S 3382 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILD CAT, rFR�y�•IT NO.
BUILDING DIVISION APPLICATION/PERNIIT PLUMItING-MECHANICAL �J 3382
-BUILDING PROJECT IDENTIFICATION
BUILDING ADDRI:S': SANITARY NO. APPLICATION SUBMITTAL DATE
b 1-5 g / 2-Z3-98
OWNER'S AME: PHONE: / CONTRACTOR'S NAME: LIC NO.
J4(, Jip it �W'( p _ NIC CONTk(11.M
CHITS T/FN IN R: LIC NO: ADDRESS: ❑
CANT T: HH(yy� HULLOING PfiRMIT IN FO -
n 4-- D ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
_ e� 0-- L�
LICENS D CONTRACTORS DEC ARATION QTY ELECTRIC PERMIT, FEE
1 hereby affirm thin I license(]u I p : f Chapter 9(commenting - JOB DESCRIPTION
WwthS ( ]000) fl) 3nheaus d1) f,sior Cd gamy license isIFIFINTI
FOOO in fall f 1 effort. PERMIT ISSUANCE
W 1, �g FDWI. El KITCHEN REMODEL
�UU L'rc: Class TI
Lic.N - APPLIANCES-RESIDENAL ADDITION El PLUMBING RE-PIPE
NZ¢] Do,, Combat.,
6¢L ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
FONm PANELSZ O 4 q 1 understoodmy plane shell be used records public rerds MODIFICATION
O'Z.. UP'T02fx1AMPS ❑IN'ITiRIOR
y H W El CHIMNEY REPAIR
Licensed Pmfeesionul
G POOLS
s4 OWNER-BUILDFR DECLARATION OVEW WAW - IMPROVEMENT �$WIMMINifil0
f� ,W
K ¢ I heeday.nffiren but I me csemp,from the Corbot e's License Law far tha OVER IOW AMPS ❑R PFRF3MBBHh}.$�I'fliR'-� Ia1PP1'%f9
O y U fallowing reason.(Section 711315,Business and Professions Cade:Any city or county SIGNS HLPATRICAL. ❑a I
I which acquires a permit to construct,alma improve,demolish,or repair nny swcmre
,F]�O p,iono as issuance,also requires meapplicam Tal ned pemsite,fleasignedstatemutl SPECIAL CIRCUIT/M1SC.
"I 'hat heir licensed purtancemthe provision,.li the Contortive.License Co.(Choice,9 _ �
WO (eommeeing with Section 7000)of Division 3 oftbe Business and Professions Code)or TEMP.METER OR POLE INST. luiI
d m that Iso is exempt therefrom and the basis for the alleged exemption.Any violation of ❑N BLD A ION E LIT
W^va Section 70315 by my applicant B,a paomd sohjed,dedplicamod a civil penally,,( POWER DEVICES
blmnre than five hundred dollars(SSW). ❑T NT FOOT SE
$�Q ❑I,as owner of The property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC I R}�OVEMENT
W will do theworNmal Them...fare is nal Intended orolffifed forsrle(Site.7044,Business OtIFAy
and Professions Code:The Confiscates License Law does not apply to an owner of OUFLETS-SWITCHES-FIXTURES
property who builds or irepmvea Parents,and who dues such work himself nr through
his own mnployees,provided that such improvements are out intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building or improvement is sold within ane year ofcompletione The SQ.1)f.MOOR AREA $ISQ.PT.
owner.builder will have the burden of proving That he did not build or improve for put- Z7 g Sr`
po[�f as owner of the pfoperty,am exclusively contracting with licensed contractors In I a TA L: (.f/I/4 D
construct the project(Sec.?044,Bu rens and Professions Code;The Connaclofs Li- h
cerise Law dues not apply id an owner of property whe builds or impmvcs thereon,and QTY PLUMBING PERMIT PEE
who mntrecls for surJh projects withacnntrmlor(a)Iicehued purswnunlhe Gmwmara ��S�
Lleene Law.
