S 3351 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. - PE IT No
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.PROJECT
- - 3351
BUILDING 1'R(IJELT IUENI'IFICATION
HUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DAIS
DIU B� 2-n /y i&^ 49
O 'S NAME: _ ��—
PHHOcF. CONTRACTOR'S ME: LIC NO:
��C§ ���
NIC CONTROL M/�
-
- I&RL tt:r iNGINEER: LTC NO - ADDRESS: ❑ { .
CONTACT: PHONE:
BUILDING PER INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
�/ ram ram g'
LICENSED CONTRACTOR'S DECfARAI ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby off rut that I am IicenseJ muter povisions of Chapte' nlnencing
OWZ with Section]IX07 afDivisionJofthe Business and Rnfessi - e,and an license i. SU RESIDENTIAL
1+100 I PERMIT ISSUANCE 3S -� �S KITCHEN REMODEL
F� In full fnrsemol efleat.
aVV Liccme Class I: APPLIANCES-RISIDFMIAL. g•" AUDITION ❑PLUMBING RE-PIPIT
L.ZaI Date tie,reactor-
f�Qa ❑MULTIUNIT El STRUCTURAL
FDH HITECTS DECLARATION PANELS MODIFICATION
Z OvJ� 1 under ny plans shell be usW os public rccoNs Z�
OZ%JO UPT0200AMPS - ZZ— FI INTERIOR El CHIMNEY REPAIR
Li sed Professional 201-100AMP5 IMPROVEMENT C]SWIMMING POOLS
Ya, OWNER-BUILDER DECLARATION OVIiR Hill)AMPS
❑BATH REMODELIREPAIR (D DEMOLITION
ed�'6 1 barely affirm that I am exempt from the Commemis Licenu Law for the
s1x O d U following reamn.($cation 7031.5.Business and Professions Csxie Any city or nmmy SIGNS IiLEC'TRICAI. ❑OTHER
W LL C H which re,mres a pemll to construct,inter,improve,demolish,or mpan any structure
yy� priorm its issuance,also.,arm,nheepplitma fnr such penniuo fifeasilled,munient SPECIAL CIRCUIT/MISC.
'n Y
than he is licensed purmma in me pmvlslons of the Contranmea License Lane Chapmr 9
i �C (conunencing with Seeion]IXIIII of DivisionJof the Rosiness and Profeuina%Cate, TIiMP.MEfIiR OR POLE INST. COMMERCIAL:
6 y say Our Im is exempt there ..and the had,far the alleged exemption.Any violation of
[I NEW NIDG/ADDITION [I DEMOLITION
it I+• Secllon]t1J1.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICIS ❑TIiNANT ❑FOODSERVICE
�rN ot mom than five hundred Dollars(g5W). IMPROVI_MENT
36 {{01q,�{{,�11 owner ollhe prrlmrty,ornry employees with wages us their sole unnpens:vion, SWIMMING POOL ELECTRIC
C1 OTHER
I' Wilfda,the work,and rhexuucture is no,intended oralferW for sale(See.]0i4,Business
aaC•oeo and Professions Code The Contractor's Licenu Use dares not apply m an owner of OU'rLlil'S-SWITCHES-FIXTURES a2�
property who builds or improves thereon,and who does such work himulf or through
his own employees,Provided that such improvements um nm intended or offered fnr NEW RFSI DENT AL ELFCfR SQ FT.
