S 3328 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY"ADDRH�S
BUILDINf.-ELECTRICAL PER�}I'r NO.
BUIPLICATIONA'ERMIT PLUMBING-MECHANICAL 3328
`v
BUILDING PROJECT IDENTIFICATION
BUILDSANITARY NO, APPLICATION SUBMITTAt.DA'Z'E
OW PHONNEE: -Q C NIRACfOR'S NAME: LIC NO:
P NIC CONTRO///L��1#
ARCHITECT/F:NGINF:ER: /I.ICN 76� 59"' S. ❑ (� Q 9 �7
CONTACT: PH E: I BUILDING PERMIT INFO CJ
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSEDCONTRACIOR'S DECLARATION QTY ELECTRIC PERMIT FE17
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Qd'Zwith Section 70fNH ofDtvished 3 ofthe Business and Professions Code,and my license is RESIDENTIAL'
DI O p PERMIT ISSUANCE
l Wfull forand effect. ❑SFDWL ❑KITCHEN REMODEL
aF.UzU Limrec Cce lass Lie. APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
N Q WDate Common,
g,Oy ARCHITECTS DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O r.Z I undersmnd my plans shall be used ass Public meords MODIFICATION
OZ4O I IIP TO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
F4t:W Le.'awil PrnlbcsinnW 201-I000AMPS IMPROVEMENT SWIMMING POOLS
��4F,; OWNER-BUILIIER DECLARATIONOVER 1000 AMPS ❑BATH REMODEI/RF.PAIR ❑DEMOLITION
C Q I hereby affirm that 1 am exempt from the Cmre
ram's License Law for the
following masmn.(Section 703I5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
47 31z•vFv11 which requires a permit to construct,alter,improve,demolish,or re%lir any sanctum _
CSO¢ prier In its issuance,also requiAs,he applicant forsuch Permit mlilensigned smtcnmm SPECIAL CIRCUIT/MISC.
that he is licensed pursuannntheprovisionsofNeConlmcmrsLicenseLaw(Chap.ar9 IV VC/
�QpC (commencing with Section 7")ofDivision 3 ofthe Business and Professions Code)or TFAIP.MITI?R OR POLE INS COMMERCIAL:
that Im is exempt therefrom and the oasis fur Ne alleged emmptinn.Any violation of ❑NEW BLDG/AUDITION [I DEMOLITION
WX Iz. Semon 10315 by re,upideranl fmapenoit mdjens lhcupplicam ioneivil penullyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
�' nom mote Nan live hundred doll...F Z Y IMPROVEMENT
W Q ❑LMowner
k, ad property,or myemployees
ntendedwird cared for their sole compensation, SWIMMINGPWLELIICTRIC
will do the work,and the susrnum rs not intended orolered for cote(Sao.70,W.Business ❑OTHER
y�j � and Professions Code:The Contractor's License Law does not apply to an owner of 0U'f1.Ef5-SWITCHES-FIXTURES
property who builds or improves thereon,and who does suclt work himself or Nomgh
his own employees,provided that such improvements are not intended or offered for NEW RES)DENTAL ELECTR F1'.
sale.If.however,the building or improvement is soldwi,hin one yearofcompletion.the SQ.FT.FLOOR AREA SISQ,tT.
mer-builder will have the burden of proving that he did not build or improve fm par-
oue of sale.).
