S 3342 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUII,DING-EIAlCI'RICA[, 1'1!l P lI no. ^
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL `V L
BIELDING PROJECT IDENI'IFICAJ ION
HUILDWG ADDRESS: ' ySANITARYNO. APPLICATION SUBMITTAL PATE
*24p s5v
'HONE: Cf TRAC DRIB 'AMR: LIC NO:
(1 N 'S N�ME' 1 ��- NIC C'U IR(E
ARCI IIT. TIIINGINFER: al"ll: A 5S: Q ❑
CONTACT; PHONE: BUILDING PIERMVIINFO
❑ Consultant Fees Paid by Applicant(Initial) LI , ELECT PLUMB MUCH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JOB DF:SCRIPI•ION
1 hereby affirm that I am licensed under provivinm of Chap¢r 9(cnnmmncing
payp wishSeclmn] f m 3atmciluxinax.-nd Prnreneir Cr idneyheenneia ESIDF.NTIAL:
w p PI RMI'I'ISSUANCE
F�Iy F lido lnrcc n ; - ❑SFDWL ❑KITCH17N REMODEI.
aUU Liven :I; I'' AI'I'LIANCIiS-RESIUUN'DAI. ❑MMA1'ION ❑I'I.UMBING RE-PIPE
FZW Demhl�
ra60. gHClld' - )- A U. ❑MDL'T1-UNIT ❑$'fRUCTURAL
FtiZ Send...and my plans shall heuwdhs NalmeceoMs PANELS ODIFICATION
Zp Z�' UP IG 200 AMPS [I INTERIOR 'lIMNEY REPAIR
F„tQt:w Liccnad Prom%siowl NII-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUIIA)UR DECLARATION OVER Ran AMPS ❑BATH RE.MODEUREPAR ❑DIJs1GLITIGN
C 0.'Q I hereby affirm that I am exempt from the Contractors Uvenm Law for he i U following movie.(Section 7031.5.Business and Professions Code:Any city or county SIGNS 171.17CI'RICAL ❑OI'HISR
W 3
LLI which maim,a permit H,mnuruct,after,improve,demolish,nr repair any stmcturc
1�'�p�' prom t 'I: 9 to ppl' tf M1p< n flsignaltt num }PECIAh CBCUITIMISC.
N
than he is wen,edp an, da, vision, I' C i t 1 I' (Chapter 9
00 (erns ungw'W ScrT ]Illllp IU l flh R . :: ll I 'C dc)or HAHEMEGRORPOf-EINST. COMMERCIAI:
p,0.ea Mutt rte is exempt therefrom and the lesis lot the alleged cla not an.Any violas r of ❑NISW 13LDGIADD T ON ❑UISMOLI'I'ION
��N Section]IDIS by any applicant Ee a iwrelit mbjec,the.pplievm to n civil penalty of 1H)W 1.'R DI!V ICES El TENANT ❑FOOD SERVICE:
n more than five hundred dollars(8500) 'NT
EE< ❑ I.a%owner of the progeny.or my employees with wages as their compensation. SWIMMING POOL ELECTRIC OTHP
p. willdnthewok.anifficarectum isnot intended or offered inside Star.lRm.Iiwiness
W
3 m and ver essions Cale:Tim Contractor's License law dons ma apply um am owner of OUTLETS-SWITCHES-FIXTURES
property whit builds or mpmves them,.,and who does such wok himself or through
In
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
'dr.if,Inwever.mc baildingor improvers cat I, old withm,ae y.uuI c,mplainn.the III�Q 4=.F1, AREA $TSU.FT.
ownei,hurlder will have the burden of proving that he did not build or improve for per- J U 1 9
po Awad'). DIAL:
[:] I,as awne,or the 1neR+ty.ant uclurivcly-nmmeting with licensed cbntfaatotx m
mans t the pmjcd(Se,.91114,Ilm..ast rind I'ed'cssions Ctdc:)'I le contractors Li-
meLaw dor,um poly to an ower,of prmpcnY woo builds or inmprnves thcrenm.and QTY. PLUM11BING PERMI FE,
who ..maters for such pmjectn with a mmrucmgs)licensed puuwan to the Contractors
I.iccnm Ltw. PERMIT ISSUANCE
1 um esempt under Sec. .B k I'C for this mason
ALII!k-GRAIN&VUNI'-WATER(UA) VALUNION
Owner Dam
WORKER p T COMPENSATION OECLANATION BACK PLOW I'HOTECT.DEVICE
0 [11 Helen)antro,abnet,penalty of p-rjary one of the following deemmbem
I M1uva and dial for by ea on 371 to
or Covxcnt m Costi,hmf,r Wurkcr'x Compen- DRAINS-1'LOGR.ROOF,AREA COND. RIES TYPE CONSTRUCTION
ext p 11f M1y} I]INI f(h 1'h Cd th p f cif the
x' I tenth.re t l Ilx'ruR1}-w HTHnr
I d ren t Worker's 1. n al I . 1 ' Ih,vi o
]IXl of the WM,r Code.Rod h'natc Iib kI wM1sh ha d OA} E SYSD.M I INC.4OUTI.EIti OCC.GROUT' APN
My WnryFyt dPof,y �� rt' ` ` GAS LA SYSTEMOVER 4 G:A)
Cortico a ncy No.:
CERTIFICA 1'OF EXEMPTIONWORKPHS' GREASMNDUSTRL WASTE INTERCEPTOR
COMI-ENSAI'[ON INSURANCE tlUI1.DING DIVISION FEES
it Icxx.l w
(Thiae ion need not be annpleRal if the permit is mrone hundred dollvrs(8100) GREASE I'RAP
1'LANCIII!CK FEE
T,clifil,th.turnam nnorthewbiieaw SEWER-SANI'1'AHY-STORM PA.28111.
