S 3367APPI R:ANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
OFFICE
CI TV OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING—MECHANICAL
BDB,DING PROJF,CY IDES I'IF'ICAI'[ON
1'li rT No.
3367
1{GILDING ADDRESS:
2• ,(- 0 (/d� i� v-�
SANI I'ARY N(1.
APPLICATION SUBMITTAL OAT
2
)WNER PII(lNl::
CON TRACIOR'S NAME. LIC NO:
NIC
❑
,1111'I1C'I II3NGINI!1!R'. LIC NO:
ADDRFSN
CON'T'ACT. PHONE:
BUILDING PERMI•IINFO
11
❑ Consultant Fees Paid by Applicant (Initial)
BLD ELECT PLUMS
El 1:1O/ MECCH
El
LICENSE;[) CONTRACTOR'S DECLARATION
E
1 hereby affirm Thal T am (meowed order pmvmfors of Chapter 9 mommu
h Seing
witection]IXXpof Divnin 13nfthe Buinex. and Profession. C:de,anJmy licence is
full liarce and dldn.
Licunsr Class Lie.#
Date C,1rrnnor
QTY. ELECTRIC PF:RMI'E FEE
JOB DESCRI('TION
RESIDENTIAL,
❑SFDWI, ❑KITCHEN RIiMODIiI.
❑ADD]IION ❑ I'LUMBING RIi1'11'13
❑MULI'1-UNIT ❑STRUC'T'URAL
MODIFICATION
C1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING PoolS
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PERMIT ISSUANCEin
APPLIANCES - RESIDPN'I Al,
ARCI 11'1' 1!C r'S DECLARATION
l understood mY plans sell be uncJ :rs public records
I'AN B.S
UP 11) 200 AMPS
Llcerned Profesimal
201-1000AMPS
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OWNER BUILDER DECLARATION
I hereby .Rrm that 1 am exempt from The Contractor Licenm taw for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve. demolish or repair any structure
prior at I '1minimsthe l such lT file .etment
nhmh I p.sumonOI, In,faro,ki oalth Conaraun,I I' (CI pmr9
Icn{,WthSul'an17N)dOv's'In3 of the Bom...;JI Isv'n.. Cdc)sr
than hn is cac ata tbrief 'mm and the basin for the rllcgcd nuailau a. Any vi ominn of
Scation 70315 hyany apPlicum 1,111, Partin sable's Ilmapplic.nuoa civil Pcoalpof
sol more than five hundred dollao (551X).
n Laxowncrefthe pmpcny. or my coaloyecs Ovid, wages ax theicsalc compersfino,
will do the work. and Thesuumure is not intended or offered for .ale(See 7044, Business
and Po4rosions Cade: The Coutracuns License Law does an apply m an owner of
property who builds or improves thenen, and who doessuch work himself or through
his own employees, provided that such improvements are not intended or offered for
note. If, however. the building or improvement is sold within one year ofeumpletion. the
❑ BATO REMODELIREPAIR [3 DEMOLITION
❑ (YFtIER T/
oVl!H I(XM)AMYS
SIGNS 1!1,ECfRICAL
M'LCIAI. CIHCUI I'/M1SG.
'I'I:MI ME I ITR( OR POLE INS'R
COMMERCIAL:
❑ NEW BLDGIAUDI'I'ION ❑ DI!MOIA NON
OffFOOD SERVICE
IMPROVEMENT`
❑OTR sk
1'0WI!R DEVICES
SWIMM"'Il .T., ELECTRIC
OUTLEI:S-SWITCIIES-FIXTURES
NEW RESIDENTIAL ELECTR SQ 17.
SQ. I7. FLOOR AREA
$/SQ FT.
ediJ not build 1,r prove for pur-
owner -builder will have the burden of proving that him
'p0'pAI.:
Isc of ode.).
❑ I, en owner of Ibc property,.1,T excluxivcly umtoucan, .In (seemed cenlradon to
rnamm the project (Sen. 7(44. Business and Pndcssions Core:) I'he CUnannor's LI-
seLaw mws not apply lost owner of prolwny who builds or improves Neremt.and
QTY. PLUMBING PERMI'E PEE
who comrucu for such projmtx with a coul..cmrl Iiccnoul..mean m the Conwanr's
PERMIT ISSUANCE
Lierna Taw.
am exempt under Sec. . It & 1' C for This reason
ALTER - DRAIN & VENT - WATER WA)
VALUATION
[)air
WORKERS COMPENSATION DECLARATION
BACK FLOW PROTECT. (DEVICE
I hereby affirm under penalty of perjury one of the following declamtiooe
❑IhuvenMwlll mainminaC'cnlBw¢ot'Consent in self -loon liarWorker'oCaIo,r-
DRAINS- FLOOR, ROOF, AREA. COND.D
STRUCIRd
vid.d or by Sadinn 3](X1 to the Labor Code, lino The perGmnance of the
,a iun, ars pmf
work lar wla,l Nin permit Ix is,nal.
