S3935 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBEJG-MECIIANICAL S 3935
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
to 501 &t Tu4n,4ave, 64Pe�?Z40
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
AJ /� cal � Jl NIC CONTROLN
,RCHRECTENNGINEF.R: /V A LIC NO: A DRFSS �G T4f 145V<! ❑
CONTACT ,, PHHONE VJL BUILDING PERb7IT INF-0/ ���� _'�/ ❑ Consaluda Fin (I
Fines Paid by Applicant nitial) BLDG ELECT PLUMB MECH
❑ D ❑ ❑
LICENSED CONTRACFORS DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm Not 1 am liccmd under ffovisioa d Chaffer 9(rnmn.encing JOB DESCRIPTION
r�,.0 ZO wiN Satmn]OW)af DivisiooJ of Nc Busirmasad Nofc.uionsCWe,and my licemeu PERMIT ISSUANCE RESIDENTIAL
���I111y-r�---t mfullfacc and cIf LicJ A / 2-P- ❑SFDWL El KITCHEN REMODEL.
nQW Dal ser Cmvrt TOFF/�a'S� ApPDANCFS-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
!-yIQ
surcP ❑hULUN �
ZO1uWcrssaWmYPlan (dull e ,ol aa,public rnntk MODIFICATION
UPTOMAMPS
O Z_C ❑INTERIOR ❑CHIMNEY REPAIR
rryFy2 LiccnsM Profeuioral 201-Ifg0AMPS IMPROVEMENT SWIMMING POOLS
ad C C Q I hereby,a1Etm No N em a cln.Pr froLDIR lml the CR ntrvcOmr'c licrnce Law far he OVER 10fl0AMPS [I BATH REMODEUREPAIR ❑DEMOLITION
13 a U fdlowing rtikm.ISenim]0313,Husircu arW Profnx:m Code:Any city err nwnty SIGNS F.LF,CfRICAL OTHER
Yl u.y¢ which"at.a permit m eansamet.alte ,dlink,
Ill .iurpre er oa..�mir any utucture
O.] prical issuvme,eiwtayuir,,l[a.PPlicani for such permit wile..signed stammer SPECIAL CIRCUITIMISC. _
ythat he i,.IicenxeJ prnaanuo Ne provision mf the Cmtmcill License law(CneI
a4O (commercial,wiNSect.70alof Divieion 3 of the BoslneaaW Professions Code)., TEMP.ME'T'ER OR POLE INST COMMERCIAL
d%o O thin Ica ie exempt IhmeGom and he hx iv far the alleged escmnilnn.Any vinIl of El NEW BLDG/ADDRION ❑DEMOLITION
W-rn Scroll.7313 by unyapplicwt for mpcTril,.bjecuC the npplicnot no.civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
1„ y Mt mxc Nan live motion!rkdlani SYK),� IMPROVGM Q � 1,aowrar of the pngcrty.army employee,with w.gca as thei...at,, penwaian, SWIMMING P(IOLELECTRIC
will dm the work,and! he wrwmrci,nmt inmWsl nrnRertd for alc(S.7I.Hequew, []OTHER _
W 3 2 and Pronoions Code :ne Commcmr's Licca,e law div not apply to wt uwnwr of OUTLEB-SWITCHES-FIKILRF_S
pmpny who bullde or impruvc tact....,and who die.m,h wok hinueep or Nmugh
his own ctnpluyaca,ffuviNd that Bach Impnrvcnwme arc nx Inm.deJ or offered for NEW RESIDENTIAL ELECIii SQ 17L
-le,If,how,c,the huildms or mpmvenentis wild withineros you Mcompletion,the �Q SQ.FT.IIAOR AREA S'SQ.Up.
m Ibunlder will have no,harden of proving Nut Ire did to bund or iia pmm fur par-
pose of ale.).
Luc owner of die pa mty.vn ealu.dvcly oommeling wiN Inmc couract...1. TOTAL:
construct the project(Sec.71144,Hasineca uW Profcuinnx Cour:)31e Gmuacnt,U-
whoseLew,does not aptly to an owner of porfcny who builds or imffmves thercun.card QTY, PLUMBING PERMIT FEE.
