Icpuir env-vwewra
,F',�0� prior a its issuance,also requires the applicant for such permit it)file a signed statement SPECIAL CIRCU IT/MISC.
F,yy that he is licensed pursuant m the provisions of the Contractors Licenu Law(Chapter 9
�po (commencing with Sectian](M)of Division]ofthe Busines,mul Profecslor GNc)nr TENIP.METER OR POLE INSE
a ey that he is cxcmpt therefrom and the basis for the alleged exemption.Any violation of <1 OCOMMERCIAL;
Nf:\V )GIADDITION ❑DEMOLITION
NScored 101 5 by any applicant fill a permit suhjec,a the applicant m a civil penalty of POWER DEVICES a T ❑FOOD SERVICE
'z net ram,trap five hundred dollars($500), 1 OVEMENT
=C� ❑ 1.u.owner of the pmperty,or my employees wish wages m,heir snlecompe..a,air, SWIMMINGPOOLIiLIiC'I RIC
PP+i�GG;C`' wdl do the work.and Ne structure is nntimenJeJ or nflcred for sale(Sm.](N4,Busincsc ❑OTHE
W and Professions Code:The Comnemrs License Ww does not apply to an owner of OUI'I.I:IS—SWITCHES—FIXTURES
6 3^ pmpeny who builds ar improves thereon,and who does such work himself or through
his own employees,pnwiJCJ nhgt such impmvcmerns arc nm intended or offered fur NEW RESIDENTIAL ELIC R SQ FT.
sale.If,however.the building or impnwemem k-ld within oneyc:Ir nfunnpled Ibc SQ.FT.FLOOR AREA SISQ.tT.
er-huilder will lacca the Imrdem of proving Iran he did not build or ilMrove fur pnr-
"e of sale.).
1,as owner of the property,sen exclusively contracting with licensed contiguous to
o.swm me project(see.7w .Business and Professions Code:)nae Cammacka a-
se Lave does not apply in an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who conwah,fur such projects withacamnnisq,)licensed Panama tame Connector's
License Law. PERMIT ISSUANCE 3
1 am exeunt,undersee. ,B&P C for this reason
AUU2R—DRAIN&VENT—WATER(EA) VALUATION
Owner Date
WORKE'R'S COMPENSATION DECLARATION BACK FLOW PRGITC*n DEVICE
�I li&vhy whiten under penalty of perjury one of the following declarations:
❑lhave nnJwillmaintainnCmlficmenl Consenunsdf-innuretiar Workers Cmnpeo- DRAINS—FLOOR,ROsi AREA,COND. STOR ;S TYPE CONSTRUCT ION
cation,use provided for by Section 3704 of tiro 1:hor Code,fnr the performance ol'thc 3 �r••�
cck for which,his permit is issued It FIXTURES—PER TRAP L/
NJ1 have and will maintain Workers Compensation Insurance,as required by Section
)of the Labor Code,for the performance of the work for which this permit is issued. GAS—IiA.SYSTEM.)INC.O OUTLM S OCC.GROUP APN
My Wnr yqp��apl�1 glance tamer unJ folic
Carrier. qrKt`�� Policy Nie�� qs GAS—EA.SYSTEM OVEkJ(CA)
CL'RTIPICAff:OP
EXEMPT ION FROM WORKERS' GR[ASIIINDUSTRI.WAS'1'I?INTERCIiPl012
COMPENSATION INSURANCE BUILDING DIVISION PIi1S
flhis xenon need nm he namplcleJ if the permit is fmanehundreddudao($U1X)) GREASETRAP
or less.) YIANCIIIiCK ITC
Icenifytha,iatheperfnrmanceafthe said,larwhlchthispeond is issued,l shall SEWER—SANITARY—STORM FA.2W PF'.
not employ any person in any nemnu seas In Mune xhiec,nn the Worked Creole- ENERGY FEE
z h Applicant nllr Dam WAI'1}It lll'A'IER W/VE:N'f/ELECTIt
ton Laws of caf
dnr
zQ Ap GRADING FT3P.
OTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMIfRFATING
(—' ? Income subject to the Worker's Compensation provisions of the Labor Code,you mus, SOILS FEE
Fak1 forthwith comply svinbmch provisions arthis permit shall be deenmd revoked. WATER SERVICE
0.
CONSTRUCTION L[NDINO AGENCY NEW RESIDENTIAL I'hMB. SQ IT, PAID
V Ihcrchy all!.Ilafthem iso construction Radingogeney lr afir,romaneaof IteceiP,N
F the work lar which this pcmdt is issued(Sec.3(N],Civ.C.)
U. Isndcrs Name
TOTAL:
Wtenders Address TAC:
ly ttnify thin 1 have real this application:mJ sin¢mat,hu aMwe info minion is RUIREFIG EE O
y earreen.I ngrcc nn uamply wi,h all ehy and country nrJingnees vnd s,nte laws rclming m Qry. MECHANICAL PERMIT PEE SCISMEC f?E
G building,omghcrc
vucnioand bynuthariaaraprusanhnives ill'In"ily aa
cer upon t he
Oerven eadartvl property for inspec,ion pmprei
(Wc)agree to save,indemnify end keep hornless,he Ciry of Cupenin0 agxin.a P F.LF.CI'HI 'PEE 0
liabilities,judgri ccim,andestsmseswIwh mayhuny wayaccmucti,orat said City A ROR AD If .rte
in ecar"Ien the gaming of Im' it. PLUMBING E V
APPIEfApph�VComhnctr
STANDS A' VEL.C(IMPLY WI N.POINT AI I DLINGUNI'I'('10IQIKKI Cl:
MECIIANICALF E
SOURNS,
AI I NIA D ) R :M CONS1 RUCTION TAX
MgmaI Date EX USE'HOOD(W/DUCT') HOUSING MITIGATION ITE
HAZARDOUS MATERIALS DISCLOSURE
W,11 theapplicant mfaurehiiliing aceupint same orhandlebvardouammedal HE 1"G UNIT('10 100,000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the 11.11h and Safety
Code,Seclion 25532mC IIB " • )wru)
❑Ycs El No VENT ILAI]ON PAN(S INGLE RISE])) PAID
Date RueiPtM
Will the applicant or future building oucepan,use equipment or devices WBOILIiR-GGhfP(7HI'OR 100,000 BTU)
hldl ^
Wti• rJous air contaminants as defined by the Bay Area Air Quality Management
f ta
,� Dlsu¢nP
BOIIJ'R—COMP(LIVER 100,000 BTU)
r LO,_ncthun�d
Ll No
tend baaamJous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
Safcryety RJe,Smimms 25505,15533 and 25571.I understand that if the NEW RESIDENTIAL MECH. $Q.PR /�
ot cutren,ly leave a un am,that it is my nespnnsibility to rmify the occupant
ents which ntusn he met prior ha issuance of a Certificate of Occuryncy.
uni dagent Date TOTAL: ISSUED BY: / x
OFFICE