S 3336 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-1a,ECTRICAL PEy l P NO
RUII.DING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S,J - 3336
BUILDING PROJECT IIIEN'ITEICATION
BUILDING ADDRESS: T SANT"TARY NO. APPLICATION SURMI I AL DATE
lexe
ME
OWNER'S NA / PHONE: CO ACTO :S NAM r: IC NO
N/C CONTROLp
ARCHITECT/1iN L[C NO: ADDp�SO /I /d,-l� ���n - ❑
CON' C'Is PHONE: vvl`/ /J/ 77 'J 6UILUING PGRMIT INFO
2 / ElConsultant Fees Paid by Applicant(Initial) ELECT PLUMB ME❑CI
El
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 our licensed under provisions of Chapter 9(wturnme ng _ JOB DESCRIPTION
O00 with Senior TO�Q�t fDOoO.n3 ofIhe Bmincssvnd PrucWons Cale and my license is RESIDENTIAL,
E. in full force a�tUf ct ^ �^�� PERMIT ISSUANCE ❑SFUWI. El KITCHEN REMODEL
�VU Iarms
• Issfff���r Lic.# ` APPLIANCES-RESIDENTIAL El ADDITION ❑PLUMBING RE-PIPE
F z w Is L4 Coal'. y�-
md0. +" }- ❑MULTI-UNIT ❑STRUCTURAL
1.ANCIII'CF.CT'S DF. �`'
zo.z do pl allbcawdv.puhli�5ecame. PANELS DIFICA"CION
Oz�O �y .b` l UP'102(NIAMPS El INTERIOR OINEYREPAlk
I.d�.nsedponhe"lclod 201-I a00AMP$ IMPROVEMENT E]SWIMMING POOLS
y'�, OWNER-BIIILDF.R DECLARATION OVER IWOAMPS ❑BATH REMODEUREPAIR F1 DEMOLITION
44''4�as 1 hereby affirm find I rm exempt from me Connacho''s License Law for the
'�y(O
as U fallowing mason.(Section 9031.5,Business rand Pmv,Odvs Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
413 u y ,Inch requires a permit m can,Imet.alter,improo, demolish,m repair any arrcmre
�Od prior to its Issuance,.tined,mes lhevpplican(fer such permit to file a signed statement SPECIAL CIRCUIFIMISC.
that he is licensed parmom in the provisions ofthe Cornracmr's License Law(Chvprm9
� �0 fienhoencingwhh Section 7000)ofDivision 3of the Bnsineasond Pmfesslore COde)Or TEMP.METER OR POLE INSCOMMERCIAL:
that he is exempt therefrom and the basis for the alleged exen,pllort Any violation of Clpw BLDG/ADDITION ❑DEMOLH]ON
m Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
Hey PANT [I FOOD SERVICE
noum than fire hmndreddollonsS50Id.
m
d0 ELECTRIC PROVGMF.NT
E31,as uwomallhe Propeny:tr my emPlnyces with wagesys theilloore mperaatme, SWIMMING POOL
will do the work,and the arunme is not intended proffered for sale(Sec.7044,Business ❑OTHER
Lam and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-MIXTURES
propeny who builds or improves forced,and who does such work himself or through
his own moployees,provided that such Improvements am not imendal or carred for NEW RESIDENTIAL ELECTR SQ FT.
sale,If,however(he building or Improvement is sold within nue your of completion,the dF SQ.IT FLOOR AREA $/SQ.FL
own
a-budder will have the burden of proving that he did not build or improve for pm-
pose attain.).