x
eanbte f..each pmjmd with sloom uctort,)licensed purmunt to theCmdaetu s
Lic.law. PERMIT ISSUANCE
l am exemff urxler Sec. ,B&PC for IN.reason
DWrb[ I3YC ALTER-DRAIN&VENT-WATER(FA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby atTnn.Her penalty of perjury me of the following declaruicri
I face and will maintain a Cenif ro of Conscm to self-insure fm Workcr's Condition- DRAINS-FLOOR.ROOF AREA,COND,
adorn,as provided For by Section 3700 of the Wee Code,for be,peffarnnnrc of the STORIES TYPE CONSTRUCTION
work for wN,h an,permit is iaueJFlRES
. KTU -PER TRAP
❑1 have ad will maintain W'orker's ComMoaduo Imumnce,a required by&pion
3]flfl of the labor Corte f«tie perfmmerce of the wok for which this firmer is luted GAS-EA,SYSTEM INC.J OUTLETS CCC.GROUP APN
My Wmkcr's C9rry�err}4' Lwwe ryc�rJ� veJ folk,num
Career «aAITZygE^ G�SPdiry Nu.: a #1012 GAS-EA.SYSfEN-0VERJ(EA)
CERTIFICATE OF EKENU"HON FROM WORKERS
COMPENSATION INSURANCE GRESSFIINDUSI'RL WASTE INTERCEPTOR
BUILDING DIVISION EEFS
(Ilii,sect ion nccd rot he campktad if the,pmorit u for win Inure 1JnIWs(SIM) GREASETRAP
a kx.J PLANCHECK FFA?
I cenify Na in theperfomarec of the work:forwhich this permit is iemsd.I shall SEWER-SANITARY-STORM EA.200 FT.
wt employ any perfecto in any moral so m to become subject to the Waken Comffm- ENERGY FEE
zZ ..don laws of Califomia.late WATER HEATER W'NEKLELECIR
Q Applicant GRADING ME
r/) NOTICE TO APPLICANT If,inner making this Cenifczm of Exmptirm,you Owuul WATER SYSTENIG'REATING
E^ " become subject to the Wor cf,Compen.atvm prewow..s M the Laos Crile,you lmot SOILS FEE
WfuNwiN comply w dr such proviswm ov Nix permit,hall he all revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEWkCSIDWT1Ah PIlAB, SQ.FT PAID
UC I bmmy affirm thuuhere ie a somal kding agency for theperfnrmnrce of [);I., ReaiPtN
Ne work for which Ni,permit is iuued(Sec.31197,Ci,C.)
u" F" LeWer'x Nmae TOTAL
O Leock,r',AdJ+ea, TOTAL:
1 cenify that 1 tactical this uptlkmpx.and..In dud the above information Is DUILDING EE
rj' correct,1 eg.ec w cxnply wim vll city cad county uNiwnw a,d intra Iawa relating to QTY MECHANICAL PERMIT FEE
U nailding mrwmepen,m.d acrtny amhmdaa repn:emmiva of mix.ity memnrapan the snsMlC FEE
mMrvwncntiadd pro,cny forao,,bn partl PERMIT ISSUANCE
(We),ne,m ewe,indemnify vvl keep hamJe,,Ne City or Cu,nninr ugoinur Iil,liC1'RIC FEE
IObilitics,judgnent,co,,and expcmcv which may In my,way uccruc aguind said City ALTER OR ADD TO MECH.
umzcyuencu mf da:gmming of Nis pcnnh. PLUMBING FTE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00W CFM)
SOURCE RECULaiDONY7 MECHANICAL FEE
44- AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Si/"um of Ap�l�✓plicenVClmfm
tc-a
t- l� /+ 7 LDvc EXHAUST HOOD OODUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the Wplicimt or future building oampad etme or hadle hvanbus material HEATING UNIT(TO IW."BTU)
an defred by the Cupcome,Mmecipal Code.Llwlger 9.12,and the Hea1N aW Safety
Calc,Section 2553200 HEATING UNIT(OVER IW,W0 BTU)
❑Yes %Nn VENTILATION FAN(SINGLE RFSID) PAID --
Data Receipt Will de applicant of furore balding occupant y A ra Air cm or devices which BOILER-COMP CUP OR I W.f100 BTU)
emit hnaardova ev mmuNnsnu a dchrcd by the Hay Arca Ab QualitySfamrgement
DlsWmp BOILER-COMP(OVER IW.OW BTU) ^
❑Yes YNo
AIR CONDITIONER
1 have read the hvsdmru nuteria4 rtyuiremera wake Clagn 695 of he Cal ISSYANCE DA
former Heabh&Safny Code.Scetiom 25505.25533 aW 23534.1 urdnvavl Nm if de NEW RESIDENTIAL MECH. SQ.FT. / r-Z_
bui"'clemourcurrcW.ficin— her,it i5 my mprnsil lily to notify the,Oc t f0
oral irtoamil ncoun feCrnU JoOTypaA
Owhm'/wauthmired ager yDaan, TOTAL ISSUED BY:
OFFICE