S 3113 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO HUILDING-ELECTRICAL PER IT NO.
BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL � 3113
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: R SANITARY NO. APPLICATION SUBMITTAL DATE
7 B
976 F- kn&P tie. 2
OWNER'. NAME: 13�N1� PHONE: Cl. RACRUIR NA Li: LIC NO030 IE WAJeA i� I
V C/ _ NIC ONIROLa
' ARCHITECT/ENGINFER: LIC NO: All CSS: l ❑
CONTACT: PHONE: / L BUILDING PERMIT INTO
❑ Consultant Pees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
❑ ❑ ❑
LICINSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby atnrto that l am fiecused under pmvlaimn of Cludi l9(emnmcnd.g - JOB DESCRIP'T'ION
DMZ with Section 70(0)oflusision 3 ufthe Business and Professions Code,and my license is RESIDENTIAL:
FOU in full force and elect PERMITISSUANCE
C,, ❑SFDWL ❑KITCHEN REMODEL
aUU License Class Lica APPLIANCES-RESIDEN'I'[At, El ADDITION ❑PLUMBING RIiPIPE
yZa Date 7CS DE'tor
Q¢ ARCHITECTS UHCLAI records
ON ❑MULTI-UNIT' ❑SODIFTUkM.
7 y PANELS
Z Z 1 undcmanJ my plans shall be uscJ as public recoNs MODIFICATION
OZ-� UP TO 2p1AM1fP5 ❑INTERIOR ❑CHIMNEY REPAIR
F�f]W Licensed l'mfessianal 201-1010AMPS IMPROVEMfiNT SWIMMING POOLS
4 Y J
OWNER BUILDER DECLARATION
C OVER 100DAMPS ❑13ATH REMODEDRIiPAIR 0DEMOLITION
C C It I hereby zlfirm that 1 stn exempt tram the Contractors License Law for the
11 O L U following mama(Section 7031.5.Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
3
F�LL F which requires it berm to condone[,Act,improve,demolish,or repair any mor _ W
O`J prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUI I MISC.
Ey mar he is licensed pursuer to the provisions of the Commences License Law(Chapter 9 e+�3
u�l�p0 (commencing with Secti0n7W11J of Division 3 of the Business and Professions Coded or TEMP METER OR POLE INST. COMMERCIAL'
6 c c that he is exempt Ihercforn:uW the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m Section 7031.5 by any applicant for a permit subjects the applicant o a Civil penalty of POWER DF,VICIiS ❑'MNANT ❑FOOD SERVICE
1-ZY not morn Nan five hundred dollars(SNH.
E � ❑Las owner ofthc Extent,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVPMENT
F will do the work,and the,struclure is not intended or offered for sale(Sec.7044,Husi mess ❑OTHER
co and Professions Code:The Conrwl r',License Law does not:ytply to an owner of DO I'LH I S-SWI'ICUES-11 X'I'URES
tumor who builds or improves thereon,and who does.such work himself or through
his own employees,providN that such improvements am not intended or offered for NEW RESIDENTIAL ELEC!'R SQ
sale.11,however,the building or improvement is sold within one year ofcomplelun.the 5 IFLOOR AREA ESQ.FT.
err-builder will have the burden of proving that he did not build or improve for pm-
pox ofsale.).
