S 3889 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF v UPERTINO BUILDING-ELECFRICAL PERMIT NO.
BUILDI):C DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3889
BUILDING PROJECT IDP:NTIF'ICATION
BELDINGADDRL S: SANITARY NO. APPLICATION SUBMITTAL DAT'.
OWNER NAME; � )N _� O� �lS NA11 F.� L/?22 7dIC if NIC CONTROLn
RCIII]fCTI[NGINEIiIi', LIC NO: ADDRESS: `?JA/ ❑
q of 2AL -i 214 ;7.5 9yo'
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONI RACI'OR'S DECLARA'HON Q'ry ELECTRIC PERMIT FEE
I hereby a1Bnn that 1 am licensed under provisions of Chapter 9(commencing JOB DFSCRIPTION
W=Z with Seclinn]gp)uf Division 3ofthe thromessand l'ndessionsCWc.and mylicens,is
WOO PERMIT ISSUANCE
I- in full force and effect. 36 .l SIUWh ❑KITCHEN REMOUF.1.
F6UU l.c Cl s D ` J Lw N APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RIiPIPE
to Q a Datci �Cnmracmr
f-< ARCHITECTSDEC •e HPOA PANELS
❑MULTLUNIT ❑STRUCTURAL
ZO'^Z Iunder,taod my plans shall he used as public records //� MODIFICATION
OZLO UPTO200AMPS C]INTERIOR ❑CHIMNEY REPAIR
1--'�1,1'".W Liucnxcd Pmfcssionul 201-HXOAMPS IMPROVEMENT ❑SWIMMING POOLS
�ie2_ OWNER BUILDER DECLARATION License Law for the (OVER IIXp AMPS ❑ ATH REMODEUREPAIR ❑DEMOLITION
Q' 1 hereby a(frm Lha 1 am exempt from the Contractor.%
O a U following reason.(Section 9031.5.Business and Proessiam Cole:Any city or county SIGNS ELECTRICAL OTHER
W B W Ha which ocnares a permit to con%tract,alter,improve,demoB%h,m repair any structure /`/eTiSC .14451919 f— ISOG/LEG
J
roar to its issuance.atm requites theappliam Bxsuch german,file a signed suamtrmnt SPF.CIALCIRC'," C.
e�'Y that he is licensed pursuant...the pro isions..fine Contract.,§License Lvw(Chapar9 Vit N,
W p0 (commencing with Section]1g0)it Division 3 at the l4rinesx and Prousslons Conde)or 'TEMP MEr POLI!INST. COMMERCIAL:
E.a e C Nm he is exempt da efrort and me basis for Ila alleged exemption.Any violmi, of N W BLDG/ADDITION ❑DEMOLITION
N Section]031.5 by any applicantfar a permit subjects the applicant to a civil penalty of POWER DP CBS TE ANT ❑FOOD SERVICE:
n mom than live founded dollurc($51X). IMPROVEMENT
=Q 01,as owner of the property or my employees with wages as their sole compensation. SWI NO IKK)L ELECT IC
E. will do the work,and theaoactum i.not intended or offered for sale(See Businns .,� ' ❑OTHGR
W m and Prn .....Code The Comma',License Law docs nm apply to an invner of ( 1'LETS-SWITCHES-19XTU10.
1 propcoy who builds or improve,Ihercun,and who docs x0,11 work himself or.hough
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTW\� SQ
sale it,bnwcvc,gamA,ia,m improvement is sold within oneyew e(eumple.irn.Jhe SQ.FP FLUOR AREA $/SQ.FT.
