S 3287 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO t BUILDING.ELECTRICAL MtIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL V 3 //�
87
BUILDING PROJECP IDF:N'I'IF'ICATION L
BUILUINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
e�PC v Era /_
OW R'S NA E: PHONE: C N'BACTUR'S NAM(? LIC NO:
_ 1 t ! ` NIC CU TROL
ARCHITEC'UHNGINEER: LIC NO: A TSS:
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' I .UN MECH
❑ ❑ ❑
LICENSEDCUNTRACnder p.iCLARgT10N QTY. ELECTRIC PERMIT FEE
I hereby«)Toms that 1 em licensed under provision.,of Chapter 9 my license
JOE)DESCRIPTION
X00 with Section ufUivis'ionJol the Business and Pmipsinns Code,anJ myli.'ense is
00 in full fora and effect. ^� / PERMIT ISSUANCE RESIDENTIAL'
Cut / 3��0 k'/ ❑SFDWL ❑KITCHEN REMODEL
FZV U Lin,I A,I Lic.p
u) Dam Contra-7}�7����6 APPLIANCIiS-RESIDENTIAL ❑ADDITION ❑PLUMNING RE-I'II'li
Fpy ARCHITIi DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O rn Z I understand my plans stall be used as public records MODIFICATION
OZ. Q UP T021NIAMPS ❑INTERIOR El CHIMNEY REPAIR
al Licensed Pmfessimml 201-11000AMPS IMPROVEMENT
CY�-,1 OWNER-BUILDER DECLARATION C]SWIMMING POOLS
K Q 1 foods Af irm that I ton exempt tram the Contractors License Law for the OVER I(NMAMPS ❑B ' REMODEUREPAIR Q N
W316E fallowing reamm.(Section]8315,Business and Profcsxians Code:Any city or county SIGNS ELECTRICAL �R
O which requires a permit err constme6 alter,impmve,demolish,or repair any structure
prior hr in issuance.also requires the applicant for such permit to file u signed statement SPECIAL CIRCUIT/MISC
S y that he is licensed Nosuznnothe provisionsofthe Contractors License Law(Chapter9
p0 (.commencingwithSectian]IXN1)al'Uivisinn3nfthe Busius'ss end l'mfessions Code)or '[LIMP.MIUHRORI EINST. COMMERCIAL'
a G c Na he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION (]DEMOLITION
Wm Sation]031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICF
No' not more than five hundred dollars]SSW). ❑TENANT FOOD SERVICE
�_< Las owner of the o norm employees with wars as their role cam nation. SWIMMIN OL ELECTRIC IMPROVEMENT
O ❑ pr pe Y Y c D Y g p.
F will do the work,and the structure is not intended oroffered for side(Sec.]B14,Business ❑OTHER
3 and Professions Code:The Connector's License Law dors not apply to an owner of OUTL -SWITCHES-FIXTURES
property who hnllds or improves thereon,and who docs such work himself or through
his own employers,pookkal than such improvements are not intended or offered for NE RESIDENTIAL ELECTR SQ FT.
sale.If.however.the building or improvement is sold within one year ofcompletion,the .FT FL A REA IT
builder will have the hmden of proving that he did not build or impmve lit[pun- D /� D
poaf sole.).
