S 3309 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PEIfp1IT NO 3309
BUamN .nrvlsloN APPI,ICATION/PERMIT PLUAIBINC-MECIIANICAI. �J`
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO, APPLICATION SUBMITTAL DATE
/b/66 �Arn/ le e. bfive (—'Ape 111 0 Rsa)
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3s B
PI B. CONTRA LIC NO:
CILOJOW• 40i! 6 l9kl Nrc CON rrRGl.x
• ARCHI ECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: ;� BUILDING PERMIT INFO
❑ Comallanl Fees Paid by APPlicant(Initial) BLDG FLI.C'r PLUMB MLCH
❑ ❑ 9J ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE JO
Op B DESCRIPTION
ON hereby affirm that I am Iimmed antler previsions of Chapter 9(commencing
D0,Z with Section 700)of Division 3ofthe Business and PrePERMI'1'ISSUANCE
fessione Code,and my license is RFSIDENTIAL:
+f I
F- in full force and CDeu. ❑SFDWI. [I KITCHEN REMODEL�UU License Class Lic.N gPl'LIANCIiS—RESIDEN'I'IAI, ❑ADDITION El PLUMBING RI PIPE
FZm Dam Contract
y 6 a ❑MULTI-UNIT ❑STRUCTURAL.
ARCHITECTS DECLARATIONPANELS
F`Z) UPIO2 MODIFCHIMNEY
ATION
Z O r^Z 1 unJemm�J my plans shall M used m public records
OZ=`p UPIO El INTERIOR ❑CHIMNIiY REPAIR
'F,; I Licensed Professional 201-10M)AMPS IMPROVEMENT E)SWIMMING POOLS
OWNER-BUILDER DECLARATION
X49" OVER I(xx)AMPS [I BATH REMODEIJRIiPNR ❑DEMOLITION
Q 1 herehy affirm Thal I am exempt from the Contractor's License Low for the
K06 U fallowing reason.(Section 7031.5,Business and Pr..fe,sin is Calc:Any city or county SIGNS ELECl'RICAL [I OLDER
which requires n permit to comwct,alter,improve,demolish,or repair any structure /J
O prior to its issuance.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
�y that he is licensed Panama to the previ.siomofthe Cnmmenr'sLicense Law(Chapter 9
y'0O (commencing with Seem.7")of Us ision 3 of the Bminessand Plnfiroinns Code)or TEMP.M BIER OR POLE INST. COMMERCIAL:
Lty that he is exempt ncarefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElDEMOLITION
Om Om Section703L5 by any applicant for a permit subjects the applicant to a civil pealry of POWER DEVICES []TENANT ❑FOOD SERVICE
ZZnot more than rive hundred dollars($500) WROVEMENT
Q ❑lasowner of lbs pmpeny.nrmycnrplaymswith wugus nsthclrxalccompenxution, SWIMMING POOLRLEGTRIG A
will do the work and the aruccom is not intended m offered for sale(See.7M4,Business li
m and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS—SWITCHES—FIXTURES
property who addition 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 ELEM R SQ Il'.
sale.If,however the building or improvement is sold within on year efcompletion,the SQ.FT.R(KIR AREA FT.
ASQ.
owner-builder will have the burden of proving that he did not build or improve for put.
Re
of salol.
1,us owner of the property,son exclusively contracting with licensed contractors or TOTAL:
msuuct the pr,ect(Sea 70",Bmincxs and Professlins Cn lc:)The Conuammns Li-
ns,Law docs nm apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such project with a conwcom s)licensed pursuant o the Contractor's -
License Law. PERMIT ISSUANCE
I an exemM under Sec. ,B&P C for This reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Ownef Uam
WORKER'S COMI'li SATIONDECLgRA'1'I(IN BACK PLOW PROTECT. )EVUE
I hereby affirm ander peoohy d perjury ma,of the lidlowing deelaratinnx:
I M1eve anA will maimein aCeniOcnte of Consenuosdf-Insure far Worker's Compen- DRAINS—Iq.00R.ROOHARLA,COND. STORIES TYPECONSTRUCflON
cation,as provided for by Section 3700 of the Labor Code,far the performance of the
work forwhich this permit is issued. FIXTURES—PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the labor Code,for the penhandance of the work forwhich this permit is issued GAS—P..A.SYSTEM-I INC.a OUTLETS D OCC GROUP APN
My Worker's Compensation Insurance curvier and Policy number are:
Carrier: Policy No.: GAS—PA.SYSTEM-OVER 4(VA)
CERTIFICATE OF EXEMPTION FROM WOR KERS'
GRGSPIINDUSTRL WAS'1'li INTERCEPTOR
COMPENSATION INSURANCE RUII_._DING DIVISION FRGS
(This section meet not be completed lithe permit is forme hundred do[]ars(s I nd GREASETRAY
or fuss) 1'LANCHECK FEE
I certify that in the pelkinconcenfthe work forwhkolffi,permit is aimed,[,hall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any menneno m to become subject m the Workers'Conifer. ENERGY FEL
O Z cation Laws al'Califnmia.Date WATER HEADER WNEN VELECTR GRADING F
7 Applicant
q NOTICE TO APPLICANT:If,after making this Ceniricine of Exemption.you should WATER SYSTEM(TREATING SOILS FEL
I^ become subject to the Worke s Compensation provisions of the Labor Code,you must
r
forthwith comply with such provision aphis permit shall be deemed revoked. WATER SERVICE
a' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. jPAAO ReceiptsL)QI hereby a0irm that there is a conswction lending agency for the performance of
UF the work forwhich this permit is ixsucd(Sec.3097,Civ.C.) TOTALU Lender',ManeLender'sAdJress AL:rtify Ihef1 have read this application d stets that the above information is LDING F Ecorrect.l agree m comply with all city and county ordinances and sum laws felufingm QTy, MECHANICAL PERMIT FEEZ building conswction,and hereby amhadze mpmwnmtives ofthis city to enter upon the MICPalrove-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE(We)ugoacm save,indemnify and keep woultes the City of Capro n.againstCTRIC FEE
liabilitiesjadgmeins,arslsand expenses which may in mty it,arenas against said City ALTER OR ADD TO MECILPLUMBING C
Q
m cansuryence of the graining of his permit, FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 100M)CFM) MECHANICAL FEF.
SOURCE REGULATIONS.
/A �.. / �x �eiAe Q . /I�e //- r7a •�S AIR HAND UNIT(O o 0.000 CF CONSTRUCTION TAX
gme reofApplicam/Contmdn Date EXHAUST (W U HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING '(TC1,11th,0111"))
as defined by the Cupertino Munici,ed Code.Chupmr9.12,n,,,],be Health and Su1'vV 199
Code.Sectio 25.132(a)? HEATING 1 IT(OVGR 10UJgf1 BT )
❑Yes ❑NnVENTILA'ION FAN(SINGLIi RESID) I+AID
Date Receipts
Will the applicant or future building occupant use equipment or devices which B011 ER TU ^
emit hazardous air contaminants m defined by the Bay Arca Air Quality Management TOT rV
District? BOILER—COMP(OVER HxkIXOBTU)
❑Yee 7 N
I have read the horrendous materials requirements under Chapter fi95 of the Cali- AIR CON oil IONER ISSUANCE DATE
foods Health&Safety Code,Sections 25505,25533 and 25534.I understand that tithe NEW RESIDENTIAL MECH. SQ.ET.
building does net currently have a tenant,that it is my responsibility to notify the acceptant
of the requirentena which must be met prim to issuance of a Cenifcam of Occupancy.
Owner or antharleed agent Duro TOTAL: ISSUED BY: 9
OFFICE