S 3067 APPLICANTTO FILL IN INFORMATION WITHIN REDLINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.RLE.TRICAL PE rI No.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3067
BUILDING PROJECT inENTIFICATION
BUILDING ADDRESS: � fk tiANll'ARV NO. APPLICAI'I(IN SUDMITI'AL UA'1'li
070 IDr rw rpt] -2
O NER'S NAME: PHONE: - COMINACTOWS NAME: LIC NO:
"N i, �il,rz"r NIC CONIROLn
ARCO['I DUI IENGINEER: 1�(A•t WlN1 LIC NO: ADDRESS: ❑
CONTACT: PHONE: EU TIDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
❑ Z?" ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTy. ELECTRIC PERM I FEE
m
I herehy alarmat I um licensed coder nookillx of chapter I)(cn..... ng .LOB DESCRIPTION
WON ON with Sulin I700(dof D.IiImu Sof lira Ensure,and Pon—ion,Codemtdnry licensees �� RESIDENTIAL:
t+lin PERMIT ISSUANCE
F-wp full force and effect. ❑SFDWL ❑KITCHEN REMODEL.
�USJ License Class Lick APPLIANCES-RESIDENTIAL. El ADDITION ❑PLUMBING RE PIPE
QW Dam Cnnuac,or
RAL
FDm ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑MODIFI ATIO
Z C)m 2 I understand my plans shall be used as public records MODIFICATION
UPT020"AMP$
OZ^0 [-]INTERIOR ❑S CHIMNEY
NG POOLS i.�I"W Liveried Pmfexaional 201-IINN)AMI'9 IMPROVEMENT' El SWIMMING POOhS
; OWN13R-ItU1LUF:R DECLARATION OVER I(NOAMI'S ❑BATH REMODEUREPAIR [I DEMOLITION
CCG 1 hereby affirm that I am exempt from the Commences License Law for the
xa C i U following nosh.(Section 0031.5,Business and Professions Cade:Any cit or county SIGNS ELECTRICAL ❑OTHER •�
aJ 3 LL F which requires a permit to construct.alter,improve,demolish,or repair any structure / S
pO
tron, t ' Sirloin.
I. q npl tf bP- i,tb Axn
math I ' . dIpr m rl C 1, la License
ic .I woarre,9
� a0 (a+manc gwOt Sem an 700(q+IDva n3 I'Ih fo. ns d§ I coChnde)0r
P U" )
COMMERCIAL
1 q o L, bar he is exempt therefrom:rod the basic for the alleged exemplion.Any vinjiumn of ❑NEW RIDGIADUITION ❑DEMOLITION
,=o`) See...7031.5 by any applicant tarn Penni,subjects the applicntnu+to civil renally of POWER DEVICES [I TENANT ❑P001)SERVICE
FZ
mare, on Vice,Vice,hundred dollars($500).>' h.,nwnern IMPROVEMENT
O6 fthepournot or hyo indemaswrofiro eseslheiSer.7044.8 sine.., SWIMMING POOL ELECTRIC
jd II oche work,andhe Conaixnorr License
1,,iw nJfursvlel,euJIH4.Business ❑OTHRR
W and property
adsCode.The oyes hclura I:menw Luo soca not apply o f owner al' OUTL6I:S-SWITCHES-PI%'fl S
F pmpeny whn builds or aided cx(bacon,and who does a do,
hunintended
,f m ori for
his own employ,..,provided Thu(such imp is sold
arc nut intended of olfered for NEW Rf:SIU13NTIAL F,LF. Ff.
sale.If,hnwcvice the building or improvement is sold within one yar of n+magion.(Ae SQ.17 FLOOR AREA SISQ.IeI'.
wnef-huilder will have the burden of proving that he did no build or improve for pur-
pose of sale.).
