S 3145 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICNI]ON/PERMIT PLUMBING-MECHANICAL S 3145
HUIT ING PROJECT IDENTIFICATION
BUiLDINGADDRESS: SANITARY NO. APPLICATION SUBMIT['AL DATE
pro -1 IF-
_0S
O I![, AME: PHONE: CON" ACTORS NAME: LIC NO:
'f 1 3 M T S ST'rN.S (L� 0 NIC CONI pill.
ARCUITECI'IENGINHER: PJC NO,^ �DI`I{{$, �r v r J , ❑
CONTAC PHONE: l ro BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BLDG EIL�ECIT' PLUMB MECi
❑ BL ❑
LICENSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby ancon that I am licensed ander pookinnx of Chapter 9 mmanenda, JOB DESCRIPTION
OCz with SEe11ain7WHbof Division 3ofnhe llusinessond Prafes'mc Cale.and mry license is RESIDENTIAL'
1- 0w. full force and cffc 7101 PERMI"I ISSUANCE. 3
=—b- to �}ao ❑SFDWL ❑KITCHEN REMODIH.
QI..ZU Liccnzp Lls Lic.M �S APPLIANCES ❑ADDITION El PLUMBING RC-PIPE
b.Do Dmc 11 Cnntmnnr
ARCHITITCCS DECLARATION ❑MULTI-l1NIT El STRUCTURAL
b.
r Z l underston l nit shift h:used blic..,us PANELS
ZOy,-, ypanssa vx pu CHIMNEY
ATION
OZ-•M UP T02W AMT'S [I INTERIOR ❑CHIMNIiY REPAIR
F•4FW Licenced Professional 201.1000AMPS IMPROVEMENT C]SWIMMING POOLS
ay ; OWNER-BUILDER DECLARATION OVER INW)AMPS [I BATH REMODEDREPAIR 0DE),IOLI'f1ON
{ C Q 1 herchy affirm that I am exempt from the Container's License law for the
{iiLL550 0.V following reason.(Suction 7001.5.Bminess rad Vafl.,ams Code:Any city or county SIGNS F.LIiCI'ItICAL ❑OTHER
r++3 LL y which requires v Permit to compact alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such Permit o file a signed statement SPECIAL CIRCUITIMISC.
pN.. mar he is licensed pursuant a the provisions of me Commemes License Law(Chapter 9
a'. (commencing will Sari nn7glBnfDivision 3 of the inosine"and Pmfeufons Ctule)ar 'GTMP.MET ER OR POLE INS T. COMMERCIAL:
d y o that It,,is cxemPr lhcreGmn and the basis for rho alleged excmPlinn.Any violminn of ❑NEW BI.DGIADDITION El DEMOLITION
LL%1 {+• Section 7031.5 by any applicant for a Mount subjects the applicant o a civil penalty of POWER DEVICES IANT ❑FOOD SERVICE
na more man five hundred dollars($500).
F•ZT / MH17R ENT
6
1,as owner
vask.ad Pe some cis rnintended w,offeewages asslei(See compensation, SWIMMING POOL F.LECI'RIC
m will do he work.andthe soucture isnot intended nr nlfc does sal a lily fine,Boniness HIiR
nd Prnfeuions Cade The Con arGon',License I.nw does not nPPly Io un owner aif OU'R.E'TS-SWITCHES-FIXTURES
4' property who builds air improves thereon,and who does such work himself or through -
his own employees,provided that such improvements are not intended or offered lot NEW RESIDENTIAL ELECIR SQ EL
side.IL however,the buildingor improvement is sold wiminone year.fcompleiam,the r$�FR FLOORAREA $/SQ.Fr.
nerhuiWer will have the burden of proving that he did not build or improve for pur- �
,.at nl'svleJ.
❑ 1,as owner,of the pmpeny,or. ,elusively enutreamg with loarsed contractors It, f TA
nsme rhe project(Sce.7044,Business and Profcuions Cotk:)Th,Contractor's Li-
nevelavit..,it.,a,toof vau,cfpmpcny who builds or impmvcs lbertnn,and QTY. PLUMBING PERMIT FEE
who cnmructs for such projects with a co rraclogs)licenced puramom to the Contractors
Liccine I.aw.