❑ 1,as owner of the property sum exclusively contracting with licensed contractors u, TOTAL:
construct the pmjat(Seo.7044,Business and Professions Cede:)The Contractor's Li.croI ,(
`t
sc Law does not apply m.anownernf propcny who builds or ingmwesdmr.rnr,and QTY PLUMBING PF,RMIT FEE JAN 1 199
who rummest for such prujecm with a comrinceno,)licensed pursuant m the Contrudor's
License Law. PERMIT ISSUANCiiwi
0 l am exempt under Sec. ,B&PC for this reason
Owner Date ALI ER-DRAIN&VENT-WATER RA)
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjuryane of the oil lowin,deviaratinne
` ❑ I have and will maintain a Cenilicate of Consent msclGimure for Worker's Compton- DRAINS-FLOOR,ROOF.AREA,CONE). STORIES TYPECUNSTRUCTION
,at on,as provided for by Section 37W of the Labor Cole,for the permarearne of the
0k far which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Comp.n.nnion Insurance,as required by Section
ID
Oof the Labor Cale,fnnhe performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROU� AI'N
My Wa cos Cn'T ym Insyra e c - d Policy num r
Came :10" OU %V�_policy 1. 0. GASI-EA.SYSTEM,OVER4H;/U
CERTIFICATE OF I'XEMM'ION FRO O t EI S'
COMPENSATION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR
(Osis sationneed not be completed ifthe permit is usma,hundred dollun(EI00) BUILDING DIVISION
or less.) GREASE TRAP PLANCIIECK FEE
I certify that in the perfonnanceaf the work for which this permit is isw.J,lshall SEWER-SANITARY-STORM Ep.200 Fr.
oat...ployamypccaminany manner so t bjecs to the Workers'Compton- ENERGY FEE
z sation Lows of California.Date r C
ZO Applicant '% WATER HEATER WNENT/ELECTR GRADING FEE
to NOTICE TO APPLICANT.If,after making this Cetificate of Exemption,you should WATER SYSTEMETREATING
('^ herons,subject to the Workers Compensation provisions of Ne Labor Code,you must SOILS FEE
.aj [nnhwith comply with such provisions orthi,ennit shall he derated revoked. WATER SERVICE
4Y
CONSTRUCTION LENDINGAGENCY NEW RESIDE?NTIALI'LMB. SQ.FI'. PAID
UQ work
yaffirm that
conitiisaaonsuuction lending agency far pertonnance of RcceiptN
0 F thewark far which this pennon is issued(Sec.M)7.Co.CJ
� LeMer's Name e/ TOTAL:
WLeMers Address 10TAL
cenif,that I have rend this application and sons that the above in[onnmion is 111.DING PEE
tZI Lefton.I a greens comply with all city and county oWi.....x andsme laws relating to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hembyatruanix representativcw(thus city to enter uptm the SEISMIC FEE
above-mentioned property it,,inspection Durposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE p 'TRIC FEE
Iiabiliticsjudgments,coin;and expenses which may in any way accrue against said City ID I
ALTER OR AUD TO MECH.
in nxquence,of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WIT Ii AI.I-NON-POINT AIR HANDLING ON]r(TO 10,000 CFM) MECHANICAL FEESOURCE UI TIONS.
�� AIN HANDLING UNIT(OVER 111.000 CPM)
' ` (�� !/�tl� CONSTRUCTION'1AX
Signator ApP1ij VComm,ua / Dmc EXHAUST HOOD(WIUUC) HOUSING MITIGATION Mr.
HAZARDOUS MATERIALS DISCLOSURE
Will rhe applicant err fmwe building acupam stoat or handle huzmdous material HEATING UNIT(TO 100,00h)BTU)
in defined by the Cupertino Municipal Cede,Chapter 9.11,and the Health and Safety
Code,Section 25532(x)? UFATING UNI'[(OVER 1110,01X1 U)
❑Yes 0N VENTILATIONFAN(SIN .ERESID)
• Will the applicant or future Wilding occupant use equipment or devices which m Receipt k
emit Incautious air conmminants as de ned by the Bay Area Air Quality Management BOILER-COMP(. OR IpLlMN1 RTU)
District? TO)'AL:
Yes ❑No BOILER-Cs (OVHR IINI,000 BTU)
I have mad the hisadmin materials requirements uWer Chapter 6.95 of the Cali- AIR )I'fIONF.R NCE DATIi
fomia Health&Safety Cale,Sections 8505,8533 and 25534.1 understand that if rhe RESIDENTIAL MECH. SQ.ET.
building does not currently have a teem,that it is my msimnsibillty to notify the ocwPam
office requirements which must be met prior m issuance of.Certificate of Occepaay ,
Owner or uuthori,acd.,not Date TOTAI.: ISSUED BY:
OFFICE