saIt.If.hnweveq the building m urn mernmer is sold within nn eyearnftimenction,the SQ.F1'.FLOOR AR CA &SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur- / Jl .rat Q
poxafseleJ. CI{ Vd
El 1,as owner ref the property,am exclusively contracting with licensedcomments,to
nnsauct the popes,(Sec.7614,Business and Professions Code:)The Contractors Li-
seLawdoesnotapplytoanownerofpropertywhobuildsorimpmvestaniand QTY. P GING PERMIT FEE
who commet,mrsuch pmjccu with a contractions)licensed paoneen mthe Contractor's ` C
License U., I PERMIT ISSUANCE"e S sd
1 am exempt under Sec. .B&P C far this..in Sd
ACrER-DRAIN&VENT AOR(EA) VALUATION
O ner Dmc
OI ER' OMPEN.ATION ECLARATIn' BACK FLOW PROITCT, VIC ,V 7 D p
w Ihereby.,Gomm cr cranny of perjury oro of the' ung declarations: (((
❑ l limennd will maintain a Ccnificatcu1Conse -insure for Wnders Compcn- DRAINS-FLOOR.ROOF.AREA,GOND. STORIES 'rYPECONSTRUCDOD
satinn,as provided fnr by$ration 3]10 n �W,Cme,for the perfnnnansx of the
work far which this permit Is Isco FIXTURES-PER TRAP
❑1 have and will mainm' mker's Cnmpensa,ion Ineurence,m required by Section
J]W of lhelaMn or the peparrom reel the work far which Od,Femoro is issued GAS-EA.SYSTEM-I INC.40OT S OCC.GROUP APN
My 1-dar? ipen.sutiau Insurance comer and Policy number are: ,
Cori Policy No.: GAS-EA.SYSTEM-OVER 4(FA)
CERTIFICATEOF EXEMPTION FROMWORKERS' ❑ItEA$FJINDl15TRl.WASTE an,RCEPfOR
COMPENSATION INSURANCE BUILDING DIVISION I6i6S
(lfiisuaion ncW nw he completW if the permit lsfmonehualaed o IINI) GREASE'fRAI'
or less., ,-lam(- PLANCIIECK FCIi
Icenify that in the pedotanse nfJMwor fnr which this pc nit is ls. boll - O
nm employ un ^� �a SEWIiR-SANITARY-STORM EA.21N)Irf. ENERGY FEE
p y y person in any mm�rrr sit as hs beetme xu jeer non orkers t _
Z xmion Laws of Colifomin.Bac '• WATER HEATER W1V' /ELECTR GRADING FEE
O Applicant n
h NOTICETO APPLICANT:If,a0e'making this Ceni, c E:. yo d WATER SYS'rliM/fREATING SOILS FEE
f^s become subject to the Worker's Cn)npcnsatinn pinrtiymslr f Itf I or Cale,y t t
cat L'7.1 for inh comply.,In such provms ri,or thixtpell k vialfbe,deemed revoked WA'fIiR SERVICE.
Q 4
Dz C(INS'I'RUC'IOfI LENDING AGENCY NEW RESIDENTIAL PLMO. SQ,Ff. PAID Dam Receipt X
V QIhereby affit Oat there isacpp swoon lending ag, h of
F Ibe work fnr which this permit is iamdl lRu;g30Y],r.=r1 ncc
W Icndcr's Z5FnL.
U lenders Address "� TOTA.' s e 0
0. I lenity that 1 have read tuN apphernom and,rote that the above infimnunnn is RUILDIN '.E
w�a fA correct.I agree to comply with all city and county committees and sum laws relating to QTY. MECHANICAL PERMIT FEE SEISM E 7 O
U Z buildingeorphowion.andhemby vuthorim mpmsenutivexnfdas city to enteropon the ws
above mentioned pmpeny for inspection puToses t PERMIT'ISSUANCE ELE E
ague m
(We) save,indemnify and keep t
p haless the City of Cupertino against
ro habilittes,judgmems,costs and expenses which may in any way imemeogainn,rid City I ALTER OR ADD TO MECH. 12--M PLL GFEE
in consequence of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI'r ALL NON-POINT AIR HANDLING IINIT(TO IOINNICFM) MECH NICAI.FEE O
SOURCE,REGULATIONS.
AIR HANDLING UNIT(OVER 100MCF10) CON TRUCTION TAX
ig .car fApPlicum{ carom Dae EXHAUST HOOD(W/DUCT) 3 LOU 0MITIGATION FEE
HA ARD S MATERIALS DISCh Sl1RE
Will theappliessmor future huiliingncmlpant store or handle haaadous mamal HEATING UNIT LTO 100.100 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 110,0110 11 Of
Calc,Section 25532(ayl
` ❑Yes VENTILATION PAN(SINGLE RESUH PAID Dam Receipt if
Will the rpplic:un or future building occupant use equipment or devices which BOILER LHP OR 1f0.0W BTU)
emit It...Won,air contaminants as defined by the 11,Area Air Quality Management T
a•-� Donnie,] J BOILER-COMP(OVER I W,oW BTU)
El yes Y�
I have read the havndousmarital,requirement,under Chapter 6,95 offs Calm AIR CONDITIONER ISSUANCE DATE
fstia Hra1nM1&Safety Cale,Secniom]55115.25533 and 25534.1 understand than if the NEW RPSIUEN'1'IAL MECH. SQ.PT,
building doe,notcomee tly haveotenant.What it is my reslamsibility m nelfy the acmpant L
of the requirements which mus,be,met prior to issuance of a Cmificatef Z y.
1ZI /QS AL:
Osterarawhorimdagem C ISSUED BY:
— OFFICE