S 3364 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OF CUPERTINO BUILDING.-ELECTRICAL PE ITNo
BUILDING DIVISION APPLICATIONAPERMIT PLUMBING-MECIIANICAI, 3364
I41111.I31NG 1'B(1d ECT IDEM'IPICA'TION
BUILDINGADDRE55: VSANITARY NO. APPI.ICATION SUBMITTAL DXU
1
OWN M P11O Ca ' k CIt':' AMI' ICNO;
NIC CONTROLN
RCIIITLLT/ENG( F.F.R: LIC NO: D J ' S' -E ��� 5 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
,s ?[-0?2 j ❑ Consultant Fens Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
1` l7G/- / C ❑ ❑ U'a"'
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby anion that I am licensed under pmviaionx of Chapter 9(commencing JOB DESCRIPTION
00 thSxlion700(om'Divoma30ffhe Bmidcrsand Pmfesxions Code,and mylicensei, / RESIN
wt 2 PERMIT ISSUANCE
� nfull mrs'a deffc �� c 7U L`(./ ❑SPDWL ❑KITCHEN REMODF.1.
I FQF..U�j Then.Cla g APPLIANCES-RESIDENTIAL ❑ADDCION [I PLUMBING RE-PIPE
P Q y Dam — ` — 'onnscier_
ARCHIT TS DECLARATIM ❑MULTI-UNIT ❑STRUCTURAL
p..D to PANELS MODIFICATION
z O fn Z 1 understand my plans shall be,used as public records
oz-� UPT02MAMPS [I INTERIOR OCHIMNEY REPAIR
W Licensed Pmfessiunal 201-10110AMPS IMPROVEMENT SWIMMING POOLS
C C Q 1 hereby alBtm OWNER I am aemprfnno me Comrac�rs License Ire for me OVER TWO AMPS ❑BATH REMODEUREPAIR 0 DEMOLITION
YSx13 c,..F following....(Section 7031.5,Business and Pndemions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
y which require,a permit In connmet,alma improve,demolish.mr repair any manure ����/
E'�sOQ pnamsscense pummrequime provisions
comfm Contractors
License
LItw(statement
SPECIAL CIRCUFF/MISC.
that he is licensed pursuanuothe provisions of the Cnnnsnnrs License hwlChapmr9
�CpO (commencing with Section 7(Xnal'Division 3 ofthe Business and Professions Code)or TEMP.A3ETER OR POLE IN COMMERCIAL:
S a o yy that he is exempt therefrom and the hard,for the alleged exemption.Any violation of ❑NEW BLDG/ADDI RON ❑DEMOLITION
�mN Section 703 L5 by any applicant for a Permit subjects the applicant o a civil penalty of POWER DEVICES El TENANT ❑FOOD SERVICE
not mom flan fivehundred ars(
d doll3500).
F X>' IMPROVEMENT
=6 I.asowneroffhepmpeny.ormyempiny .%with.agesastheirsden.mpensvtion, SWIMMING KWI.ELECTRIC
Xt: will do the work,and the instant is not intended or offered for,ale(Sea 711M,Rusincca ❑OTHER
X and Professions Cade:The Contractors License Low docs not apply to an owner of Olfl'LICS-SWI'(CfiF_S-FIXTUR
.. property who build,or improves thereon,and who does.such work himself or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECfR SQ
sale.If.however,the building or improvement isodd within one year of rouplaiun.the SQ.pt.FLOOR AREA NSQ.FT.
owner-builder will have me burden of proving that he did not build or improve for pun
pose.Lala). Q
TOTAL:
1.ax owner of the property,am exclusively contracting with licensed commema,to
mw Law
a The es red
o an owner ors and Professions d%or i Tho C.s ther on.and
tense Lawdoesnaapplytoanwith
ae onctory wocioho ndJsaimpmves Contractor's
QTY PLUMBING PERMIT FEE
=�
who contracts far such projects with anmnsctor(al license)puauum to the Conmecesrs DECt 1 as 1998
License Law. PERMIT ISSUANCE
1 am exempt under Sec. ,B&P C for this rcnsnn
ALTEiR-DRAIN&VENT-WArER(EA) B VALUATION
owner nate y
WORKER'S COMPENSATION DECLARATION BACK(LOW PROTECT.DEVICE.
