S 3181 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF C'UPERTINO BUILDING-ELECTRICAL PE HNo
BUILDING DIVISION APPLICATION/PERMIT PLUMIING-MGCIIANIL'AL 3181
I uB BING PROJECT IDENTIFICATION
BUILDING A DDRP_SS: SANITARY NO. APPLICA'110N SURMITTAL DATE
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OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC
—_>77NIC COM'ROLg
'CHITF.CT/ENGINEER: LILN ADDR _ ❑
sl� LFII
CONTACT PHONE: BUILDING PERMIT INFO
AHK G/e1ve- r cn6, 97q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECB
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PI7RM IT FEE
I hemhy alum that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
Wa 0.'Z with Section 700apd Division Jol the Boxam"And Pm! Ccallit license is RESIDENTIAL:
WOO y PERMIT ISSUANCE
FW. in full fume(code a. /%I�? ❑SF'DWI. (]KITCIiF.N RIiMODIiI.
QUU Licensa Eta-/�Lic.p �J=r APPLIANCES-RL.SIDIiMIAL ❑ADDITION El PLUMBING RE-PIPE
NQS DPIe� Cnmm[Inr
b.0, ARCHITECES DECLARATION PANELS ❑MULTI-UNIT ❑MODIFI STRUCTURAL
MODIFICATION
z0o)Z I understand my plans shall he used as public records MODIFICATION
O•Z.4—M UP TO 200 AMPS C1 INTERIOR C1 CHIMNEY REPAIR
FQ4LW Licensed PrultiAmill 201-1000AMPS IMPROVEMENT E]SWIMMING POLIS
Cy ; OWNER BUILDER DECLARATION OVER IIXq AMPS ❑RATH REMODEUREPAIR Ll DEMOLITION
C 0.�'Q L hereby offrm that 1 um exempt frntn the Contractor's License Law for the I��m�
3 P F following reaam.fSmtinn 7131 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. �]T6�E —
W m Which y I I al t t II p I t I'hrepairany structure A
F. to prig t ts issuance,alsoy thi i for,ouclipe...ill It)II 'g I tatcne t SPECIAL CIRCUO'/MIST A/�0/7 L
y•] that he is licensed pursuant to the t title Contractile,License L (Chapter9
0.20 thathesex,withSeattlrnm k))olnd Inv 1 tI I{ sin If fes: ns Code)or TEMP METER OR POLE INS'I'. COMMERCIAL
00
(� not more than live hundrcJ Jallnrs ISSIXI r Ih JI gel ex pl Any vinlmion of [I NEW BLDG/ADDITION ❑Dh:M01.1''ION
W N Section 7031.5 by nny appliumt Ino u permit auhjects the applicant to a civil penalty of POWER DEVICE 3
❑IMPROV (_1 FOOD SERVICE
F=ODI.as owner of the prapeny,or my employees with wages as their wile compensation. SW IM M I NO POOL ELEC I R IC IMPROVEMENT
P. will do the work,and the structure not intended or offered for sale(Sec,7(134,Business ❑OTHER
Cwand Pmlessionx Codc:aloe Contractor's License Low does not apply In an owner of OUTLETS-SWI'I CI{his-FI%'ILRIiS
6 property who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELECrR SV I'L'.
sale.IL improvement'is wild within one year of however,the building or imrovecompletion,the SQ.FT.FLOOR AREA 1/SQ.FT.
ownnr-builder will have the huMen of proving that he did not build or improve for par,
,Amof salt).
