S 3217 (2) Id%PLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 1�
BUILING-ELECTRICALTY OF CUPERTINO PLGMHING-MECHANICALgUIL@ING DIVISION APPLICATIONIFERMIT PE rr No.
3217
BUILDING PROJECT IDENTIFICATION
nU1LDINGADDRESS, > SANITARY NO. AI'PLICA'Hf1N SUI3MI'rfAL DAT[
WNlR'S NAME: {ONI?: CDNTRACIY)R'S NAME: LIC NU: NIC CONTROL#
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ELC_ 3-17 3 7 rsreve �,..
nTecl'/Er\EER: V ucG SO AI>DgWSg /�'� i/3't. ❑ /
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CONTACT: PHONE: BUIIAING PERMIT INFO
Consullanl Fit.Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
e— f— cfi
LICENSED CONT'RACTOR'S DECLARATION QTY ONT'A
CTRIC PERMIT FEE JOB DESCRIPTION '
1 hereby affirm that 1 am hern>ed under proloo.ns of Chapter 9lcsnmmencmg
4.Z with S¢tinn l(N0)of Division3of the Business and Professions Cndc,and my license is -"} O RESIDENTIAL:
00 PERMITCE J e5mca L ❑KITCHEN REMODEL.
{a� n lull force and effect. C
LL F L0anse Class Lic.p
dzw AI'PhIAF.SIOENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
MZ¢ Onus Cnnwnnr
M¢4. []MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DEC bli A'c10N MODIFICATION
N Z, I understnnA my plans.hall M u.,W ns puM1lic recons PANELS
Oz``� f . []INTERIOR ❑CHIMNEY REPAIR
Licensed Professional pl I IMPROVEMENT []SWIMMING POOLS
01 'OWNER-BUILDER DECLARATION OV E I ❑HATH REMODELIEF,PAIR ❑ITHM 11O1 hereby affirm that 1 am exempt front the Contmars License w for the ❑OTHER U following moron.(Section 103 L5,Busines nnJ Prnfessmns Code:Any c ty ¢ SIGL IO ewhich requires a Permit In construct,alterimprove,demolish,or renwclurcprion.its i..nan',also resimcatbe applicant for such permit,.file augn sav¢menaI 1. -)thmheislicensedpursoa.. ,,.heprou,mr,of the Contractor'sitf�(�l (cmnmencing with Seclum7000)of Division 3.f the 11mune,sand Profess] TIiMPR POLE INST. �� y"Iek6e C that he is corolla therefmm adthe han,far the alleged exemption.Any violationof ❑NEW DG/AU31O N EM0MM7TTTON
POWERS ❑TENAI I •/V� FOODSERVIC
not-are than five hundred dollars 5500). IMPRO 5MENT❑I,aownernfahe propeny,or my employees with wages as mcirsoleemome.,uaion, SWIMML ELECTRICb will drubs aawk,md theHmaure is am imeadedoroflered forade(See 704,1,Business ❑OTHER
W3 m and Prolessiona Code:The Cmntractofs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
a' prnperty who builds or improves thereon,and who does such work hi..self nr through q4 a
..-��"-�
his own employees,pnoidud that such improvements are not intended or offered for NEW RESIDENTIAL SELECTEE r
sale.11,hnweveq the huildin6 nr improvement is nolA wiahimm�e year of c.mllni.n,Ne / SQ.FT.FLOOR AREA S/SQ.FT.
owner will have the l n den mf Proving that he did not build ur improve for par- 3 `p Q /1 /{�
Iwwofe.1a.) Q 7.. yUp x/P-
090
El 1,as net of the property,am exclusively convecting with licensed contractor,In
construct the project(Sec.7044.nosiness and Professions Code:)The Com on,on s Li-
c ocontrd.esnstepplymun with
a co'propeny whesidprsds oruantfirrip )me thereon.and QTY. LUMRING PERMIT FEE
who Law.for such project,with a commeror(e)licensed pursuant ru rte Cnmrannfs (� U o
License law. PERM NSF. '3-5_,,5"0 a
Imp exempt under Sec. ,R&P C for this reason
ALTER-DR ENT-WATER(EA) VALUATION
Date 3 (0 O
WORKER'S COMPENSATION DECLARATION BACK FLAW PR T.DEVICE
1 hereby affirm under pcnuby of perjury one of We fallowing dalumaions:
❑ I hivelnd will maintain a Cerairicam rfC.nsent,o self-insure for Worker's Compen- DRAINS-FLOOR.ROO , A,COND. STORE: TYPE CONSTROCTIOM1
,inion,to provided for by ScOm.3700 of the Lelmr Code,for the perfornamce of the
work for which this permit is awed, FI X3'URES-PITR TRAP'
❑I have ad will muinmi.Workers Cnmpemsmi.n Insurance,as required by Station
370Od the labor Code.for the performance ofthe work lorwhich this Permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP �/ n
y
CamMy e,
�ppp Q 9Jnsua�c ICY Poit licy Or
1� GAS-EA.SYS rI3M-0VER4(EA) f0
CLNLCV®PA a o18
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRIiA51]INOIISTRL WASTE INTERCEPTOR )ILDIN*1VIS1(#N_FEES
TFtis section need not le completed ifthe permit is home hundred dollars($pill GRCASETRAP q
nr lest.) ZPLAN _2�'
Ie,nify that i.nhe perhrnansealha work for which this permit is issued,]shall SEWER-SANITARY-STORM EA.NO IT
not employ any person in any manner so as to become subject 1.the Worker,'Compen-O Zsatin.U.v of Calimind..Dam WATER HEATERW/VENTIELEC'IRApplicant
NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption,you should WATER SYSIHM/IREATING becomembjrn mthe Wnrkcr's Compcn,mion provisions or the Labor Sou,you must{II Gmhwhhcomply w ith such pmvi>ions or this peram,shall be deemed revoked WATER SERVICE
QCONST RUCTION LENDING AGENCY NEW NESIDP.NTIAL PLM.. SQ.IT.I hembyaffitm thin there iseco nrumi IenA' gngatcy f.nM pedbrmanceof Receiptp
the work for which this permit' mo (Sec 091, .C.) ALenders Name �TyaALeL a
1 certify Nm I lave read this appy anion nnJ stem thus the nlxwe infnrmatinn is
iF. N comect.l.g.t.,nnNywithalleityQTY. MECHANICAL PERMIT FEE r�
C.JZ building c.nsweciacrod hereby afthawl,representmivesofthis=oiry menterupa.the SEISMIC : V
ahnve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indmnnify and keep harmless rhe City of Cupertino ugam,l ELECTRIC FEE
liabiliaies,judgmcnts,costs wdcxpenus which may in any wayaccrme.,moxald City ALTER OR ADD TO MECH.
