S 3855 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT No
BUILDING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL S 3855
BUILDING:PROJECT IDENTIFICATION
BUILDING ADDRESS' SANITARY NO. APPLICATION SUBMITTAL DAL
Z Zosc� 4 ,:�y
l ,R:S NAME: >�'1'+87-822b
CONTRACT J,SVNAMI:: LIC NO'.
333 jS / O JO :JLC /� CUNTROLp
lil'(E_CT/F,NGI EER: �LIC1���� ADDRESS: ❑ 9 / /q/
Co CT•I~rs(]• PHONE: BUILDING PERMIT INFO
1 1 -I s T/Y , - 014c I_ ❑ Consultant Fees Paid by Applicant(Initial) HLDG ELEM PLUMB MEyC�IJ,
711`"� LICENSED CONTRACrOOR'S DECLARATION lv QTY ELECTRIC PERMIT FEE in-
LICENSED
J CJ
I hereby arum that I am licensed ander provision of chapter 9(commencing JOB DESCRIPTION
Q=Z with Sedion]f10U)of Uivisiun3of the Business and Professions Cale,and my license is 1
W O PERMIT ISSUANCE
FSB in full farce and eli«t. FDWL ❑KITCHEN REMODEL
e-yu Liccmc Class Lic.p APPLIANCES-RESIDENTIAL []PLUMBING RE-PIPE
d L Date Conoacmr
ARCHri Em,s IIECLARATION ❑MULTI-UNIT []STRUC I'URAL
Z O A Z 1 mndcramnd Imy plan.,hall be used ac public no,ords PANELS MODIFICATION
OZ=`� UPT0200AMPS [I INTERIOR []CHIMNEY REPAIR
H Z'HW Iicenm ProRsaimal 201-100OAMPS IMPROVEMENT E]SWIMMING POOLS
C IYG 1Hereby affirm hWNEmBO1mPF.R mEh ContmOor's License Law for the OVER lad AMPS []BATH REM�ODE�U��RE�PAI�R D DEI}�f�CLITION
X 3 0c UF following reason.(Section]0315,Business and Professions Cede:Any city or county SIGNS ELECfRICAi. OTHEIR paao'Y�YJ.I S!InSI
W LL N which requires a permit In construct,alter,improve,demolish,or repair any structure Nlaw Y� YI Q11
0g prior to it,iswance,assn raplirm the aPPlicum lor.mch pennil4t rile u,igned.uutnnent SPE
CIAL CIRCUIT/MISC.
9999 than her,licensed puonion in he IFnns aI he Contractor's liacneo l.aw Chapter
aQ� (cnlnmeneing with Snaion]IXp)ofD..lainn Sof the Banmes,md Protdssinn,Code)or TEMP.METER(1R 1101.171NST. COMMERCIAL:
a 6 e that he is exempt therefrom and the basis for the alleged exemption.Any violation of []NEW BLDGIADDITION D DrNOLITION
S«tion]03IS by any applicant for a Permit subs«ts the applicant to a civil penalty of POWER DEVICES []TENANT El FOOD SERVICE
rot more than five hundred dollars(5500). IMPROVEMENT
�SQp (] Los ownendthc prnpcnY.or mY employees with wages as theinnle asmpemation, SWIMMING POOL ELECTRIC []OTHER
F. will do the work,and the stmeture is not intended or oBcred for sale(See.]011,Business
a3eo and Professions Code', He Cmsmcmr'e License Law does not apply u)an owner of OUTLETS-SWITCHES-FIXTURES
propuny who Wild.ar improves thereon,and who does such work hi.owHor fhmugb
his own employees.provided thin such impmvmncm,arc not intended of n6crcd lar NEW RESIDIN'I[A],ELEC'IR SQ Fil
sale If.however the buildingorimproventent ksold wiftionne ycarol completion.the SQ.FT,FLOOR AREA $XQ.FT
but err will have the bund,.of proving that he did not build or impmae for par- O
le.),s se
be
TOTAL:of the mscarry,am exclusively contracting with licensed commrn to TOTAL:ITAI.
owneras in :
os
emo rum the project(Sec.]UM.Business and Professions Cede)The Contractor's Li-
ripple Law
i-s eLaw d«s on apply to an owner of property who builds or improves thereon,and QTY. PL PERMIT FEE ���� ////
who...mmm,fo..uch pmjeaswiIn a compo,... )licensed panoanl tothe Cnnrramnr'e / �' ((p VJ 1
Liam,Law. I'CRMIT 1 NC' l.P
lame m sunder See ,I3&1'C fill this reason
ALTER-DRAM 'F-W R(' VALUATION
Uam 12
rte RKP OMPENSA'I'ION R DECLARATION BACK FLOW PROD ICE
I herchy of mm.IM natty of perjury one of the follow ing dcdamliuns:
I have and will nmirtmn a Certificate of Conseono self-insure for Workers Compen- DRAINS-FLUOR.ROOF,AREA,C STORIES TYPE CONSTRUCT
IOK
,anon, provide)Inn by Section 3700 of the Labor Code,for the perfnnnance of the / 1
ork for,which this punnet in issued. FIXTURES-PER TRAP
[]I have and will mdi^min Worker's C e.ofxlhe w I kfor which
h o,Perm by Scalia.