cF:
❑ Iuntexemptmaler Sec. ,B&PCfimthlsruason r n
AhTB Dfan &VE I' WA 7 VALUATION
Owner [)ate
WORKER'S COMPENSATION DECLARATION 113ACK PLOW PROIT BE
I hereby nIBr l under penalty of Perjury one of the fail lowing declandinne
r ❑ INwv and will nutimaina Cenlfenm of Conxcnun sel0.lnsure lin Wrnker'e Cnmpe✓ D F )( R IIA ). XIORIES TYPE CONSTRUCT ION
sermon,as provided far by Section 371X1 of he Lahr Gale,for the Perfmmnnce of the
work for which this permit is issued FIXTURIS-PER TRAP'
1 have and will maintain Workers Compensation Insurance,as required by Section
.7 I ofthe Labor Cale.for the performance affM work for which this permit is issued GAS-EA.SYSTIiM-1 INC.40UTLE'S OCC.GROUP APN
My Wnrkds QlNpensminn[a,u(unw uaricr and Policy nuY5111 y r ,,/r� ;fin^)
Carrico l.e 1�gw...Tx/ Policy No, N1�b Y•I
CBRI'IIECATE OFII=.XI MPI[ON FROM WORKERS' ❑RFASFIINDUSTRL WASTE INTF:RCEPIOR
COMPIiNSA'1'ION INSURANCE BUILDING DIVISION FEES
('T his section need not be completed ifthe permit is future hundred dollar,(S I DO) OREA$E'1'RAP or Ice,.) PLANCHECK PER
I cerifythatimhe performanceofinework l itrwhich rhispermit isissued.I shall SEWER-SANITARY-STORM EA.200 IT.
urn employ any prison in any man yr1s�y rp l c.mbject m the Workers'Comp m- ENERGY FEE
,z union laws of Ca' A 1 WATER HEATER WNENTIELECfR
7�7 Applicant _-� GRADING FEE
FN NC111C,rRaAPPLICA N'I:If,anernntkinglhi,s Ccdlticme of lixemprimt you should Wq'ICR$VS'I'ITM/fRIiA'I'ING
a ; heconm subject a the Worker's Compensation Pmvisimns of rhe Lahm Calle,you must SOILS FEE
{A transit comply with such provisions or this pernta,hrill Is,deemedrevnked. WATER SERVICE
aQ
Uz CONSTRUCTIONsac muLENDINGAGENCY NEW RIiSIDITNTIALPLMII. $Q.Ff. PAID Dom H
1 bcreff co
hy ot had there
is n ... dion lending agency lot he pafnmumec of mpr M
L. the work for which this permit is issued[Sec.3097,Civ,C.)
01•'x' Lenders Name TOTAL:
V Lenders Address TOTAL:
L eerily that 1 have read alis application and state that the advise information is BUILDING FF.
Val canal.l agree mcaatply wirball airy unJ wnnny ordinmlms and,arra laws relwingm QTY, MECHANICAL PERMIT ITE
U 7, building companion,and hereby amhoriu represcatutivesofmis city local,upon the3�3enSEISMIC F1717
alxwe-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE r
(We)agree m save,indemnify and keep hamticu be Ciry of Crouton.spirit ELECTRIC FIB: O
liabilities,judgments.costs and expenses which may in any way acerue.gain.st said City ALTER OR ADD TO MECH.
in mseyucnce of the gnualm,of lhix Pemtir. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO I(LIXNI CFM) 0
SOURCE REGUI.A'f1ONS. MECHANICAL.Fi:F. Z
AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCTION TAX
Sigmmnre of ApplicaaYCom.m, Date EXHAUST IIOOD(W/DUCT) HOUSING MITIGATION FITIi
HAZARDOUS MATERIALS DISCLOSURE
Will the applimm or furore building secupam.w.m.,handle huaeduahoun.l HEATING ON['T(TO IW(ll1 BTU) 2- 0
as defined by the Cupeninn Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)'! HEATING UNIT(OVER Illation BTU)
Yes ❑No
VI3NTIhA'IION PAN(SINGLE RE$ID) PAID
Date Receipt N
Will the applicant or future building occupant use equipment or devices which
emit hazardous aireomaminana as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District?
EJ Yes 0 N BOILER-COME(OVER Ho,001 BTU)
/
1 L(
1 have read the hmmdous materials reyuiremenk under Chapter h95 of the Cali AIR CONDITIONER ISSUANCE DATE
ford.Health&Safcty Cede.Simons 255(15.25533 and 25534.1 understand than if the NEW RESIDENTIAL MECUL SQ.FE
building docs not conically have u tenant,use it is my reslmnsibility to notify me occupant ((((
of the reyuiremenks which mus be men prior m issnanee of v Cenitienle of Oceupnnny. �..r�
Owner or amhonzed agent (late 0 ISSUED BY: /
OFFICE