S 3870 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
3 O
BUILDING DIVISION APPLICATION/PERMIT PLUM -MECHANICAL 7 O
BUILDING IBOJ(IJECT II3FT"1'IN'ICATION S J J o
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAT.
t a 36 2 5. -7" TA-H u'c,�• Ccs Plaoe•rm o c.A-az-99
OWNER'S NAME: PHUNE: CONTRACTORS NAME: LIC
.eh 12 F & t./k F C c (t0 p,S "932 NIC
CONTROL«
CHITECVENGINERR: LIC NII: ADDRESS: ❑ 9by ?
No MA/Pt&b( elp90
CONTAUT /� PHONE. BUILDING PERMIT INFO
/3R[tN ^a �ijR t�/-( L ❑ Consultant Fecs Paid by Applicant(Initial) BLDG M.ECf PLUMB MECH
5-5-9-3191- (Vo)ZY3-312s E9— Er- E- 0-
LICENSED CONTRACI OR'S DECLARATION QTY. ELEC'T'RIC PERMIT FEE1 hereby unit.Ill.,1 am licensed under p,nvieinns of Chapter 9(commencing JOB DESCRIPTION
{"{yZ with Section 9000)Of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL
F,= In fulliomomdeti"n. PERMIT ISSUANCE `-S� ❑SFDWL C1 KITCHEN REMODEL
QUU Liccnac Clans 4c.k APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIi PIPE
f-Z W Dam Commcmr
ARCHITECTS DECLARATION PANELS MODIFICATION❑STRUCTURAL
�Dy
Z p=Z 1 undccuwd my plans shall be wcJ as puM1lic.cords MODIFICATION
OZ.. IIP TO 200 AMPS ❑INl'IHGOR C1 CHI MNLY REPAIR
_yF� cenxd Pmlersinnal 201-10CLOAMPS IMPROVEMENT (]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER I000AMPS C1 BATH REMODEL/REPAIR ❑DEMOLITION
t5 C Q 1 hereby amr.that 1 an,exempt Item the Cmttmetnr'e License Law for the
,R W U ❑OTHER
K 6 following reawn.(Section 9031 5,Business unit oo,demolish,
h,,,Jes Any my nr county SIGNS ELIi }1!
2 3 LL vF<i which requires a permit to construct,cellar,improve,dnnolish,or repair any structure
OJ Ice'its issuance,also re the licunt For such tam file a signed /dLe• =��' ��
VVii pant quires pp Permi paw SPECIALCBCUITIMISC.
.t2 that he isllccnwou pawnammine provisions none conuumor's License Law(Chopter9
W�CO (c°msnencingwith&etion 9lB)of Division3ofthe Huxiness and Professions Code)or 'I'P:MP MITfER '1 'I71 U1 COMMERCIAL
d%o W that he is exempt therefrom and the basis for the alleged exemption Any violation of ❑NEW BLDG/ADDITION C1 DEMOLITION
Lid
�m Section 90315 by any opplic rel for o pendm
nil subjec ,he applicant o civil penalty of POWER DEVICES (]TENANT C1 FOOD SERVICE
t more thin live hundred dollars S500). IMPROVEMENT
. kiURDING
<SQpQl.as owner ofthe property or my employees with wages as their wit,compensation. []OTHERSWIMMING
C F.'. will dolhewmk,xndthe struc.re runt inrcndedmrnHered for sale(Sec.9044.Business
L 3 as .,,it Pad oinm Code:Ti,Conlboblo s Liceme Law docs not apply n,an owner of OUTLETS-SWITCHES-FIXTURES
pmpcny who build,or i.pmees thenen,and who Ates such work himxlf or through
his own employees,pmvidd that Such improvements um not intended or oRered fell NEW RESIDENTIAL ELECTS SQ -
side,If.however,the building or improvement is sold within one year ofcompletion.the a SQ.FT R-OOR AREA SISQ.FT
awn
cr-nulldur will have the huNnt of proving that he did not build or improve felt par.