❑I am exempt under Scc. B&PC fur the emus, PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATHR(EA)
O Iii /y p�,� Date // VALUATION
(� WORKER'S OMPENSATION UECLARATION�T BACK FLOW PROTECT.DEVICE -2—(,.,
/ `I ^ O
- i hereby affirm underpmilry of pejuryane of the following declamtlans: 2— L V
❑ I have and will maiaminaCenlli.N.Consent toulf-insure far Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. - STORIES TYPE CONSTRUCTION
nation,as provided for by Section 3700 of the Labor Code,far the performance of the �a
work for which this permit is ismiaL FIXTURES-PER TRAP _Z_
❑ I have and will maintain Wnrker's Cmmprhsation Insurance,as retuned by Section
3700 of the Labor Code,for The performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APE
My Workr's Compensation insurmed carrier and Policy number are:
Carrier Palley No.: GAS-EA.SYSTEM OVER 4(EA) /
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR n § h,
(Thi ,red,,nacedan,bechmplulediflhepermit is formic handed]delta,,($IW) ILUIN IVT$ION IiLf Sa + t yy
nr less,) GREASE TRAP PLAN EL F'E
Loy any perinthe pddarnenceof thawodloawbich this the Wokd,kC, Ebb-,hall SEWER-SANITARY-STORM EA,200 PI',
ern employ any person in any mrnnu so as m heaome subjrc to the Workcb'Comprn- P.NF F.H 440
hZ.r submit Laws of Californio.Date WATER HEATER WNFNTTLRCTR r
4 O APFlicunl G NG E
y NOTICE' TO APPLICAN"E If,after snaking this Ce ificata of Exemption, an should WATER SYS]EMGHEATING
abecome subject m the Walker,Compensation aso c,mm of The Lahe,Cale,you most SOILS PP.
[�y Q forthwith comply with such Pmvisianxee this permit shall be deemed revoked. WATER SERVICE.
�O CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL TIME. SQ,CU
I herehyaffvm that here iso conatmction lending agency for the performance oC Dae Raeipi#
V. P thew.,klof which this permit is issued(See 3092.Civ,C)
0Lender's Name T
} W Lender's Address TOTAL:
1 Ancify that 1 have d IF:application and state that the above information is BUILDING FEB
rF.(4 correct.I agree to comply with all city anti county ardamersesund send laws relaf g to QTY.- 'MECHANICAL PERMIT •FEE -
C..> Za. build' g I ion a d hereby authorize p sentatives ofthis city a antarupanlne I SEISMIC PER
above-m mphared pfoperty for inspection i urpusav PERMIT ISSUANCE
(We)agree to sane,indemnify and keep harmless the City of Copsmin,against QLEC'PRIC P E �.
liabilities.judgments,coals anA expenaea which may in any way.reem,againstaaid City ALTERORADDTOMECU
in mwgar,c of The Saluting of this pdnonc, PLUMBIN FFE
APPLICANT UNDER AND WI COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE R OULATIO S. MECHANI .P,
AIR HANDLING UNIT(OVER 10,000CFM) CONST O AX,
Signatureof Applicant/ atinemr - Date EXI IAUST I IOOD(W/DUCT) HOUSING MIT iNITONFEE
HAZARDOUS MATERIALS DISCLOSURE
W,111mappludes nr furore b.ildingmccmmd store m handle hazamme,nnterivl HEATING UNIT(TO IIx1,Om)BTU)
on,defined by the Cupertino Municipal Code,Chapter 9.12,cad the Health end Sefety -
- Code,Sermon 25532fifil - HEATING UNIT(OVER 100,000 BTU) -
❑Yes ❑No qs
VENT H,AJ ION PAN(SINGLE RESID) PAID 7 P-" I
Da Rcaipt#
Will the applicant as funic building y the Bt use ea Air Qu or device which BOILER-COME(3111)OR 100,000 BTU)
Diel hazardous sir contaminants is dc0ned by the Ray Arca Air Quality Mvnagemmt
DierinOAl7 �
E)Yet E:]No BOILQR-COMP(QVER 100.000 BTU)
I have mad The hazardous manrialsrements under Che¢,6.95 of the Cafi- AIR CONDITIONER -
mqui p ISSUANCE VTE
I'omia Health&Safety Code,Secdnne 155n5,25533 and 25534.1 undeannd that if the NEW RESIDENTIAL MECH. SQ.FT.
building doepnrembeadyhavca lcnan4l t iemyrespmneibihtym unify lhcomupern
Head. ,nems wli must he missuvaee of o Cieifwtc of Occupancy.
I
wall or authan,ed inlaid Date T ISSUED BY;
OFFICE