S 3153 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL ' ... 11 NO 3153
BUILDING DIVISION APPLICATION/PERMIT PLUhnnNG-MECHANICAL.
HOILDIS'(:PROJECT IDENT'IF'ICATION
IiUll-OI G IIIRCSS: SANITARY NO7P,,LICATION SUBMITTAI,DATE
11 �� 3 dsdl 7 �lP
lW 'S NA PII(NH: CO 't Clr 'AM LI N/C CON'IR01.®
9� 3 -7-Z:3
—I Clill EC`FENGINEF;R: LIC NO: ADDJSS: _ n fl ��95 ❑
I OJ 6 U !l.]H/V�i_Y_�•Sv�ULe-nK/�i /
CONTACT: PHONE: \ BUILDING PERMIT INFO
J-!_ -7 O33 /f ❑ Consultant Fees Paid by Applicant(initial) BLDG EL6CF PLUMB MECH
/ 712 �tYY// / 7 [/ ❑ ❑ ®/ ❑
LICENSED CON'fRACIOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
1 nercny arson mm I a,n heen.m nnaer pto.;aion.of cb:,g,er 9(com,ncneins JOB DESCRIPTION
��Z ,n section 7a10po_ Bmhess andlmre,ann,Cr,do.and myr e,mh RESIDENTIAL:
b Wlfullfomc:m0bp)"�aLI PERMIT ISSUANCE
tY�E- u, t-36 GfS / ❑SEDWL 71 KITCHEN kIiblOUlil.
QUU Liccnsc las Lic.p
ZZW Uwc % Commmor APPLIANCES-REti1D1!M'IAL ❑ADDITION ❑PLUMBMG RF,-I'IPR
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F..Dh PANELS
trlZ [understand myplamshA be used us public recaras MODIFICATION
OZ4UPTO 20AMPS
F'Ll "W Liccned l'rofeasinnal ❑INTERIOR El CHIMNEY REPAIR
2UI-IIXIUAMPS IMPROVEMENT
� El SWIMMING POOLS Y�, OWNER"IiU1LUERnalthe RA't10N OVER IOIN,AMPS ❑BATH REMODEUREPAIR ❑DEMOLH']ON
0 C d 1 hcrchy of itm Lha,I nit,exanp,Goin rite Contractors License Law lar site
I+1'3a U following reason.(Section 7031.5,Imume,.and Prnfcain is Ccdc:Any city car county SIGNS ELECT RICAL ❑01 HER
1a�y which rcyuircs n plat.If construct,alter.improve,dmnoll.n,no reputr any.m,cture 72' 17D A
prion..i..l.smnmc,ul.o,cquire.,htmppGcum torsion perm oto file a signed statement SPECIAL CIRCUI UNUSC"
tbuthe is licensed pursuant to provi.smrmofthc Contractors.License law(Chapter9
(cunmmn,ia,w,,hScotinn]INNIpd Dlv'uinn3ol the Basin..unit Prue,on Code)nr TEMP.METER OR POLE MST. MER 1 1:
a k m y tom he is exempt therefrom and the na..i.for lite allegeA cxemp,ion.Any vinlainn of NEW BLDG/ADDITION [IDEMOLITION
H Section 7031,5 by any applicant for a Penni,subjects the applicant o a civil penalty of POWER DEVICES ❑FOOD SERVICE
F=qm son e'ban five hundred dollnm(S50).
]R,mowner of,hc pmpcny'or my anployces with wage astMirsole compensmion, SWIMMING M)OL ELECT RIC 1 VEMIINT-
p., will do the work.and the structure is not intended or ollmed for sale(Sec.7614,Business oER
ad3 and Profession.Code The Corr m C,Liwnse Law docs no,apply to an owner of OUTLETS-SWITCHES-FIX'I ORBS 7
property who milds or omptavev,tenom,and who docs such work himself or through /
his own un,ployca.,grnv fiat that such impfoven...as an ma intended or offcmd for NL'W RESIDEN'TTAL ELEC.-'R Sp IT.