❑ 1,as owner 0 the mpony,can vxolusively contract,with licensed.....trounces I. e O
cuu,dro Ota pmjui(Site.7044,Bushcss and 11rnfeaain I,Coda:)The Cunuucmev LI-
se Law dors not apply In ad 0-101 of propony who builds or imprnvu Ihereon.and Y. 1 G PL I PEE
who contracts for such Pmj¢ts with a n+mmcmgs)licensed purscam u+Ihc Comma
rmp
License law. P. SSIIA �'
❑I an esempt under5ce. '1sk ' ,B&PC Ia
vso ALT DRAIN&VENT-WATER(EA) VALUATION
WONT .L000MI'13NSAT JDI?CI,ARATION ,OW PRp'1'13CT DEVICE
Novo 5 1998
IM1erchy ulfirmt er remtlly of rerjurY nuc of the following Jeclur' 1`f V
El Ihw'eund will maintain.Criifiereof Cnmrnl and.-insure for Workers mpem DRAINS-hL00R.ROOF,ARI3A,CONIJ,
.cation,as provided for by Section 37W of the Labor Code,for the perf rrman f S'TOHIIiS '1'YP STKIIfTION
work for which his .it is issued. FIXTURES-PER TRAP
EJ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3700ollhe Lobo Gxlc,for the perliamvnce mOm,work for which this per it is issued. GAS-EA.SYSTEM-I INC.4 OU 11.1 SPN
My Worker's Comr...ation nsurance.arflerumd Polleynumherarc:
Cartier: Policy No:
GAS-EA.SYSTEM OVER 403A)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL\VASTE INTERCEPTOR
BUILDING DIVISION FEES
(ITis section need not lwcmmpleaW ifthe.Am+B is hone hundred dollars($100) GREASETRAI'
or Inst 1'LANCHECK P13Ii
I crony hal in the licit rea.cfine work turwhido thispenion is is sued,[shall SEWRR-SANITARY-STORM[IA.201 PC
not employ co,Person In any harmer,'+ns u+hcconu.anhj.el to the Win on,Compen- ENERGY FEE
OZ satin.Laws of Culifnrnia.Dale WATER HFATHR W/VENTII31.13C'IR GRADINGFEE
2 Q Applicant
ti NOTICE TO APPLICANT.If,after making this Certificate of Exem.tion,you should WATER SYS'HENVfREATING
1" Income subjec,to(he Workers Comrensalmn pen eisinns of(he L.M.GWc.you most SOILS FEE
both,lot comply wish suds procknons or this permit shall be deemed revoked. WATER SERVICE
a Q
CONS i1CTIONLENDING
ngACENCY
agency NEW RESIUI3N'I'IAL PLMB, SQ,FI', PAID
Z IJ:uc Remipl p
rJQ Ihemhy affirm that mem isnamnwmion lending agency Torahs terfntmnncenf
the work far which this permit Is issued(Ser.3099,Cie C)
1--' Lenders Name TOTAL:
W Lenders Address TOTAL:
1 certify mm I have read this Appheter n and state that the above informmion is BUILDING
f%j cone..1 agree in oov,ly with all city and county ardimmocs and slum luwx rclat,.g or QTy. MECHANICAL.PERMIT FEE
V 7bung construction,and hereby umhorizeretrexentntives of thiseity menternponlhe SEISMIC W11
abaso-memin.cd pmpeny for inspem(ion purProt, PERMIT ISSUANCE
(We)agree to save.indemnify and keep harmless the City of Cupetioo against ELI:LTR 3 (�
liabilities,judgments,costs and expensus which may in any way noncom against said City ALTER OR ADD TO MECH.
asequence ofthe granting ofthis permit. PLUMBIT;
APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REnJLA'1'TONS, MI?GRAN IAL 11.17
s AIR HANDLING UNIT(OVER 10,00(1 CFM) CONSTRUE' IN TAX
ignamre of Applicant n deme Date EXHAUSTHOOD(WNUCD HOUSING MIT 'ATION FEE
I ALAKDOUS MATERIALS DISCLOSURE
Will the applicant or home,building occurynt morcor handle haaWousmaterial HEATING UNI'1'(10100,000 HTU)
as defined by the Commie.Municipal Code,Ch finer 9.12,and the Ihealth and Safety
CWc,Section 25532(a)? HEAD NO UNIT(OV IzR I00f(M I It'G)
Vox [-1 No
_ VENTILATION PAN(SINGER BE PAID Date got#
P Will the...]in.,or future building occupant use equipment m devices which
emit hazardous air contaminants as defined by the Hay Area Air Quality Management BOILER-COMP(3HP OR 100.000 It'E-E
District? T(YI'AL:
Yea No BOILER-COMP(OVER 001001OU)
Alit CONDI'T'IONER
I haavc read the haznrJous nvneriuls tequircmcnU under Chapter d,95 of the Cali- ISSUANCE DATE
fnmia Ifcahh&Safety Code,Sections 25505,25533 and 25534.1 understand(hal if thu NEW RESIDENTIAL MECH. SQ.Fal / �.I T
building does not currently have a,snook thptm
at i,is my ressibility to notify the occupant
of the recruitments which must be met prior m issuance of a Cri iticme of(,cursory.
Owner mnmlhorized Agent Date TOTAL: ISSUED BY: Q
OFFICE