S 3219 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECDANICAL S 3219
BUILDING.PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO, APPIA ATIONSURMI'1-TALOATE
d ee/ Itz _ter �9
OWNER:SNAME: �� PHOONE. '31ACONTRA ( $NAME: LIC NO: NIC CONTROL#
4A gie
�ARCI ITEC] NGINEF,R: LIC NO: ADDRESS: ❑
CONTACT: PfIONE: BUILDING PERMIT INFO
❑ Consuhanl Fees Paid by Applicant(Initial) BLDG ELECT' I'LUMI3 MECH
LICENSER CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby viflmt that I am licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
o�Z with Ser ion]000)ofDivincat3ofheBusinessridProfessionsCode,andntylicenseis RESIDENTIAL,
DENTIAL,
W O O PI7RMIT ISSUANCE
F in full force vnJ ellen. ❑SFDWL ❑KITCHEN REMODEf.
aUF License Class Lic#
6Z U APPLIANCES-RESIUIiNT1A1. ❑ADDITION El PLUMBING RG-PIPE
zi<4 Da1C 'rS DECLARATION
ARCIIITIiCI'S DECLARATION ❑MULTI-UNIT ❑MOSTRUCTURAL
O
p.,O m PANIiLS MODIFICATION
Z O 'O 0 1 Mrsta
end my plans shall M uW e
ss public rtnsNs
OZ� u
— UPT0200AMPS I [I INTERIOR ❑CHIMNIiY REPAIR
F,Mfu] Licensed Pmfessi...I 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
a CLARATION
C W Q 1 hereby nftion hOWNER-BUILDER vcxmt fromL he Contractors License Law far the OVER IM)AMPS ED BATH REMODEI/REPAIR DEMOLITION
O d U following,,wore.(Section 7031.5,Business and Professions Code:Any city.,,,)airy SIGNS ELEM RICAL ❑OTHER
W 3 LL which requires a permit consumer,alterpro
,imve,demolish,or repair any strvctule
F-LLp!y m ru
prior to its issuance,also requires he applicam for such permit o file a sigood statement SPECIAL CIRCUITIMISC.
ggNa3� tmtt he is licensed pursuant to he provisions ol'the Contractors LicensC Law(Chapter 9
COMMERCIA
SCO (Cmmnnming with Section]I0sh of Division 3 of the Business and Professions Code)or 'TEMP.METER OR POLE INS'U
a IL p C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DPOLITION
�m
Section 7031.5 by any applicant for a famtit subjects the applicant,to a civil penalty of POWER DEVICES ❑'TENANT ❑FWD SERVICE
more run frv<M1undred Jallars($5 W). RMENT
O m 1,as owner of the prnpeny.nr my employees wih wages as heir sole cnmpensatinn, SWIMMING POOL ELECTRIC DW
IR
d.me work.and Inc atraemre i..ria mtnape m mDerta rte ares tsm.]ata,Busmen
Niunit Professions Calc:The Contractors License law does not apply to an owner of OUTLETS-SWITCHfeS-FIXTURES
a' property who builds or improves thereon,and who does such work himself or through
his own employees,pm,idkd that such im....counts are nor intended or offered for NEW RESIDENTIAL ELECfR SQ 17.
ed,If,however,he building.,improvement is said sidiume yearofenmple11on,the SQ.FE FL 'A EI$Q.fT.