wnerhuilder will have the burden of proving that he did not build or improve for pur-
parso,m sti
L as owner of the prn)wity,aim exclusively crmmcting with heated comractnn to jr
msuun the Pnijem(Sec.](W.Bu,ines,and Profession,Code:)The Crnvuc.or's Li-
caseWwdcesnotapplytoanoxaerofpropertywhobuildsorimprovethereon.and QTY, PLU ING'P' MIT FEE
who contracts for such projects with a eonaaemons)liar d pursuant o the Crntreeors
License Irw. PER SUA
❑I em exempt uMe,Sce. .B&P C far this..on
A -DR '&V -W 'R(EA) VALUATION
�0wmcr Umc Pa's
WORKER'S COMPENSATION DECLARATION HACK ROPE .VICE % QV• (Pro
I hcrny affirm unJm penalty of perjury one of the frlhming dedamunm:
❑ Ibavoarovide!forbyection 377 of ConsearCode.for the Worker's Camper- DRAINti- P.AREA,COND. STORIES TYPE.CONSTRUCTION
moon, r provided for earn
Section 3]00 ol'the Luton Code,for the performance of the
nk ave and
will
maintain
issued. PI%TURES-PE RAP
1 love uLa will Ioca I n iv, rfo, ranc of me w rkfor ce,ashi h required by Section
300ofthe Latin Code,for the performance of the work Gawhich this permit is issued. GAS-UA.$YS'1 BM-I INC.40I1'1'LFTS
ROUP APN
MyWinkeryns dofapN[ icrmsdPolicynuj�V,RI��" G
Cmricr: ', rPolicy Nn.: GAS-EA.SYSTEMOVER4(EA)
CERTIFICATE OI'EXEMPTION FROM WORKERSGREASPIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissectimneedful,he Ounpletd it Norm,is for one hundred dollars Ci IBd) GRPASH TRAP
PLANCIIECK FEEor Irv,.)
I certify lhminthe perforce.twO.Ohe work far which his pe ani,is issued,[,hall SHWER-SANITARY-STORM EA.2W FT..
am entpiny any".a in any m rte m 'y ns,he Workers' ENERGY FEE
Z saint.I-awsrf Califomiu.Dm an WATER HEATER WIVEN'I/ELECTR y54
Z O Applicant r.o - t mI GRADING FEE
'zr' NOI'IC17 TO APPLICANT:If,after mal ng,hi,Cenifieae of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
a; baht...,s.hjc,lto tuc W..kre,Cmnprn,u ion pfnd..aux of(he Lance Outfit,yrs mux[
Ibrthwimhanmp[y whh,ach provisioner,this permit shall be deemedrevoad. WATER SERVICE
Q
a CONSTRUCTION UTNDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID laic Rcc<ipr p
U Q Iherchy efhnn mhauherc iseconsttuaion lending agency fm the perfnrmmrcenf
w F the work for whish this .his issued(Sec.3092 Civ.CJ
O U Le lOC,Name _ BUILDING F
TOTAL:
LQ Leacte,Add.,, TOTAL:
LQ
} a I rtify thin I have red this application and Ham shot the ahem,information i,
ce
`� to correct.I agree to comply with all city and county ordinances and state laws relining to QTY. MECHANICAL.PERMIT FEE
U Z buildingcrnswaina
n. nd herehyeuthnrill nPownatives of this city In encrupon the SEISMIC p-
above-mentioned pmpeny for inxpection urfawes. PERMIT ISSUANCE.
(WO agree m aavr,indemnify and keep hamiless the City of Cupertino against ELECTRIC FEE
liabilities,jucancro.costs and experucs wbithre,in any way ve,mc against said City ALTER OR ADDTO MSCI I. •S0
in consequence of date granting of this Permit. PLUMBINGP •o
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM MECIIANICAL P
SOURCEf�RPGULATIONS.
//1 at %' /�y--' (� AIR HANDLING UNIT(OVER 111, CPM) CONSTRUCTION TAX
Slgnuwrc ufAPplicnnV nmmcmr �`{ u Da(m� I,XHAI1ST I lOOD OVMUCD HOUSING MITIGATION FHB
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building IXcupao6store or handle humardous material HEATING UNIT(TO RABTU)
as damn d by the Cafe,iou M.mieipal Cole.Chapter 9.12,and the DcuIN and Safety
Cada.Section 25532101:' HEATING UNI'I'I -R Ivo.mloitI U)
C]Yes VENTILS110 AN(SINGLE REBID) PAID Date Rec<iptp
Will the appllam or future building iavupant use egNpme l or device,which BOILS CONIVOHPOR 1L`B.000 BTU)
mit hazardous air cvtmmimams a'de tied by the Bay Area Air Quality Management TOTAL:
District' rAIR
COMP(OVERIdB,(MBTU)
❑Yes
I have read the havurdimv mmentds requirements under Chapter 6,95 of the Cali- ITIONER ._ISSUANCE DDATE
fnmisHealth&Safety C'de.Seefins 255115.25533and 25534.1 understand in.[iftheDENTIAL MECII.
building does not currently haveranter,that it is my respnnsibilitym notify the occupmm
atone mquimme ,rAwha yet ace fu enifem Oc Y.
Dwner or amwr gen Imo 'TOTAL: IssueD BY:
OFFICE