ENERGY FEE
Amt employ any in Anymanneranca m become wnject,offic Wnrvn'C.onlpn-
Z canon Laws nt California.Dam WAI Ilk IEATER WHENN Efll.liC'IH
Z2 APPllc;an GRADING FEE
ti NOI ICI'TO APPLICANT:IL alter making this Cenifievlc of 13.canum o.,you should WAI'I!R SYS'I ENETREATING
ti $DIES PEE
[•'
becomesubjectcomply
the Wodcr'x Compcnsutis pmvixihal affair,therml r Cale,you most
117 fnnnwithcomplywith.wchprovisinnsonhis lrermit shallMdccmcd revoked. WATER tiI!RVICF.
a �
CONSTRUCTION LENDING AGENCY NEN'RESIDENTIAL PLMB. SQ.IT. PAID
1 hereby affirm that there is a consumption lending agency No the perfommence of Ume t M
{U3. the work for which this permit is issued(Sea.3097.Civ.C.1
TOTAL:
ULenders Name
lunddx Address 'ID'PAL:
>" a I ramify.mat I have mad this xpplicmion and xfro,that the above ial ou n e Is BU1I,DIN TSE
rN c Pea.I aura IInnnply'alball cityted county ordinances and mm-laws relating'. QTY. MECHANICAL PERMIT' FEE. SEISMIC FEE
U Z buildingeo.accoten,and hefchy ennoriacmpreamaativex nl Ods cit,mantel noon'lic
ad ovecoantiored prnpeny f ll inspection 1111111-x. 1.17HMI'1'ISSIIANCE 131JiC1'RIC 1[F
(We).gree m save,indemnify and keep harmless the City of Cupcminn spainst
Iiabilhics.judgmems,;..1,and ca"nscs Z.
mayinaty way weram ninst said City AM ISR OR ADD TO MECH. 1'I.UMHINC 'EE
in vnnwyuem grunting offfio mit.
APIgACA UNDF WILL COMPLY WITH A.I.I. 'ON- OINT AIR HANDLING UNIT TO 10,00i MECIIA ICALFEE
SOURC RF Of
I / AIR IIANDLING UNIT(OVER In0X)CFh1) CON. RUCTION TAX
Signtu of ApplicaMC ucmr Dam EXHAUST GOOD OMMUCp) TIO :INC,MITIGATION ITB
HAZARD A A''ERALS DISCLOSURE
Will the applicant of none h coupnecapeostereo.handl,ba....la.,material HEATING UN1'T(TO I cm.(m)BTU)
w dethoul by the Cupenint Mori p'1 Coale,Chapter,9.12 and the I Ictdlh and Safety
Coda Section 25532(.)! IIHAI'INC,UNIT'(OVER I0f,N10 if'I U)
�Vcs N VEN'TILA'HON FAN(SINGLI3 RI?SIU) i'AIU
U, Hcaciplp
Will the applicant Inmm building occupant use equipment or devices which BOII.ISR-COMP CUP OR IfXL(XH1 BTU)
mit M1vnNous ver commnanu a -fined by the Bay Area Air t)uality Management 'r OTAL:
District? BORASR-COMP(OVER i00.00d BTU) t
E3 Yes No
I have read the al Ion mntariils requiscrand under Chapter 0,95 of the Cali- AIR CONDITIONER IS. ANCE ATF:
liana Iludth N Safety Cale,Sttti,na 25515.25533 and 25534.1 undcstand ry it the NEW REMPHN'I IAL MECIL SQ.FT.
nerd' t rmdyhat tt f ludif ix taymawnadmditytom Pym t
of tell xt .- et,r ofamm"ottL ere(
autnort, agent fame 'TOTAL: ISSUED Ill:
OFFICE