S3267 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEttl r NO
BUILDING DIVISION APPLICATION/PERMIT PING PROJECT:fENTFiC J " 3267
Buu.UfNr.PROJECT Ines nelcnnuN
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Lay)Q&fCJat! f I A. q o i� _ ?
OWN' I�I �000,NyI�Ifgb �^ ONTRAC LIC NO:
I} lF�ikV�. of (1] 'AME: I NIC CONTROLII
ARCHITECT/ENGINEER: LIC NO: ADDRESS: L ❑
r
CONTACT. PHONE: OOILDING PERMIT INFO
I I /'I ff'�/1,�/ �D ❑ Consultant Fees Paid by Applicant(Initial) BLD F.ISC� PLUMB MECH
FLr
LICENSED CONTRACTOR S DECLARATION l/L�' Q'rY ELECTRIC PERMIT FEE rL�-✓(
I hereby affinno Intl anno licensed d ousoma,of Chapter/ham....main, _ JOB DESCRIPTION
D 4eZthS i ]OOID nrD M1oOhe fus nes,and Prefic T ,Calc d licenseyRESIDENTIAL:
Faoilfrc n t 1S NCRMIT ISSUANCE��(QQyyce 1 ❑SFDWh ❑KI'rC11LN R1iMODF.1.
4 V U
Li
"'a,
Class
oleo M
izZ W Ilam Contractor APPLIANCES RESIDENTIAL ❑ADDITION ❑PLUMBING RF.PIPE
'nab ARCHITECT'S DECLARATION ❑MUTAFUNIT ❑Sl'RUCTURAIL
r-mZ Iundemandm 1 hll be used as public records PANF.1ti MODIFICATION
Oz�O YPunxsa Pu UP TO 200AMP5
INTERIOR ❑CHIh1NEY REPAIR
F r?�{A Licensed Professional 201-1000AMI'S IMPROVF,MEN'I' E]SWIMMING POOLS
,yMj OWNER-BUILDER DECLARATION OVER IOfIOAMPS ElBATH REMODELIREPAIR ❑DEMOLITION
R a;S a I hereby axion that I am exempt from the Contractor's License Law for the
X30.F rollteL (S B 71315 B dl f :L le Aly E} stns SIGNS ET RICAN ❑TYfH1iR
til�OH which rt -apcm T t n mpn e d I'.h .Mge
I aur
E'er a poo t t I. q thapplicantf suchPe a rl lane SPICIALCIRCUIT/MISC.
thath I Ip : m th 1 fth C I L hi pr 9
ai ha g da,ScT ]qNp fD 3 ITh B :. dP f or TEMP MITER OR POLE INS'E COMMERCIAL:—a Xo that he a esemptIhcmfromandtheBuss for the alleged exemptAauon of ❑NEW BLDG/ADDITION ❑DEMOLITION
ge�N
Section 7031.5 by any applicant for apermit sehjcays the vpplican Il penalty of POWER DEVICIS ❑TENANT E3 FOOD SERVICE
not more than five hundred dollars l5510J. v IMPROVEMENT
E=C ❑I.as owner ofthe pm Yom mY cmplmycaxithaagc-a.the Ic compensation. SWIMMING POOL ELECTRIC
F will doth.wmLind the, cmmisnm intended nneRcmd it ale(. ]04f.Busimess []OTHER
W i m and Pmtoiseam,Code 'I c Contmcua's Lesille w does re apply ,,an control OUTLETS-SWITCHI S-FIXTURES
property who build,or i Ipmves thereon.and who ,such w himself or through
his own cmplovees pn 'tried that such impmvemen -not i ended or offered for NEW RESIDENTIAL ELEL:R SQ FT
le It n di h. ifin"numpeorainni orme year efcompletion,the SQ.FT FL(WR AREA $/SQ.ET.
'owner-hudder will Ice, the burden i foadvan in1 d 11il build or improveI n put-
qem of sal,).
FIT1, f thepent' d -ely c t g th I c re J contractors to TOTAL:
m ahs vical 7044B dl :Codr)[It domain,t.
s l wdoes oma a wnrdprapmty who bu tris prov,-s men^nand QTY. PLUMBING PERMIT FEE D
xfiocontmetsfarsto pmjem. �Irhe omranrn(s)Iicensedpumuantmlhe Commmars ,
License Lew. PERMIT ISSUANCE
El ton mm
exnpl.11 c,
See. .B is 1'C for this re;
s..