I,as comer of the pmpeny,ran exclusively contracting with licensed convectors to TOTAL:
construct the project(Sec 7041,Business and Professions Coley The Contractors I.i-
moseLaw does not apply to an owner of ptopeny who builds or improves thereon,and QTY. PLUMBING PERMIT FBB
who coo met for such projeels with a coatroom(,,)licensed pursuant,the Commeam's
License law. PERMIT ISSUANCE
❑ Iran exempt under Sm. ,B At P C for this mason
Owner Date AUFER-DRAIN k VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
Fl I have and will maintain a Cenlfivamuf Consent tosdf....re for Workers Conui DRAINS-FLOUR,ROOF AREA,COND. S'TOHIES TYPE CONS"rRUCr1(lN
,,alio.,as Provided for by Section 3700 of the Labor Code,for the perfor mom of the
�or�t r which this permit is issude . FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as requited by Section
3700 of the Labor Code,for the llerforounce of the work for whicb N is"it is Issued. GAS-EA.S YS'I'Ell I INC.4 OUTLETS OCC.GROUP A1'N
Myra cc 's Cul do Insumncg Ptnic Ponld YtN('y yumher'l GAS-IiA.SYS'I IiM-OVER4(EA)
11II nIFICATIi OF E%Eh11'TION hROM WORK1iRS'
COMPENSATION INSURANCE GREASErINDUSTRL WASTE INTERCEPTOR
BUILDING DIVESI(iN FEES
('rhissemi0n need nm heeumpklW iltire lammit int onto hundred dollars($I W) GREASE"TRAP
or less) ANC 'EE
I certify that in the performance of the work for which this permit is issued,I shall SEWIiR-SAN ITA RY-STORM EA. 0
not employ any person in any manner so as to become subject to the Workers Compen- ERGY
mZ sutiou laws of Cndifirtnl.,Dulm WA'IHI`111la
?A'IFIRWNENTIIiLIiCTk
Z Q Applicant N PI
y 2
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
aIrewme subject o the Worker's Compem.ion pmvinum,0f the"ber Code,you must SFE
r forhwhh comply with such pmvNum-ur this pammit shall he emitted resented. WA'I'HR SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW HPSIDENI'IAL PLM1iB. SQ.II'. PAIU
U O I hereby infirm Nat there I,.construction lensing agency for the performance of x cello a
the work tar which this permit is issued(Sm.3097,Civ.CJ
Do U TOfAI,:Lenders Name 'ICTAL"
U nders Address '
r Le
0. 1 certify that I have mad Nis application and state new the above information is / BUILDING FE 7 O
fm ,E esreat.l agree to comply with all miry mind county ordinances and stare tows redwing m QTY. MECHANICAL PERMIT FBG
C„J IZ building construction.and hereby authorize representatives of this city to enter norm the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep humidities the City of Cupertino against ELECTRIC ITE
habil ities.judgments,costs and expenses which may in any way accrue against said Cityin PLUMBING ITE
AhI'EiH OR ADD TO MECfI. D
consequence of the granting of this permit.
APPLICANT UND.RSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOU ��F{�.UI. IONS.
L/ L //��/G 71 AIR HANDLING UNIT(OVER BLOW CFM) CONSTRUCT ION TAX
Signamr mApplicanJComrenor I Date EXt1AUST HOOD(W/DUCI) HOUSING hur GATION FL'L'
HAZARDOUS MATERIALS DISCLOSURE
Will the applicentorfuture building mutant stem or handle hazallous material HEATING UNIT ITO 10.100 BTU)
as delined by the Cupertino Municipal Code,Chapter 9.12,Ind NC fludth and Safety
Cade.Section 25532FO? HEATING UNIT(OVER 110,110 B'N)
EJ Ye, VENT IATION PAN(SINGLE RESID) PAID
Date Receipts
Will the air conn m fume huifined by he ti vac m Air Qu or devices which
emit hmardous air contaminants err defined by the tiny Area Air Quality Management OOILHft-COMI'(3IIPOR I100,I00B'I'U)
Tt
District? BOILER-COME'(OVER 100.000 BTU)
❑Yes
I have mad Ne kuusudous materials requiremcnl.s under Chapter 6.95 of the Cali- AIRCONDITIONER ISSUANCE DATE
from.Health&Safety Code.Sections 25515.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.Fr
buildingd0rs not euere ly havearenant.Nat it is my msponsibility to put the mailman �/ Z (/�•- 9jX
nl the rcgd 'Ira must be amt prior to ismunce of a Ce sof h,y, U
Owner or auNadN zagent Date TOt'A h: NSUED BY.
OFFICE