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S 3387 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAI. PET NO. 3387 BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL t`7 BUILDING PROJECT IDENTIFICATION, BUILDING ADDRESS SANITARY NO APPLICATION SI1dMITTAI.DATE 2 s Cv 1Z17/ 61 iz 2 �- N NAMh:: ^ 40 PHONE: . CONTRACTORS NAME: LIC NO: I// ✓Y NIC CONTROLM A ' FLONUERICNO2 f_ ADDRESS: l�egq / v HONE CONI Consultant Fees Paid by Applicant(Initial) BLDG _UI ELECTPERMITPLUMB/ MUCH _ LICENSED CONTRACTORS DECLARATION i ©/ ` L-✓ ,L-'Y,/ Y. ELECTRIC PERMIT, FEE , Iseeny err . a d p fenaptw9momm g - JOB DESCRIPTION Woo with Seclon 9000)ofDv'sion 3 ofthe Bo d Pmfeeslons code angry lc Lea's RESIDENTIAL H,- tholfanccandeffect - i PERMIT ISSUANCE WF ❑ADWL ❑KITCHEN REMODEL �UZU License Class - Conte - APPLIANCES-RF.SIUF,NPIAL �AUUITION El PLUMBING RE-PIPE rFdi Date - Contractor - ARCHITECTSDECLARAI'ION ❑MULTI-UNIT ❑STRUCTURAL p.,pmPANELS MODIFICATION �Z p m> mns❑ I mTdersnd my plashat bonsai as public recnMc � OZ�+p lq"10200 AMPS gl[INTERIOR ❑CHIMNEYREPAIR W Lieeused Pmfecslonal 201-1000AMPS �f IMPROVEMENT E]SWIMMING POOLS +SFJ OWNERBUILDER DECLARATION t OVER 1000 AMPS ❑BATH REMODE1./REPAIR El DEMOLITION C 1 hereby affirm that I am exempt trans fine CounaluoTh is License Low for e - l1 following reason.(Section 9031,5,Hudnees and Professions Code:Any city or county SIGNS ELECTRICAI.� El OTHER _ W a W F which hamums u permit to e Marr ,aper,imps ve,dcmoliwh,or repair any xtmcmre a7C)4 prior In its issuance,also requires the applicant fnrsuch pemtiuo file vsigned slatemenT SPIrCIAL CIRCUI DMISC. may'' In.,no is licensed pmmmrtmthcpmvisimncofma Contractor',Lactose luw(Cnapmr9 d'� (commencing with Section 7000) or of sin the Buess and Prnfessinns Code)or TEMP.MCTER Ok POLB INS'L COMMERCIAL: d o y�y Nat he o exemptex therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION DEMOLITION ❑ W,y;N Section 703 IS by any applicamlbr a permit subjects the applicant o a civil penalty of POWERDEVICES ENANT FOOD SERVICE m not ore than Fee hundred dollars($500). FqZ6 I,ax owner oflhe pmperiy,ormyempinyceswith wagesas Theirselemmpensation, SWIMMING POOL F.LECTRI MPROVP.MP.NT � 2H0 ❑OTHER will do the work,and the structure is not intended or offered l meal,(Sar.70TLIs mass 0.F 3 and Professions Code.The Contractor's License Law deer not apply to an owner of LETS-SWITC M URES property who builds or Improves thereon,and who Joos such work himself onhmugh his own mnpleyces,provided that such imprwements are nm intended or oRerad for NEW RESIDENT E R SQ FI: ,all.11,howoscribe buil ding or impmvemain is sold withinoneywr of oomplwion, me S .I"11 A $ISQ.PI'. {oowner wn/rfbcuilder will have The huNen of proving that he did not build or improve for put- -' 7 Vl""'owen). / � r oftheproperty,am exclusively contracting with Iicenved contractors m cot ttth project(S 1fM4 B . dP fC d.)qh C t .....