FIX'TURI!S-PER IRA('
L] I have and will maintain Worker's C(anta ns1,Tlon Inamnce, as nrltumd by Section
3700ot l he Labor Cale Onthelxrform:mec,1fthe work for which his pernthix issued,
GAS -EA. SYSTEM -1 INC. 40U11'LE'I'S
R( JI'
AI'N
GAS -13A. SYSTEM -OVER 4 (EA)
My W'orker.s Compensation Insurance carrier and Policy numMr Ire:
Comm. Policy NU.:
GREASEVINDUSTRI. WASTE IN1 ERCEPTOR
CERTIPICApE OP EXEMITION FROM WORKERS'
COMPENSATION INSURANCE
Y BUILDING DIVISION
FEES
GREASE 'rRAI'
PLANCHF.CK FEE
(This section need not be completed ifthe permit is for one hundred dollars ($100)
or lend
I unify that into, performaner of the work for which this permit is i....sit Is hall
sol entpluy any person in any manner..1,n to become xuhnel Tube Worked Cnanpeo-
SI!WER- SANITARY - STORM EA. 20()17.
ENERGY TLE
WAIT 17R BEAT ER WIVES 1'l1?1.ECI'R
WATT ER SYS'I EM?REA'rING
.-r
(TRADING PEE
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I. ULender's
WLender's
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aF-T fn
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an I La" of C.hFarnin. Dale
Appllcall
NOT IC13'10 APPLICANT: 11; alicr mnking this Cramfien e of Exemption, you 0 old
are se subject In the Worker's Compensation pmvieions of he labor Code, you mull
forthwith comply with. Inch pnomorsor his perTnilobaM revoked. ll devoted
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the pedormarce of
the work for w blah this pcmtit is i .... d(Site 3097. Civ. C.)
Name
SOILS FEE
WA'IIER SERVICE 5 O
PAID
Receipt
Dote Hcui
NEW RESIDENTIAL PLMB. sQ. IT.
IOTAL
'IOTA.. O
Address
u
If I11LDINC FY.E
ove itanumun
Nat I have mud thin npphcatin I and ante Ilan the ablu
unreel. I agrcc tocnoply wllh:Jlehyand un:myuMmanees and sane lawn at
builAing.nnatrucninn, wul hereby unnhoriecrcpmsamailclul lhixnitymconalmon the
FEEcertify
QTY. MECHANICAL PERMIT PBE
SEISMIC ItiE
PERMIT ISSUANCE,
Ii1,E CIRICFEE
ab,1vomcon cal property lin inslnetimI pur3asus.
(We) agrcc m sane, Indmnnify and keep harm(cs The City of Cupertino against
liabilitirviudgmcnts, costs and expcnws which may in anyway accrue against said City
ALTER OR ADD' FO MECE.
1'LDSIBING FEE 3
in consequence of the granting of this Permit.
APPI,ICp UNDERST,\NDS AND WILL COMPLY WITII ALL NON -POINT
AIR HANDLING UNITOTO 10.001 CFM)
MECf{pNICALF :E
SOUR )TIONS.
AIR HANDLINGUNIT(OVE:R I0.000CI'M)
CONSTRUCTION TAX
ogm of Applicant/Cnnlr cn)r Dam
1IP.ZARUOIIS MA'1'17RIALg DISC ASI1REi
Will l ha 1,ppBeama, Boum dui)ding occupmt fn cur handle hamnlrux nt,cdal
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION 1'1713
III!AI'ING AIT' (TO 1000)011"IU)
"Aetna' bym, Capenlno Mm"`I our. Chapter 9.12, and the I ImNh and Safety
Calc, Section 25532(.)'?
BEINC, IINI'I' (OVER I00AX0 BI U)
VENT LAI ION kA . N(SINGLRESID)
Q Yen
PAID
Umc Hcccipt X
Will the applies, or future building rccupare um raf ipmenl or devices which
emit ha mous air contaminants as defined by the Bay Arca Air Quality Management
BOILER -COMP (3HP OR 1110.001 BTU)
"TIAL.
BOILER -COMP(OVER 101000 ITITT)
District?
❑Ycn L'.No
AIR CON[) I(INER
ISSUANCE DATE
Ik mail the b J t t ode Chapter (J5 fNe Cali-
fun 11 ITh & 41 ry C 1 T' _550 255.. J 25534 I understand 1 that if the
NEW REIs ?lt TIAL. MEG11. SQ. 17.
hood) k t 1' 1.11a T ts, ih l ly t I 1
�(p �
d'dlarluernnlxwn 0111,11111d TAfIj 'aC Tl lad n]0
(I
T�
TarnL.
ISSUI!D ISY:
Owner or au(hnnud nn Dane
OFFICE