S 3187 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ME ELECTRICAL PERp11T NO.
BUILDING DIVISION APPLICATION/PERMIT DINGPPLUMIBNG-b1ECBANIFIC S
BUILDING I'llfl.l F.1,T IDENI'INICA'I'ION 3187
BUILDING ADDRESS: SANITARY NO. APPLIGI N SIIBMI'I'1'AI.DATE
c �l2 -`i J
f3WNHR'S NAMI: PHONE: CONTRACTOR'S YAME: LIC NO,
e / NIC CONTROL
ARCHIT LtENGINEER: LIC NO: ADDRESS. ❑
is
CONTACT: 1'IIONLi /�9: EUILDING PHRMI`I'INFO _
306 ❑ Consultant Fees Paid by Applicant(Initial) BLDG F.LECf PLUMB MIiCII
LICENSED CON'TRACTOR'S ECLARA' N QTY ELECTRIC PERMIT FEE
I barony alarm mm I am!,erased sneer pro.ionw of ampler,9(,air anc'mg JOB DESCRIPTION
OaZ - lh Seri„70(Xdof yOsinm3,1'I helbilayssanl Profen orxGila.m dol interior'
RESIDENTIAL;�
y.,_ wt rQ��}� PI?ItMI'1'ISSUANCH
to full fume anti clic rr !� O ❑SPDWI. El KITCHEN RIiMOUIiI.
<—U License Clas Co.A p r APPLIANCES-REMDENT1AL ❑AUDITION C PLUMBING RIiPII'E
�<d Dam Cnmlacror - O
ARCHITCCI'S DECLARATION OMUUI'1-UNIT ❑STRUCTURAI.
H p'n PANELS MODIFICATION
Z O m Z I madmand my plans shall he mW as public records
O Z'O UP ED 200 AMPS [J INTERIOR [I CHIMNEY REPAIR
F4Licensed Professional 201-1000AMPS IMPROVPMENT E]SWIMMING POOLS
ye, .t OWNIR-ICA DER DECLARATION OVER INMAMPS. OHA'I'H REMODEL./RITAIR El DEMOLITION
k C Q 1 botchy Arion that I am exempt from the Cnnmmtnr's Llceme Low fill the
{ixs�5,0 a.U following reason.(Section 7031.5,Business and Profession.Code:Any sayer county SIGNS ELECTRICAL D OTIIER
W 3 tL H which requi¢s a pcnnir to construct,eller,improve.Jenmlish,or repair any structure /y�
(:^�g prior m its ismame,d,regniarsdon npplivua forsnch ponnir 1.file asignedslmemenl SPECIAL CIRCUIT/M ISG `
} that he is licensed pur.uanno the provisions of the Contemnors License Law(Chvpter9
QC (commencing with Section 7000)of Division 3 of the Business and Profession,Cole)., TEMP.METER OR POLO INST, t COMMERCIAL'
Cthin he io exempt IhcreOnm and the basis for the alleged exmnpnner Any vinlaliou of ❑NEW BLDG/ADDITION D DEMOLITION
..y
Section 7031.5 by any upplicnm fm a far ilsubiNa lhcapplicvnt tea civil pcnnlly of POWER DEVICES ❑TENANT [D FOOD SERVICE
ISFl2} not more than live hundred dollar 13500). - IMPROVEbfENT
�=Q 01.as owner of thepropeny,or my employees with wages m their sole cunywnsminn. SWIMMING POOL EL[CfRIC ❑OTHER
F will do the work.and the structure is not intended or offered for sale See.70.14.Business
sad Professions Calc:'rile Contractor's License Low des.,or c,1,In sea owner of OUTLETS-SWITCHES-FIXTURES
d 3 ,amocny who builds or improves man n,,mod who does such work hirealrnr tnrougn
his own employees,provided That such linpowenents am not intended,r utrard liar NCW RUSIDIINTIAL ELECTR SQ lel'.
sale If,however,the huddling or in......a at druid within nrmycarnfcnmplotine,'he SQ.IT,CLO ARI?A SXQ.PI'.
ownerbuilder will have the banderol'Pmoving that heralnotbuildorimproveliarPur-
Due of ole.).