-L- - /+�� -��-����/�,�(� Q acute 1 f C pply t e f property I Wild. p m d QTY. PLUMBING PERYL FEE b I�C3�C�l�r I r l[Z whotarts for such project,Afht contract..iso eamedp . ittlu cContractors License Law. PERMIT ISSUANCE Ell 4Io o ,B&PCfor Ihtc w ITER-DRAIN&VENT-WATER LA) VALUATION Dela WORKERS COMPENSATION CLARATION BACKFLOW PROTECT DEVICE �7 ©�, ,,,( Iherenyoffnn under penalty n[per]vey one oRhe following defier.tion ❑ I have and will mountain a Cerifeate ofComent to self-Insumfr-Workers Compen- DRAINS-FLOOR,ROOF AREA,COND. STORIES T ONSTRUCTION sminn,vs providoe for by Section 3900 of the Latwr Gra for the perfnrmonce oft Z work forwhich this permit is issued. FIXTURES-PER'I'RAP ❑ 1 have and will ormalso Workers Compensatlon Incarvncc,vs requimJ by Scetioa 3dlflmflhe Labor Cade,forthe performanceofmc work for which this permit is iceued. OAS-P.A.SYSTUM-I INC.40UTL8'TS OCC.GROUP AP�1F �I My Worker's Compensation Insurance oilrier and Policy number are: 070, �� 2(y�.lO �Gy Carries Polley No.: GAS-EA.SYSTEM-OVER 4(EA) CERTIEICAT60F EXEMPTION PROM WORKERS' RBASEIINDUSTRI,WASTP.INTERC[?PI'OR COMPENSATION INSURANCE xBIRLDING DPHJ1QNPITP.S u _ (rhis sermon nein not heu�mplemJ if Thepennitie Cor onehundreddollam($100) ( EASETRAP Z' or less.) ./ PLANCIIGCK THE ; I earth,Lunt the performanceoime work for which this permit is iesued,lshallSUWER-SANITARY-STDRM HA.200 Ff. �IF not employ any phumn Irony mamon so as to necounu mb ell m the Windamo Compcn- ENERGY FEE mtinn Luws of Calitomio.DoleWATER HEATER WIVENT/ELECTR OQ ApptiwnI i GRADING FEE NOTICE TO APPLICANT:If,after making This Contracts of Exemption,you shout. ^ WATER SYSTEMO REA'TING 5 become subject to the Worker's Compensation provisions of the Labor Code,you mustSOUS PEE wFy forthwith comply with such provision¢or This permit shalt be deemed revoked. WATER SERVICE SP Q CONSTRUCTION LENDING AGENCY NEW RESNENTIAL YhB.MSQ.Ff PAID Z" IherenY u[firm mat there is acumtructlon fencing agency for me performvnw of Ina, keteipT# UO ThesoIf..wnie which this isna.it(Sao 3091,Civ.CJ Q ULenders Name O W Leader's Address _ I court,th T l lovemodguis applicationd lure that The above information �ffHLDING FEE. faq torrT.I g t p1Y lh II 'TY, nd ry ti sand state lows relm g T r Q'IY. ECH ERMI FEE e-T 1 U Z bu'IJn ,comer den and hereby rad rm......candivas ofthiscty m enter upon the T t SEISMIC PBN !� 4 obova-mentioned property for inspection petposes. PERMIT S NCE (We)ogres to cove,Indemnify and keep harmless theCity of Cupnntno iguinsl ELECTRIC FUE _ I'mhi litiess,judgmers,costs and expenses which may in any way accrue agaihst said City ALTER< D E I. incnnmgmei eoflhe gmming mf This permit. PLUMBING FEE 2_m © eZD APPLICA T U ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HA N ING IINIT(T(3 111,0011 CPM) S URCP E 1 T 5. MECHANICAL FEE 0 -0 n HAZARDOUS MATERIALS SCLOSURE AIR HAN L UNIT(OVE CONSTRUCTION TAX Stgnomrc fAp iennuCommemr nm! EXHAUST (WIDUCT) HOUSING MITIGATION NEE Will the applicant or future building occupant store or handle homrdnus material • I[BATING UNIT(TO 100,000 BTU) as defined by the Colonic.Municipal Code,Chapter 9.12,and the Health and Safety - Code,ScoTIOn 25532(o)) 1, 1 HEATING TINT I(OVER 100,000 BTU) ❑Yes VENTILATION FAN(SINGLE REMO) img PAID Data Rccelpl# Will the mortician or future building occupant use equipment or devices which BOILER-COMP(3IIP OR 100,000 BTU) mit hazardous air conmminvms as defines by the Bay Amu Air Quality Management DihrotJ BOILER-COME(OVER 100 T U ,000 I ) 5 71g E-1 Yea W^ I bavo mad The hamnlnoc materials requirements under Chapter 595 of tho Cali- AIk CONDITIONER ISSUANCE DATE Rhode Health&Safely Code,Semens 2.5505.-25533 and 25534.1 undecaanJ that Fire NEW RESIDENTIAL MECH. SQ.IT. �- in in hear au cryhave a tenant,that'it is my responsibility To notify the ocenpam it I I iprior cof it Cinnamon,o-Occu nay. ir Owner nr uulht rived agent ate TOTAL'I &, ISSUED BY: OFFICE