1,as owner of the properly,um exclusively contracting with licensed con neons to TM
consumer Ne prober.(Sec 9044.Bosun, it Pmfesions Code)The Conhacmds LI-
ccnseLawdoesnotapplytoonownero r pony who builds or improves,hereem.and QTY, PLUMBING PERMIT
whoa rsTome etswitha nctm
a mba licensed pursuant the Comemnr's
i.ic :e Ir PERMIT ISSUANCE
ler Sec. .B&P C for Otis reason
em a
Data MALTER-DRAIN&VIE -WATER IFA) VALUATION
/[
-N9AA�LLa[LfA ION IfACK FLAW PROTECT'.DEVICE Sw(( /y''�
I her ul' .undlty of ryrjury conal d,'lhc following Amixmtinns w
er%:na
❑ Ihavem Ila nainn Certificate nl Cnnsemmaell insert for Worker's Camper- DRAINS-FLOOR.ROOF,AREA,CORD. STORIES TYPE CONSTRUCTION
cation,as p 'J far by Section 37M of the Labor Code,for the performance of the
work for which this pandit is issued. FIXTURES-PER TRAP
❑I have and will mainmia Workers ComIaosation Insurance,as rtgnired by Section
3701 ofthe Labor Cale,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Worke s Compensation Insurance carrier and Policy number art:
Correct: Policy No, GAS-F.A.SYSTEM-OVER 4(FA)
CERTIFICATE OF EXF,M"ION FROM WORKERS' GREASFJINDUSTRL WASTE 1 NTIiRCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thissccbmr incident be completed if he permit is toren,hundred dollars IS 100) GREASETRAP
or leas.) PIANCHECK FCL•
I cenify that in the performance ofthe we&forwhich this permit is issued,l shall SEWER-SANITARY-STORM EA.HIO FT.
or employ,any person in any monnera,us to becomasidjecrto the W..kem Co pan- ENERGYFP.E
OZ cation Lmwsof Cxlifand.,Date WATER 1117ATER WNENT/F.LECTRZ LD GRADING FEE
Applicant
1 H ^ NOTICE TO APPLICANT:If,afar making this Cardona,of Exem%inn,you should WATER SYSTEMUREATING
become subject to the Werke/s Compensaion provisions of the Labrt Code,you must SOILS FEEAl
Wfon hwith comply with such provisions or this permit shin l he deemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PI,MB. SQ.Ill PAID
U O Iherebyaffrm,hmfere isamnsmrainn leadingagency fnnheperformaneeof Dme Raroi%#
the work for which Nis%mtit is Issued(Sec.3092 Ci,C.)
14 Isndcr's Name TOTAL"
O U Lendce,Address TOTAL:
I cenify that I have mad this application and notation the above informntian is BUILDING FICh
hcorrect.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U rZi building eonemstics,and hcrchy milt ice re,macnhnives of lhi,itynt enter n%mthe SEISMIC FEE
is—
above-mentioned property for Inspection purposes. PERMIT ISSUANCE
agree m save,indmnnify anJ keep hamJess III of Cupertino against ELECTRIC PCI:
had l d`,`tr=ms suadespenseaw ch may in any way#ccrue against said City ALTER OR ADD TO MECH.
in msegm ace Ufthe6 tingof th' pe n. PLUMBING ITE I
PLICA " DCI 1'ANUS. . D ILL COMPLY WII'Ii ALL NON AIR HANDLING UNIT(TO I0,0x1CFM7
MECHANICAL FEE
Ua.r NS. AIR HANDLING UNG'(OVER 10.000 CFMI CONSTRUCTION TAX
SignData EXHAUST HOOD(W/DUCU HOUSING MITIGATION FEE
AZARDOUS MAI'TRIALS DISCLOSURE
am or lbwre huilding occupant store or handle hazardous material HEAT]NG UNIT(IT)110.000 BTU)
asdeeninoMunicipalCode,Chapar9.12,endtheHealthanJSafety
Codem)9 HEATING UNIT(OVER 100,00011711)
No
VEMI'ILAI'[ON PAN(SINGLF.RESID) PAID
Duro Rosi%#
Will the applicant or future building occupant use equipment or devices which
emit hazardo ,air contmninants ss defined by Ne Buy Area Air Quality Management
BOILER-COMP(3HP OR IIXI,(NXI BTU)
Dtnlnct?
❑Yes E]No BOILER-COMP(OVER IWrit)BTU)
I have acid the hazardous materials .s under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE DATE
#quire
fomia Health n(Safety ad,,Sections 25505,25533 and 25534.I u artily ml that it Ne NEW RESIDENTIAL.MECH. SQ.FT.
I)tiairdinwitemmmcarendy hnveat meteNati.ismyres ofaC ulicanotifyceeporcy,m 2-
OwnernT.he rWuircmcnm whirls inn.t be me.pdanoissnanca ofaCmillcate n[Occupunuy.
Owner or authorized agent Dare TOTAL: ISSUED BY:
OFFICE