S 3350 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUIL DING.ELECTRICAL PFN..
BUILDING DIVISION AI'PLICATION/PERMIT 1'LIIMBING-MECHANICAL. { 3350
BUILDING PROJECT'IDENT'IFICA'TION
BUILDING ADDRESS n TT =132f
ON SUBMITTAL UATE
O NER'S NAME: 1 d d F.�{O/N�E: CON/T/JtACf R'S N �L: LIC NO:
rrR*LD �• ✓•I"� — �� G/►f/N TROE,p
IARCHITIir-T/F.NGINFER: LIEN ADDRI•SS.CONTACT: ONE: T INFO❑ Consultant Fees Paid by Applicant(Initial) ,M(B MECH❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hrrcny of ant that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
QaZ with Seginn7(IflOpsf Divisi.n3ofthe Business and Professions Cale,endo licenu is RESIDENTIAL,
I ,2 l full farce and effect. y PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�Ut) License Class Lie.TO
I--ZW Dale Contractor APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPIT
.<m [I MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION
F'y Z I understand my plans shall be used as public IcemJ. PANELS MODIFICATION
07.n^n UP TO 20t AMPS ❑INTERIOR ❑CHIMNEY REPAIR
f WF'W Licensed Professional 201-INMAMPS IMPROVEMENT E]SWIMMING POOLS
�YF,; OWNER-HUILDER DECLARATION OVER 1000 AMPS [I BATH REMODELfREPAIR ❑DEMOLITION
S' 1 hereby stir..mat I of.exempt from be Canasta's License I.ow for the
iqS O y U following reason.(Section 7031.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL [I OTHER
W d. which requires a permit m construct,alter,improve.broadish,or repair any nrm
acrc
�� prim to 11,issuance,also requires The applicant(orsach prove,m file a signed amlentnn SPECIAL CIRCUIT/MISC.
<<s y that he is licensed pursuant to the previsions of the Contractor's License l.aw(Chapter 9
W (commencing wish
C Scelon 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INS'L COMMERCIAL,:
qqx,c that he is exempt merefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION r
Wvo Section 7031.5 by any applicant for it permit subjects the applicant a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
r� not..or Than live hundred dollars($501).
�=6 I,av owner of me norm em lu cos wpm wa es as meirxole cora nsmion, SWIMMING POOL ELECT RIC OTHER IMPROVEMENT
r, 0 pn'pe Y Y P Y 6 1, []OTHER
y
will JOthe work,nodes he Contractor's
tots License
Law
to an whereof
a�� and Pmfexsinns Cale:The Cenoamnr's License Law docs ern apply m an owner of OIJTLFi'S-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,pmvided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ f1'.
sale,If,however the building.,immnt
oveem issold wilhinnne ycarofcmnpletion,the SQ.FI.MOOR AREA SISQ.FI'.
nwner-hi ilder will have the Tunica of proving MUT he did not build or improvr ler par-
Ra of valents TOTAL:
/r'I�(\� of the pe,.709 ran exclusively and amvacting with licensed contractors i.
ceaseL Chess awtpply7(W4,Businessandwho builds
or i noContractorsLi. ` j
whoelawdcesnm apply nun ownend pnspeny who bnIpursant to the menton.and QTY. PLUMBING PERMIT FEE 1
who Lomsfnr such projects with uamtrnmor(s icensed pursuant to Contractor's
L¢cruc Law. PIiRM'I-
❑ tum exon oder See. .B&PCfnr dinneaxon T
A GR+I IN& B -W (EA) VALI. VA' ) '
Own D
WORKER'S COMPENSATION Df the following
ION BA K FLOW Pft(IIECf.DEV
1 hereby affirm under penally of Perjury one of the(..lowing declarations:
❑(have sad willn,for byneCion 37be of the Labor
Cwl odensumfor Worker'sue of th LOS I. )RIMA A NR STORIES TYI'F.CONSTRUCTION
worn,as provided for by Sermon J11x)of the hvMt Cadu,for the purtummnee of th�
work for which This pem:il is issued. PIX'(URCS-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Seclio
37(x1 of[lie LaborCale,for the performance of The work for which this pemdt is isxu GAS-ITA.SYSTEM-I INC.40IIT ID'S OCCGROUP AIN
My Worker's Compensation Insurnnce canter and Policy number arc: 77
Cmnor. Policy No.: GAS-EA.SYS
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASUINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCENUILDING DIVISION FEES
(This section need not be completed l foo permit is for one limited dollars($IBB) GREASE TRAP
PLANCfiECK FEE
or les)
I cemi y shat in the performance at the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.201)FT.
not employ any penin in any amnner so as m became subject m the Workers'Co.,. ENERGY FEF:
0 Z, smion Law,of Coliforms.Dam WATER HEATER W/VENT/ELECI'R
Ll O Applicant CRAVING PEE
NOTICE TO APPLICANT:IL aper making This Certificate of Exemption,you should WATER SYSTIiM?RIiA'1'ING
y SOILS FI3C
Ft5 hcemne suompm the Wicket',Compensation provisions oftheLabor medrpole,You mart
.�i Fel
forthwith comply with such pmvisinnn or permit shall he doomed revoked WATER SERVICE ,
Uj ❑
C'.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FC PAID
I hereby affirm that there is a construction leadutgagency forthe performance of Da Rtteiptp
[Ula F the work for which this Permit is Issued(Sao.3097,Civ.C.)
Q Lenders Name TOTAL:
Lender's Address TAL
:
1 ecnify dwt 1 have mad this application and slate that the abuse information is BUILD PEE
y correct.I agreeh:comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FFR;
rZ biddiagconsuuclinn,and hereby sulhnve represenmtivesid thiscity,m enter.,a The SEISMP
above-mentioned property for inspection proposes. PERMI'1'ISSUANCE. ELEL' C F.E
(We)agree m save,indmnnify mol keep harmless the City of Cupertino a6uin.rt
liabilities.judgments,costs and expenses which may in any way accrue against said City AITERORADDTOMECIL PLUMBIN FT13 O
in onsin uence of the granting of this pen .
APPLICANT UNUERSTANDS AND I COMPLY WITH ALL.NON POINT AIR HANDLING UNITTO 10,000 CFM) MF.CHAN 'AI.I'FF.
$DD IiOULAT
AIR HANDLING UNI T(OVER IB,IxNICFM)
CONSTRU ON TAX
mol •of ApplmcumC.ntrama, Date EXHAUST 1 IOOD(W/DUCIT HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant ar future buildmng:ecapardia.mar handle haamomanuterial HEATING UNIT ILD 100,000 BTL)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the health and Safely
Cede,Section 25532pd? HEATING UNl'T(OVER 100,11f 11 TO)
Dyes ❑No VENTILATION FAN(SINGLE REST[)) PAID
Date Receiptit
Will Ne applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,0110 BTU)
emit hvaNwnta
,air comlmms as defined by he flay Arca Air Quality Management TOTAL:
District! BOILER-COMP(OVER 100.0010131U)
❑Yes 1-1 No
have readthe hmardeus material,nquiremcnls under Chapterfi95 of The Cali- AIR CONDITIONER ISSUANCE DATE
'�
htmia Realm&Safety Cole,Sermons 25505.25533 and 25534.1 un icmmnd that if The NEW RESIDENTIAL MECH. SQ.Fr �- 7
building does not currently have a Tenant,mat it is my responsibility to mady'the a:cupare /2i- le
of the requirements which must TO,met prior to issuance of a Certificate of Occupancy.
Owner or amMsriaeJ agent Dam TOTAL: ISSUED BY:
OFFICE