ALINR-GRAIN d VENT-WATER(EAj VALUATION
Owner Date
WORKP.R'S COMB' '.SAI ON IIFALAkAT10N BACK FLOW Pk(YfECT.DEVICE
I hereby uthrm under pcmah,we,dGry ern mf t lf-hre owmgW dm,',Car
❑on,as and willfor byneCion 3700 of the Labor
Code,for the Wufinicace of the
DRAINS-II.WR.ROOF.AREA,GOND. 'PgGON:I RUCTION
s�Ito provided f by Section A]W 0 the L h Code,f the�H c. fi the
kl 'h hiti:pr d. IIXTURFS-PER I'RAI'
Ih d will 'it Worker's Compensation Irequiredby Section
} eLabor Cale for permanenced the work for which the.Permit 3:sued, GAS FA SYSTEM-I INC.4 OUTLLI'S (>CC GROUP APN
MYWorkcr's mm mxue..(OMPENtiATI munA l'nlicY mllyM1c�pp.Z�yB f`A GAS-EA.SYSTEM-OVER4000
Cerricr: ff� ,P PIN...: K YI rl.C]'/
CERTIFlCA'IN OF XEMPTION rTCDM WORKIiRS'
ON INSURANCE GHEASFIINDUSTRI.WASTE INTERCIiIT(lR BUILDING IIIVIs10N FEES
('Ihissecllan nttN net be amnplumdi(tbe permit iv fur omihandeddellnm($100) GREASETRAP in,less) PLANCI II7CK FEE
I oadifythvt inthe pofermaurcof the work fora hien his .it is issued,I mall SEWER-SANITARY-STORM F.A.200 FE
n..,employ any perearm any normor x^us to hewn,object l^the WnrkemV Compen- ENERGY FEE
OZ, savard' sof Califomia.Uma WATER H HAIFk W/VIOUT/EIECTR GRADING INP,
Z O Applicator
q NOTICE TO APPLICANT:IL arm,making This Certificate of Eacance n,you should IVATF,R SYS'INM/1'REATING
become subject I^the Worker's C...top.^..Tion pmvlsom,of the Let C..Je,you most SOILS FEE
W lonbwith comply with such provisions or This pemeit shall Ac teemed revoked WATER SERVICE
Q
U Z CONSTRUCTION LENO lemon,AGENCY NEW RESIUENTIAI.PLMB. SQ,FT. PAID n-� RcceiplN
U O kfor,hick hithat There is..ad( ec.i^n len ding ngcncy for the perfimuunec nl
F the work for wnicn this permit is rssueJ(Sec.311Y].civ.C.)
Q V Lenders Name TU'1'AL:
Lender's Address TOTAL:
r I certify Thvl l have real this nppliemion and,roto TM1m the above inhmaim ian is BUILDING PBH
a
F In conen.l.agrecmmmply with all city and county ordinances and state laws mlml^E to QTY. MF.CHANICAI.PERMIT 199F,
VZ building construction,and herebynmhmive representatives ofthis city menrerapnn the (( SEISMICIFE
ah—a..nenti Bred property I..r i2,didion purposes. PERMIT ISSUANCE J
(We)agree to save,indemnify and keep harmleo floc city of Cupertino.,.,a,' IiLGC'I'KIC FEC
kEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADDTO MECH.
Pl.ummac FET:
In amsttrycnm mf the grnmil of this p.mlir.
'j)..ANTUNDE%11 US. D WILL COMPLY WITH ALLYO POINT AIR HANDLING UNIT(To 101100 CFM)
GULATION: MECf{ANICAI.hili �O
�Il AIH HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
S1,abodure of Al,vaod moor Dam EXHAUSTHOOD(W/DUCI) HOUSING NUTIGAI]ON ITE
HAZARDOUS MA'T'ERIALS DISCLOSURE �N
Will theapplicum( lions, uilJing nc<upantsmre o,handl.hazvrdmisnederial VENTING UNIT no 100,M)[I I ID
as relined by the Cupertino Municipal Code Chvpler 9.12,mod rhe health and Safely
Ce0c,Section 255J2(rd! HEATING UNIT(OVER 100.000 BTU)
Yes Viso
VENTI LA[ION FANS ING1,17 11 ESIDI PAID Blum Receipt#
Will the applicant or future building occupant use equipment or devices which
`
mit ba.anlom air contaminants as defined by are Bay Area Air Quality Management BOILER-COMPUTHP OR 100,00( TU)
Dimna^ BOILER-COMP(OVER I IXLIXIO BTII)
ElYes
I have read the hmadvers mammals reyuirtlnents under Chapter 6.95 of the Cad- AIH CONDITIONER ISSUANCE DATE
fo,�r1,Tm,�,,Iloath&satcty Code Sections 25505,25533 unit 25534.1 understand that irtne NEW RESIDENNAl.MECH. SQ.FI'. i- �l �,4 Qx
hLJlsx norcmremIy a a mane lhm itivny ..IxmsibilitY mnnufy occupam C� I /
a 9i swLicnims m9 In iss�.ufegef�Cenili.aT /pc�
Owmermr out m...sar cN \Y-1 �J l aL/f � '1'f Issmsu BY:
OFFICE