I]1.av owner of the property,am excomment.,conclusively coming with licensed contractors In T(YI'AL:
ammom et the project(Sec.7044,Busines and Prlfesai are Cale:)The Clund om's Li-
c sel-awdas nal upplyroan owner-edpropeny whobnildsorimproveathereomand QTY, PLUMBING PERMIT FF,E
whoconvums for suchprojects with u conuvaor(s)Iicen,eJpursmtm mlhe Contmnnr's
License Law. PHIIMIT ISSUANCIi X
D ism excmduralsr Sec. ,H&P C or this reason VV
AUUoR-DRAIN&VENT-WATER LEA) VALUATION is,
Owner Date
. WOR KER'S COMPENSATION DECLARATION BACK FLOW PRUI'ECT.DEVICE
1 hereby off rm under penalty of perjury one of the following drelamnions:
D l haveand will naitnaina Cenilicate(ifConsent mscllcureforWorlues ComPen. DRAINS-FLOOR,ROOF,AREA,COND. S'T'ORIES 'TYPE CONS'IRUCI ION
smion,as provlda l for by Section 3700 of the Labor Code,for the O rfonmtnce in she
work for which this permit is issued. FIX'I'URCS-PER'TRAP
D 1 have and will maintain Worker's Compensation Insurance,as required by Section
370(1 LaMar .Cede,done Nnornance ofthework for which this permit is issued, GAS-FA.SYSTEM-1 INC.J OUTLETS OCC.GROUP MIN
My Workers Compensation lmmdince carrier and Policy marker are:
Cartier Policy isit GAS-HA.SYSTEM-OVCR 4 LEA)
CERT1 FICATE OF EXEMPTION FROM WORKERS'
COMPI!NSAI'ION INSU RANCI! GRIASEANDUSTRI,WASTE INTERCHP I OR
BUILDING MVISION PEES
CI'his--.a'linn noel not beeotnplclad it the pnnn
nil is lume hunJrW d,llurs(SIIXO (iREASETRAP - - -_ -�—
nr less) PLANCHECK PEE
I crony that ionic performance,fine work far Much this permit is issued,l shall SEWER-SANITARY-STORM EA.200 PI'.
not employ any person in any manner so as r0 become subject m the Woken Compen- ENERGY FHE
,Z satiom laws of California.Data WATER HHATER W/VIiNT/F[-]:MR
O Applicant - GRADING ITE
ffV/,r, NOI'ICH TO AI'I'LICANT If,otter ntaAing this Cenifcnne of I!xemptlon,You should WATER SYSTEMfLU A'I'ING SOILS ITT
L✓ become sahi,cl us the Workers Compensation Inevisinms of net Labor code,you most -
forthwithcomplywithsuchDowlidon,nr this permit shall be deemed revoked. WATER SERVICE
0.
52 CONSte is a coma LENDING AGENCY NEW RFSIDENTIAI.I'Lh1 B. SQ.IT. PAID pate Raving
L)Q Iherchy affirm rhauhere is nconnnmion lending agency(or the perhrmmntt of
F-' the work for which this permit is issued(S ].Civ.C.)
W. Lenders Name TOTAL:
V loader's Address '1'(TTA,
I certify the,1 have real this nPPllcvtion and sate that the above inhmnwinn is
IiU1LDING
VI correct.I ngrce mcomply with all city and county ordinances and state laws velli ng to QTY. MECHANICAL PERMIT FEE,
C,J Z building contraction,and hereby amh,riad representatives,(this city m enter upon the SEISMIC FEE
above-mentioned pmpeny,for inspection parryus. PER ISSUANCE.
(We)agree 1,sn.e,indemnify and keep hadma'a the City of Culenino against ELECTRIC PL s
5L 3
liabilities,judgnmms,costs and expenses which may in any way acerae against said City A CI It It OR ADD TO MFCII.
ucgnens-o or the grunting of oln coram, PLUMBING FT:L'
APPLICANTUNDERSTANDS AND WILL COMPLY WITH ALL NON-1'OIN1' AIR HANDLIN .UNI'I'(TO 10.000 CIrM)
SOURCE REGULATIONS. MECHANICALI uE
AIR HANDLING ON['I'(OVER[Land CFM) CONSTRUCTION TAX
Sgna reef Ap mor Date MAUST HOOD(W/DUCT) HOUSING MITIGATION DEC
HAZARDOUS MATERIALS DISCLOSURE
Will the nioplicam,r furor,handing occtmant more nt handle haranlerinl IIRA'11NC,UNIT(ID Collins)BTU)
us defined by she Cupertino Municipal Code,Chapter 9.12,and the Hwlth silk Safety -
Code,Section 25532(o)'fHEA'L'ING UNIT(OVER 1a),000 BTU)
E3 Yes - ONo VENTILATION CAN(SINGLE REST D7 PAID --
- Dare Receipt♦
Wall the applicant it future building by the B use an Air
Could,
tiesiceswhich
emit hazaN,ns air mnmminantn vs AdineJ by the Rey Areu Air Quality Manngemenl BQILIiN-CONI'I1HI'OR I(X),(lIXl BTU) 'T( AI.
Donn] BOILER-COMP(OVER Nf000 B1'U)
D Yes D N,
I have read rhe haNnus materials requirements CONDITIONER
zamaterials under Chapter 6.95 of the Cali- ISSUANCE,DATE �k
fond.Health&Safety Cade,Socials 25505,25533 orad 25534.1 mabestand than if the NEW RESIDENTIAL MECH, SQ,I.T. UA
!/
building does not currently have a trend,that it is my responsibility to notify the ocnpant
of the reyulrenved,which must banner prior to issuance nl'a Cenificnle of Occupancy.
1 Owner nr aulhnd"'i age”( Dula 'IYITAL: ISSUED BY:
` OFFICE