In cou
myucrre of the gmmingof this pernal FLU. I GLEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CIA{)
SOURCE REGUI.Ar10N5. M H ICAC FEE
AIR HANDLING UNIT(OVER 10,001 CFM)
'RUCTION TAX
Signamren ApplicanUCoal DUOS ATERI S Date e— EXHAUST HOOD(W/DUCT) H( SING MRIGATION FEE
Mt0$UnE
Will th caaor future building aupant,torenme or handle haetnoms memriW HEATING UNIT('N I(O,WO 111 U)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a):' HEATING UNIT(OVER 100,000 BTU)
El Yes ❑N. VENTILATION FAN(SINGLE RES ID) PAID Date Receipt#
Will the applicant or future building Occupant use equipment 0 devices which BOILER-COMP LEFT OR 100.0]01(1 B'TU)
ma
mit hruous air contaminants as defined by the Bay Aa.Air Quality Management
District; BOILER-COMP(OVER 100,000 BTU)
❑Yes ❑NO
I have real the Trianon,materials re{ryiremenb under Clupmr fi.95 of the C.li- AIR CONDITIONER ISSUANCE[gfil;9
f.min He 4.6ia t Cade,Sections 5,25533 and 25534.1 understand When if the NEW RESIDENTIAL MECH. SQ.PT. - / /
building does wt caw yhuvea ten, tai yrcspnnsihiliay mnotily the osculum
ofthercgni hichr hen prior nccofaCMlBcaa of Occupancy.
owner or rued agenr DateT� •O ISSUED BY: -
OFFICE
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Inspection Query for a Specfic Permit n /21/02
In
PERMIT# SITUS ST fTUS'STREET Lo_t#._, INSDESCRIP_T. _ InsT " DATEDESIRE DateDori Ins cto Units PasstFail. Co O, �
S3217 120030/20 FOREST !FOUNDATION _� 7/14/991 7/14/99 CC I 21P
S3217 20030120 FOREST GARAGE FLOOR 7/23/99! JS 3 P
— t----—
S3217 20030/20�FOREST jUNDRFLR MECH 8/9/99! AD i--'21P
53217 X20030/20 "FOREST UNDRFLR FRAME I8/9/991. AD I 21P
§3217 20030/20 IFOREST PLBG — �' 8/9/99: 8/9/99 AD 2f _
S3217 20030/20 !FOREST PLBG 8/9/99: 8/9/99 AD 1P
53217 20030/20 !FOREST — GARAGE SLAB 8/24199 8124199 DS 213 _
S3217 20030/20 FOREST JUNDFLR INSULATION i 8/24/99 8/24/99 DS 2!P
S3217 20030/20 FOREST FIREWALLS_ i ! 9/8/99 9/8/99 JS 2iP _
S3217 20030/20 FOREST i :SHEARWALL 9/30/99. 9/30/99 JS 41P
S3217 20030/20 FOREST !ROOFNAIL 9/30/99. 9/30/99 JS 31P
§3217 120030/20 FOREST :FRAMING 11/1/99 11/1/99 PS i 61F
S3217 20030/20 FOREST !PLBG-R — _ 11/1/99] 11/1/99JS i 21P
S3217 /20030/20 ,FOREST MECH-R 11/1/991 11/1/99JS _ 3F _
S3217 :20030/20 FOREST y ELECT-R 11/1/991 11/1/991JS�— 3P
n S3217 20030/20 - - /990 11/1/99JS 2 P
53217 120030/20 FOREST ;FRAME 11/17/991 11/17/99 CC 3P _
S3217 20030/20 FOREST INSUL r 11/17/99 11/17/99 JS j 2P
a S3217 120030/20 FOREST j ELECT METER _ 4/4/00 4/4/_00 JS 2 P
a S3217 20030/20 FOREST 1506 7/11/00 7/11/00 JS ( 3 P
S3217 120030/20 FOREST 507/PLBG-F 7/11/00 7/11/00 is 2!F
S3217 20030/20 ,FOREST 508/MECH-F 7/11/001 7/11/00 JS 2;F
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