psa mf sale,. _ :k 2Y 3•S y2
1,as owner d the pmPeny,.B exclusively contracting ns with licensed Contractors
i. �' Q t V7 j x Z-p
n,xtraal the project Sec, ,fain,Business and Professions Cd1U The Cl Eleveols Li- 2
se Law does ouch p roman with
aofprctor(s whosedprnation,the
amrcon.and QTY. PLUMBING PERMIT FF.T:
who comracss for xuchp jcns with aconsracmrts)licensed pursuannO the Contractor's
Licence law. PERMIT AJANCE
❑ Ian,exempt under See ,B&PC frnthis reason
ALTER- AIN&VEM'-WATER H!A) VALUATION O G
Owner Date
WORKERS COM1IPENSAIION DECLARATION BACK H.O ELT. 'VICE
4nrchy utGnn under pmmlty of perinry one of the following declarations:
'sad will maimeinacenificate ell Consenuo self-insurt lie Waders Compen- IlHAINS-FLOOR. Iir.CONII. S'I OWES TYPE CONST RUCHOI
cation.m proridcd for hY aretion 391 of the Labor Code.for the Performance of the
work for whim thin permit iz ioueJ. FIXTURES-PER TRAP Z S/'aA•/e—
❑ I M1ave and w?II tnuintain Wuske'x Cntuponsetiom Insurance,as minted by Sectlnn
391 ofthelabor GWe,Tor the pofamullom!the work far whichchis pennil is issued. GAS-IiA.SYSTIiM- .n LE'I'S OCC.GROUT' AI'N
My Worker's Comiansaiun Insurance carrier and Policy number am:
Carrier: Policy NO.: GAS-EA.SYSTEM-OVER 4(EA)
CEKI'IIICAI'E OF EXEMPf10N FROM WORKERS' GREASIJINDUSl81.WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he complete ifthetennit is raronehundreddollars(511) GREASETRAP
nr loss.) PLANCHECK FEB
Icenify tha,'mthe pedomene,ofthe wmk for.1ich this mad is issued.l Shull SEWER-SANITARY-STORM EA.2I FT. p
not employ any Person in any manner so as to become subjecun the Waders'Compete IiNERGY FBB .J f
Z ,Z .cotton Lmus of Culifomla.Dula NATER HEATER WNENTIELECB /\ GRADING FEE
Applicant
y NOTICE r10 APPLICANT:IC after making this Certificate of Exemption,you should WATER SYSTEMn'REATING
f•' Facomc subject to she N'odcls Compensation pmvisinns of the labor Cde.you must _ S014sr EE
CZfindwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE ��aU L
04 CONSTRUCTION LENDING AGENCY NEW RT:SIUENTIAL PLACE. SQ.FII / PAID(a
V0 IMreby affirm that is a concoction lending agency for the performance of V UD�te/, n ReceiptN
F the work Int which Ibis pennil is issued(Sac.31Y19,Civ.C.) c, /rY/n 1�
0TOTAL:
Lender's Name p ,I
UJ I.emlcr's Address TOTAL /x 111/ ODO s 0l
1 certify that 1 have read this application and state that the above information is BUILD IN , E O o
.H., p] 'omen.I agrer it,in ly with all city and mumy onlinunces emit store lows mladng m, QTY. MECHANICAL PERMIT F
FF //s�/ & GQ
V Z building concoction.and hereby ramorim representatives Of this city to enter upon the �.� SEISMIC FEB
above mentioned pwperty for inspection pmpous. PERMIT ISSUANCEesg5115 VI,ELECTRIC FE 9x
(N'N agree u)save,indemnify and keep harmless the City of Cupertino against
liabilalex.iudgmonx+,castsand cape..mawhicb may In any will accmc against sail City ALTER Oil ADD10 MECH PLUMRINGFE 2ys
in onmyuence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHAN ITIi
SOURCEREGULATIONS.
AIR HANDLING UNIT(OVER I0,000 CFM) CONSTRU ) '1'A%
Signature of ApplicanJContranor Dae EXHAUST HOOD(WMUCT) HOUSING IGATIV E y Qci
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplleam nr l'ulurcbuilJingnwupum store nrnunJk haalloue n,merinl HEAPING UNIT ill 11XX0 BTU)
as demand by the Cupertino Municipal Code.Chapter 9.12,and the Health and Sal sty In
Coda Section 255321a)9 HEATING UNIT(OVER 11,fgp BTU)
[I Y,, ❑No VEM'[LAI[ON FAN(SINGLE RESID) PAID etc ReceiptN
Will the applicant or fumm Palms,occupant it,equipment or devices which
1
clhmallous air nmtaminnnts m JdincJ by the Huy Arca Air Quality Management BOILER COMP(3HP OR Ba"BTU) TOTAL:
tach BOILER-COMP(OVER IIAhIIIYJ RTU)
❑Yes ❑No T
I have soul the hm:oJom mmcrials rcyuimnmms under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
Iorma Health&Safety Code,Sections25505,25533 and 25534.1 understand that it the NEW RES IDEN'IIAL MECH. SQ.PI'.
bill Imniverne yhave' enryth that it ix my responsibility to notify she necupant
fifth me�whi II mull pdnr e,issuance ofn Cenificac !(ecu y.
' a 2 l ISSUIiU HY:
Owner rind opens Ute TOTAL:
OFFICE
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