F] 1,as owner of the propeny,am exclusively containing carnations ng with licensed cartions to TOTAL'
construct the project(Sec.7014,Business and Professions Code,)The Contractor s Li-
recast Law does net apply toanowner fproperty who bupd,or imp rnvrs thereon.anti QTY. PLUMBING PERMIT FEE
who contracts for such projec,with a contacmgs)licensed parsuenl to the Comramds
Liccrve Law. PERMITISSUANCE
n I are exempt under Sen ,B&PCforthis reason
ALTER-DRAIN&V EN'F-WATER(FA) VALUATION
Owner Daft
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declinations r+
❑I have and will mammon a Certificate ofCOrsent it,sd6lneure for Worker's Comped- DRAINS-FLOOR,ROOF,A REA,CONO STORIES TYPE CONSTRUCTION
smio es provided for by Section 3700 of the Labor Code for Ila performance at the -
forwhr [his permil isissued. FIXTURES-PER TRAP
O rad will ntainmin Worker's Cnmpenemion insurance,as required by Section
OO of the Labor Code,for the performance{of the work for which this pencil is ice GAS-P.A.SYSTEM-1 INC.40UTLBTS OCC.GROUP APE
My Work• : n" Isar a 'c and Policy Cil
Canna: tic NpOMT(
: GAS-EA,SYSTEM-OVER4(EA)
CEkT IFICAT OF EX• PION FROM ORKF.RS' GRFASEANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not he Completed iDhc Petrillo,for one hundred dollars($100) G EAS.TRAP
or less) 11II PLANCI IP.CK FEEIunify Inst in l he pefonmic,of@n work for which this permn is issued,I shall 'S wH SA III ARY ORM .200P'
nor employ any person in any manner so as(Ibecomesubject m the Worked Cmnpen R ENERGY FEE
zZcation Laws Of California.Dam TER H TER'W/V•NT/ELECTS
Q Applicant GRADING FEE
M-n to) NOTICE TO APPLICANT:If,after making this Certificateof Exemplinn,you should A'I'Ek SYSTEM/I'R:AT G SOILS THE
in
become subject In the Worker's Compensation provisions of the I.aMm Cade,you must
Lok) coy fndhwith amply wish such pnrviaipnv or this permit shall be deemul revoked. +ATER SERVICE
Z:) z CONSTRUCTION LENDING AGENCY NEW RESNaliNTlALPLMH. SQ. PAID ate Receipt#
1 hereby affirm the, here i...on.vwminn leading agency for the performvna of
n UP the work for which this pamlilN issued(Sec.3097,Civ.Cj
TOTAL
� Lendeds Norm
WLender's Addres, TOTAL:
p, 1 cenify that 1 have mad this application and slate[hal the above information is BU D C FT3P,
Z c rest.I tgrw nI comply with all dry and mommy ordinance, ,,it ,are laws relating In QTY. MECHANICAL PERMIT FEE
U 4 buildingeonstucdon,and hereby methane repetWoUtivea of thiscay to enlarupnnthe SEIS PEE
drove-mentioned property f rr urNa pion purppses.
(We)agree to save,indemnify and keep hunmleav the City of Cupw[inn against PERMIT ISSUANCE ELE CRTC FEE
Iiahilkles,judgmcats,was and expenxe,which may in any way accrvc agvinstwid City ALT'ERORADDTOMECII. PIAS
I ING ME
in co
sof be gaming of[ ix permit.
AT ICAN' IINDERSTAND ND r COMPLY WITH ALL NO -POI T AIR HANDLING UNIT(TO 14000 CFM)
MGCfiA CAL FF.E
URCP 'CU
NR HANDLING UNIT(OVER 10,00(1 CONSTRU &ION TAX
gnowm of App lc nUCnnwm , oro EXHAUST'HOOD(W/OUCTT
HAZARD IIS MATERIALS DISCLOSURE iIOUSING MITIGATION FLE
Will lheapphcart On future building Circulated store Cir handle hazardous rime.nal HEAT ING UNIT(TO 10fin 013TO)
as defined by the Conamo0 Municipal Code,Chapter 9.12,ned the Health and Sn@ty
Code,Seeder,25532(a)^. HEA'fINO UNI'['(OVER 100,000 BTU)
❑Yes VENTILATION I AN(SiNGLG RESI D) PAID Dam Ruei
Will the applirml 0 fwurc 'mg ocnlpom use equipment or devices Wblch
-rah haeardpus uI,count It ts .dcfined by the Boy Area Air Quality Management BOILP.R-COMP(dLIPOR 104(100 H'TU) 'O L:
'Oral°all BOILER-COMP(OVER HDOOO RTU) All
❑Yeseip
I Novo read the hazaMpus mmeduH - mems under Chapter It95 of the Call- AIN CONDITIONER ISSUANCE DA E
forma Beall&Sot,, Cnde,Sc ns 25505,255. d 255311 wldersed I[hat if the NEW RP.SIDENTIAL MECH. SQ.FF. ,-s � �, �• y
boil ' o[c alcnam,Ifinch odyn tsihility moot thv alarm -L/ ( (�
n race a h doer,
[ mCi purr u'iauancs f
owner or authori ager Dude TOTAL ISSUED BY:
OFFICE