9]Ipnf lire L.MsrCeda(nr Bra performance of the work for which Otis Permit is issued. GAS-EA.SYS'1'ENI-I INC.(GUTLET$ OCC. ROUPAPN
My W'orker',Compensation Insurance carrier and Policy number um: 32
_& -b3_
Carrier: Policy No.: GAS-FA.SYSTF:hhOVER 1IFA) f— 0,4/,
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FE[S
(TTis scninn recd nrn hecomplticJ if thepemtil is lnrone hundred dollars($Ilp)
,it
r less_) PLA 'P? 3
I ccnlfythat in lheperrormnnceil flee work fit which fhl,,nnit iclssucd,I shall SEWER-SANITARY-STORM EA.200 I'l
Hol employ any Peron in any manner,o as In herons subject to the Workers'Co.,.- FF 3
Z wtio^Lawsof California.Date WATER HEATER WIVENT/ELECTR
ZO Applicant G sE
NONCE TO APPLICANT:If,after making this Ccoifcate of Emnaptio.,You should WATER SYSTEMnREA PING S ILS E
I-- become subjeet as the Workers Comp.1mion provisions of the Labor Code.you mull
W Q forthwith comply with such provisions or this permit shall W deemed revoked. WATER SERVICE / O
73
9 i CONS'I'ROUT[ON LENDING AGENCY NEW RESIDENTIAL PLMIL SQ,IT. PAID
LJ0 (hereby off" dolthene is a c^aamutii lending agency for the Pedioo
ncnce of Ilam Receipt.
F-' the work for which this permit is issued(Sec.3097,Civ,C.)
V lenders Name I"
} {+7 Linder,AJJrtss TOTAL: I
y 1 certify Ihal L have read this application..it stem thd the above mdurmmmn is BUILDING FEE
F" N correct.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEL
V Z huildingcotmruclion,and hereby nothorize mprewomlives oflhiscily or enleruWn the SEISM( E
ahove,mennonod prnpedy for inspection purposesPERMIT ISSUANCE
(We)u,m,u,saw,indmnnify and keep harMesa the City of Cupvlino against -2- / S
libilllle.s,ph,prems,costs and expenses whidnnay in any way accrue agnipo,nd City ALTER OR ADD TO MECH. PL5 61N
in .sequence of the granting of this person.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO In"CFM) MEry C FEE Ci
SO' 'E REGuLAHONS.
AIR HANDLING UNIT(OVER 109"CE MI CO TR CTIONT
in a"o ppbnr /Cr mac., sal, EXHAUST HOOD(WI)UCI') PIOUS MITI�A ION FEE
It',ARI)OUS MA'L'I:liIAI,S DISCI-OSURI,
Will me nppl ant orfmurebuildingocrnpalllelnrcnrhandl,loondnu,mmerial HEA'T'ING ONI'I'('IYI HS,(XX)BTU)
as defined by the Ca,scrinn Municipul Code.Chapter 9.12,and the Heal h and Safety
,. Calc.Section L5532(a)'! HEATING UNIT(OVER IW,WO BTU)
C)yes CNO po inVENTILATION FAN(SINGLE RESID) PAID
Will the applicant or future building occupant equipment or devices which
mil hazardous air comumunu as defined by the Bay
A Date Receipt#
Arca Air Quality btanagemem BOILER-COMP(3HP OR 100,000 BTU( TOTAL:
D...mcC BOILER-COMP(OVER 106.1yd0 BTI)
❑Ye, [_1 No
I have read lire treasurer,materials ¢under Chu 6.95 ufthe Cali- AIR CONDITIONER ISSUAN EDATE
I5.2553 cn pair
fomie Health&Safety Csde,Sections 25hat i 25533 and 25531.1 ardente^)(hal if the NEW RESIDENTIAL MECH. SQ.FT
huilJi nolxurnnOy have a¢manl,that it is my responsibility atnrnify the«cupam / / —g$ �Q ``CC
of m imarprovshi,li m be ma us lssmncc of C,W m i a n v. ((( efff
am r age t // 1 le TOTAL: ISSUED BY:
OFFICE