owner builder will have the burden of paving that he(lid not build or improvs,for put-
pose
I, f owner of the propcny,am endo>ively contracting with licensed rommaors to TOTAL; y^
marno the project(Seo.1N4,Business rad Professions Cale)The Commemrs Li. F
cense law does not apply to an owner ofpmpcny,who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who summers for such projects with a commelons)licensed pursuant In the Contractor's
License law. PERMITISSUANCE r
❑lam n deg. .B&PC built,reason
ALTER-DNAIN&VENT-WA'IEN(EA) VALUATION
rby WORKER'S COMPENSATION DECLARATION BACK FLOW PNOfECT,DEVICE
I hereby affirmmunderunder penalty of e perjury one of the insure log declarations:
Co
❑Ihme addwillI.,binection 3700 ofneLaor Cod birdie Worker's Cooper. ❑NAINS-FLOOR.ROOF,AREA,GOND. STORIES CONSTRUCTION
smirk,as provided for by Section 3]00 of the labor Code,birdie perfommnce of the
work for which this permit Is Issued. FIXTURES-P13R'TRAP
3 1 M1ay. La will maintain Worker Compensation
msee. e Insurance, h N.....by Section
My Wfthe Lada Code.bathe Insurance cancer and work far cwhichthispermit is issued. GAS-EA.SYSTEM-I INCA OUTLETS ROU70 -6 APN
My Workers Compensation Insurance carrier and Policy number ort:
Caries Pulley No: GAS-EA.SYSTEM OVER 4(EA)
CERTIPICAI E OF EXEMPTION FROM WORKERS' n.
COMPENSATION INSURANCE GNEASFRNDUSTRL WASTE INTERCEPTOR tl S(This section need not becompleted ifhe permit is fornne hundred dollars($100) GREASETRAP or less) ECK -EEL
I eerily that in the performance of the work for which this permit is issued,l shall SEWER-SANITARY-STORM EA,200 FT.
not employ y person in any manner so as m beernm subject n the Workers'ConiNs- ENERGY FEEany
Z labor laws of Calimrnia.Date WATER HEATER W/VENT/ELECTR
0 Applicant
Z1r NOE'ICE TO APPLICANT:If,atter making this Certificate or Exemption.you should WATER SYSTL.MII'REATING
became subject to he Worker's Compensation previsions of the lady Cale,you must SOILS FEE
forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RB.SIDFNf1Al.PLMB. SQ.FI'. PAID
V O l hereby affimvhatthem is a construction lending agency forthe performance of Dae R t#
Phe work for which this permit is issued(Sec.31190,Civ,C.)
Lender's Name TOTAL:
WLenders Address TOL' L:
P. 1 cendy that 1 have mad this application and Verb,tow the above information is BUILDING ME
� to) correct.l agree to comply with all city and snooty ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
CZ building construction,and hereby andiron representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection pugnsas. PERMIT ISSUANCE
(We)agree 1.save,indemnify and rs t
keep hamleshe City of Cupertino against ELECTRIC PEI:
liabilities.judgmenu,costs nit expenses which may in any way creme against said City ALTER OR ADD TO MECH. O
in onsequcnce of he tin nr lhisperna. PLUMBING FEE
API'L NT UNDP' ST DS AND WILL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO❑I,IXIO CPM)
MECHANICAL.FEEF
SO' R GUI„ 1
/�`� AIR HANDLING UNG'(OVER Ig010)CFM) CONSTRUCTION TAX
I ppbcanUContmdor Dam EXHAUST HOW(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
I Will theupliheml.,future building occupant store.,handle hazardous material HEATING UNIT(TO 100.00 BTU)
as de iced by the Cupern Municipal Cale,Chapter 9.12,and the Health and Safety
Gyle,Section 25532(a)7 HEA9'INC.UNIT(OVER I W,(M BTU)
E]Yes ZN. PAID
VENTILATION PAN(SINGLE RESIU) Dam Nucip#
Will the applicant m firm,building occupant use efo,norm or devices which
mit hazardous air containment,as d fined by he Bay Area Air Quality Manngemenl BOILER-COMP UHT'OR 100,00)BTU) OT L
District'! /f BOILER-CONE(OVER 100,0110 BTU)
❑Yes (j N.
I have mut her rdws ream' quiremems under Cbapmr,6.95 or the Cab. AIR CONUI'LONER ISSUANCE DATE
tsmia Health&Sayyrert de,Soviet
un c 255( , )and 25531 E understand that if the NEW RESIDENTIAL MECIL SQ.FT ip
bulldimgdoes�r t1,hove nm• mYrespomibility m notify he occupant /_.
of the requl unr ick nmsla acne,nfuC nifi�i of c ✓
Owner or nuhnriz.d xgem DaI TOTAL: ISSUEDBY.
OFFICE