❑I,as owner of the proilial ata exclusively contracting with licensed contractors to )TA
instruct the project(Sec.7DH,business and Profession,CMeo The Contractor's Lu-
move Use docs not apply in an owner of proiterty who bonds or improve,thereon.and QTY PLUMBING P17RMII'
who contracts for such projects with a cintractons)licensed pursuant to the Contractor's
License Lw. PERMITISSUANCE
❑ I um exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(IEA) VALUATION
Owner Dam
WORKI3R'SCOMI'ENSSFIONDIiCl.ARATIO14 BACK FLOW PROTECT.OCVICIE s—I hereby affirm under penalty rf perjury one of the following declamlions: s
441 I have and will maintain a Certifcam all Consent to for Workers Compcn- DRAINS-FLOOR,R(H)P,ARHA,COND. ST RIES TYPE CONS'I'RUCTION
satins,as provided for by Section 37M of the W Mr Code,far the performance of the
work for which this permit is issued. FIVTURF_S-E'ER TRAP
50 1 have and will maintain Workers Compensation Insurance,as required by Section
370T ofamLabor Code,for the peHivmanceofthc walk for which this tenon is issued. GAS-EA.SYSTEM-I INCAOUILErS ❑ OCC.GROUP APN
My WorkerP�y iia I!p e��amierand Policy rummer we: CA. -IEA.SYSTEM OVER 4(CA) O
Carrier: 77 Policy No.:
CERTIFICATE OIt EXEMPT ION FROM WORKERSGR NDUSTRLWAS'IIEEUHRCEPIT)R fl
COMPENSATION INSURANCERUILUINO DIVISION THUS
flhiswda need sol baa illiberalifthepannil is furore hundred dollars S,an GRI .1E R --- -
or line.) PLANCHFAK FET.
I cenit'y built the performance ill me work tar which this permit is issued,I shallSC 'ANI'fAl2V-S'ITIItM EA.2no lot's
not am,loy nny person in nny mmin..sons to heentne suhjad m the Workers'Counter- ENERGY FEB
Z
.anion Lmaol QBllornia.Dam WA i !A'1'ER VENT"
z 0 Applicant GRADING FET.
.-i In
NOTICE DO APPLICANT':If,utternelkingmi,Cenilicam of Exemption,you should WA ER SYSi EM i SOILS
4 ^s become subject to the Workers Conlpenxndnn provisions of the Labor Coda,you mus
04
aQ funhwilh comply with such provi.siomnr this ,all,shall toleemed revoked WATER SERVICE P
� z CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ,FII Dateeiplb
V 0 l hereby affirm thauhem k ll,mcwctinn lendingagency forthe performanceof
IL E-' the work for which this Permit is issued(Sec.3097,Civ.C.)
Lenders Name OTAL.
Lenders Address TOTAL: I '
ft' 1 reality that 1 have read this application and vale Baltic aNice information is UING FEE (�
F fA correct.l agree to comply with all city and county ordinances and are Iaww relaying to QTY. MECHANICAL PERMIT FEE
U z building construction,and hereby autherim representatives of this city to enter upon the SF SMIC HE O
abme-metnioned property for inspection peroses. PERMIT ISSUANCE
(We)flame ill rave,miand keep harmless the City of Cupeninn against F.CTRIC FEF.
liabilities.judgmems,costs and expenses which may in any Way acerae against said City ALTER OR ADD TO M ECH.
in consequence of the granting of this permit. PEN,
L 1RING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(IO 10,000 CPM)
SOU RE ULATION.S / /n METH ICALNE
�. /!_{i.rV4' Y� AIR HANDLING UNITIOVF.RIB.IXXICPMI CONSTRUCTION TAX
Signature of ApplismanConlmetor Ua, EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
EIX' RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sore or handle hazaNnus material HEATING UNIT(TO IWAXXI BTIB
as defined by the Copious,Municipal Cale.Chapter 9.12,end the 1{c lm and Salary
Code,Section 25532PU HEATING UNIT(OVER IIXI,gXI I{'I'Il)
El Yel ❑Nn PAID.
VCNTILA'fION PAN[SINGLE RCSID) Date RecciplM
Will II¢applicant or future huilding cen,inum use equipment or devices which 'BOILGR-COMP(31111 Oil IIXI,fFlll BTU)tit haannloms air cnnmidams m dnOneA by Bay Arco Air Qnality Management LIP
i,ariclY
❑Yes El No ROILL'R-COMP(OVEIt IIX1,(IINI R'flll 13
I have rand The hnmrdnux Tnhmrials Ivptiretnvm,x undo Chltpmrfi95 all AIR CONDIIION17R the Cell- ISSUANCE DATE
forma I Iadth&Sanity Code,Seat in is 25505,25533 and 25514,1 undcNand thin if the NEW RBS I DENTIAL M13CI I. SQ.FI'.
huilding Anse not amm�lly Inrva a Tenant,than a is Iny responsibility m and l'y the eacupme 7
I',
the requirements which must he met prior m issi unce of it Cer,ifcam of Occupancy.
Owner or rulharizcd agent Date TOTAL: ISSUED BY:
OFFICE
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