,ale"If,howeveethe building or improvement issold within one year ofcomple,ion.the SR FI'.FLOOR AREA S/SQ,Cr,
owner-builder will have,be hunten of proving that he did no,build or improve for put-
1,as owner of the pmpcny am exclusively contracting with licensed com,anon,n TOTAL:
nutruct Lha project(Sec 9014,Busme.a and Podev.iom Coit J'Ine Commems,Li-
cwse law does not apply it)an owner of progeny who builds or impmvesthereon,and QTY, PLUMBING PERMFIFFE
hncomruc,sti,rsuch projects with acuntrnacm%)hrenedpmomm to the Cm muchns JUN
U,ea,e Law. PERMIT ISSUANCE 17 199I n
❑I am exempt under Sec. ,B&PCfonhismason
nCfEH-UNAIN&VENT-WATER(Ertl VII UAI'ION
,net Dam
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT'.DEVICE
I herebynrfrm under penally of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to nclf-inmm for Worker.Compete DRAINS-FLOOR,ROOF.AREA,COND' sT(IRIiS 'N - UCTION
anion,as provided fur by Section 390..fine Later Coat for the per(nrmance of the O
A for which this pm,it is:..wads FIXTURES-PER I RAI'
_E;�aave and will maintain Workies Compensation Insurance.as required by Section
3700ofthe Labor Catfe.Inr the perfnnnaneeoRnc work or which this perm:,k awed. GAS-EA.SYS TEM-I INC.4 OUTLEIS OCC.GROUP ANN
My Workers Campens�u Inyy. ca rand P,b, hu h
Carrier: kp,� ,f[7L..Ol nae hiePolicy No.: �uab R% Dal GAS-EA.SYSTEM-OVER 4(EA)
CERI'IRCATIS OF IiXHMPR'ION FROM WORKERS'
COMPENSATION INSURANCE GREASPJINDUSTRI,WASTE.TN rERCEPTOR
('Ibis vection need utabucompleted it he colt is for no hundred dollars(510) BUILDING DIVISION FEES
or less.) GREASE TRAP
PLANCHECK FEE
1 eenify,hm:.trite pennrmanemf the work for which this permit i.i.sued.I shall
notch, Io SF;WER-SANITARY-S'T'ORM EA.MIO FT.
P Y Any person in Any nwnnonn m m he bID m me Worms'Comped- ENERGY FEE
t
Safi li Wws of ',lifo - y*y
O z am' - 1'�/ 9 9 WAI'F.R HEATER W/VEN"f/ELECTR
GRADING FEE
Z O Appfiea,tt
of NOTICE TO APPLICANT IC ufmnnuking this Cen,ificam of Exemption,you should WATER SYS'TEM?REATING
a ; heeoe msubject u,the Warlua`s Compensation pmvCcionc of,hc IaNn Caic,You mac, SOILS FEE
Uj forthwith cotnply withsuch pnnisiunsor this permit,hall be dae„marevaked WATER SERVICE!
a Q
= z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLAN. SQ.FE PAID
V p Ihnvby of lim,th;n,herc ixacnnawctinn lcnaing agency for the perfannance of c Receipra
0. F-t the work for whieh his perm:,is noted(See.3097.Civ.C.)
O V Lenders Name VFEE .
I OTAL:
W Landers Address T TAL
(•" y I ready that I have read this application and Nate that above information is C
H concet.lagree m comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
V z building convarection,and hereby authorise representative.ofthl..cit-mann uponthe
above"mentioned progeny for inspection purl PEHMI'I'ISSUANCE
(We)igrce ,,tve,indefinably and keep hnumc de,Cnyof Cupertino agsuam ,
dabil'nies.judgmems,costs and expenses which may in any way accrue against said City ALTER ORADD'IOMECIL
nuyue" of egrumin I,hi.permit. EAPPLICANT EH STA SAND WILL COMP Y WITH ALL NON-POINT AIR HANDLING UNIT(T(l I ropbcFXUS UHCIi '.ATIO' L cE 'AIR HANDLING UNIT(OVER 10.(10 CFM) N'I'AN'
S awn. ar Dam EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEP,
HA%ARDOUS MAT'iHtIALS DISCI.OSURI!
'ill,heapplfcam or future building nccupam store or handle hazardous material HEATING UNIT fro 10.(0X1[I FU
as deli ncd by the Cupertino Municipal Rale.Chapter 9,12,and the Health and Safety
Cale,Sectio 25532(x)'! TREATING UNI'I(OVER Iuh.0(01 BTU)
E3 Yes []No
VEN'1'ILAHON FAN(SINGLE RFSID) RAIU Dam Receiptp
Will,he applicant or furor,building occupant use equipment or device.which
unit hanrdous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP @HP OR 10,110 BTU)
District, T L:
F1 Yes EINo BOILER-COMP(OVER 110.000 B I'U)
I have read the h,omaterialsr,quircnm" underChapter - ATR CONDITIONER
ismu Hulrh&Snlety Cade"I'm, 505.2533 and 25534.I umk,rand that it he
ISSUANCE DATE
NEW RESID1?NTIAL MECI1. SQ FT.
of
of the m eAamou
v cull nt.thw t iis my respmsinibty tono,ify he occtupum /
inwhen the met rRono amance oracmificmearoc-gooey (' /y-.
O , :mihunrc,L,,,d D re TOTAL: T -I--,ISSUED EIV:
OFFICE