Thereby affirmunder penalty Mperjury nm of the following decimations❑I have and will maintain aCenificate of Consetn toself-imure tau Worker's Comped- DRAINS-FLOOR,ROOR AR EA.COND, STORIES TYPE CONSTRUCTION
Noted,as provided for by Section 3700 of the Luber Code,for the performance of the
work for which this permit is issued, FIXTURES-PER TRAP
I have and will maintain Workers Compensation Insurance,as required by Section
3700 ofthe Lahnr Cade,for the performance ofthe work led rywhh�ich this permit is issued. GAS-IiA.SYS'IEM-1 INC.40UTLETS OCC.GROUP APN
My Wnr nm permit n In surm not.cutnd Poli,xiii 0 � GAS-IiA.gYS'1'fiM-OVER4(EA)
Carried: 1x �i Policy No.:/UJI`!/6.�-t--_r_a-
CERTIFICAT-EOF . EMITION('ROM WORKERS' GREASIVINDUSTRLWASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(Thicsectinnneed rotM completed i0he pc...it is Ionia,hundred dollars($100) GRFASH'I'RAI,
or less.) PLANCHECK FEE
I certify that in the perfnrnaveenfthe work for which this permit is is,acd,(shall SE TR-SAN I'PARY-STORM IiA.200 PT.
not employ any parer in any manner I,as to become olive, I,the Workers'Couper- N ENERGY FEE
OZ ,union Laws of California Date WA'IIiR I IENFER WNUNUTLECTR
Applicant 1 GRADING FEE
G NOT CH TO APPLICANT:It;after naking Phis Ccniticaseof liscmption,yrs should WAI US SYS'I HMIFRENI ING
F bwome suhject to the Workers Congsunxmlon provisions nI the I.uha Coale,you ai I SOILS PEE
{ail fonhwimcomply with such provision.,nr this permit+hall ladeeutedravoked. WAI'UK SERVICE
Q
Uz CONSTRUCTION uccon NOAOI?NCY NIiW RESIDIiNI'IN.PhMII. SQ.Ff. PAID Dam ReceiptN
UQ (hereby affirm mm num
there is lending agency l'nnhe perliornumre nl
E~ the work for which Ihls pernif is Issued(Sea 3097,Civ.C.)
Leader',Name TOTAL:
C) Leach's Addms, TOTAL:
�+ 9L. BUILDING FEE
[r 1 certify o c 1 have rend this city
and c i un and dime ordinances
slid shove iws rnation is d
i..t t� covect.I corer ct comply with y city and county ntative of ons xmm lows relating he QTY. MECHANICAL PERMIT FEB
Uz
building construction,and herebyaushorimreprcnrnmtive.+nl ibis city wenter upsnfhe SEISMIC FEE
above-mentioned property for inspection pugasres.
(We)agree to save,indemnify and keep hnmdess the City of Cupertino against PEiRMIT ISSUANCE a„Ja� ELECTRIC FEE
liabilities,judgmdnts,enosandexpenscs which may in any wayvicemc againsuaid City ALTER OR ADUTO MECIT
in consequence of the gaming of this North. PLUMBING FEE
APPLICANT UNDER STANDS AND WILL COMPLY WITH A LL NON.POINT AIR HA SOUND UNIT TIMI 10.0(X1 CFM(
MECHANICAL FEE
SOURCE kEGULATIONS.
AIR HANDLING UNIT(OVER Uts.1 CFM) CONSTRUCTION TAX
Signature of ApplaandContmnm►R-J��1_"—`l/ DFaa', EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIN6 DISCLOSURE
Will flit vpplicam nr fmurc building orcupvm score.handle haamJoud material HEATING UNIT(TO 100,0011 BTU)
as definal by The Cupertim Municipal Cale,Chapmr 9.12,and the Health and Safety
Code.Seen.25532007 MATING UNIT(OVER 100,000 BUT,
[3Ya 9< VENTILATION PAN(SINGLE RESID) PAID
Date ReceiptN
Will the applicant or future building occupant use equipment or devices which BOILER-COMP TEW OR 100,10(1 BTU) ,..• f
emit haaudws air contaminants as delinN by the Bay Area Air Qualify Management TOTAL / 1
01'District?
0Yes [TR BOILER-COMP(OVF.R 100.00)BUD
/! I have real me haallous milixols witimpmems under Chapter 695 of the Cali- AERCONDITIONER ISSUANCE TE
fates Health&Safety Code,Sections 25505,25533 and 25574.1 understand that if toteNEW RESIDENTIAL MECH. SQ.FT.
building nes nd cueendy hvveatewnt.d but if is my nNausibilisy touchy thnciaoladt
o(Ihe mems which must me prior to u tofu Ce Li0cvmalIZI
' -
Owner m sum stmt.gem Dam TOTAL: ISSUED BY:
OFFICE