S 3222 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON'CUPERTINOBUILDING.-ELECrRICA]. PE�TT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
3222
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI'1'I'AL DATE
-1596 b— 44 '04e. No 0 5a/ /.—
OWNER'SNAMI3: /!,61� � PIIONB, CONORACf011'y AM .IC
4. IY_I/ IC CON9ROLM
fAIiCHITE(T/LNGINEIiR: LICNO ADDRESS:
CONTACT: PHONE: 'BUILDING PERMIT INFO
❑ LEC
LD
Consultant Fees Paid by Applicant(Initial) BG ET' PLUM MGCH
a- 3-ao�a E:1 El ❑
LICENSED CONTRACTOR'S DE LARA11ONf
ya powi,io p k QTY. ELECTRIC PERMIT FEE
I hcrcn IEnn dmf pans licensed under ns nfcna Coupon, fcotnmencin. JOB DESCRIPTION
"Z with Section7lMXBorDivixionJnf tic Business end Pmfessionz cafe.anJm licenm is RESIDENTIAL
a00 I'IiRMTI'ISSUANCIi ❑SFDWL ❑KD'CHEN REMODEL
�F i11 ntll rarer and CR !� /
¢F.UU Liccnxe Lic.K APPLIANCES-RESIDENTIAL ❑ADDITION C3 PLUMBING RE-PIPE
NG Zai Date CSDECn
RCI 111 DF,CL 1'I ❑MUl:fl-UNIT ❑STRUCTURAL
(.,O m I'AKELS MODIFICATION
Z O N Z 1 understand my Plans snag be u.ved as public rcroMs /
O Z,n.! O UPTOIIIBAMPS ❑INTERIOR [_1 CHIMNEY REPAIR
(-4 ".W L'mcnsed Prol'e,onnel 101-1011AMPS IMPROVEMENT SWIMMING FOOLS
'1
OWNER-RUILDER DECLARATION
.a.I I hereby affirm thin 111111 exempt from the Comracum's License Low for the OVER IOW AMPS ❑BATH REMODHI./REPAIR DEMOLITION
iqS O a`+ following reason.(Section 703 1.5.Business and Profnsiun.CINe:Any city or county SIGNS ELECTRICAL ❑OTHER
s+r 3 a.I- which re imor,a permit ,,construct,alter,improve,dcmolisn,or ii any amcmfc
priorm it,"I tarme.iilsorcquires lheupplicalm forsmh permit n filennlg11es10ammea SPECIAL CIRCUIT/MISC.
that he islicensed pursuant to the provisions oflne Comucmrs Uicenu law(Chapmrt)
1+I�00 (commeneing Ivan Section 9Wo)of Division 3 of the Ru.mess 11nd Professions code)or 'ITMP.ME'I'Ell OR POLE INISF. L:COMMERCIA
d X m C that he is exempt nerefmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 70315 by any applicant for a penmt.mpjectn the appliaam ma civil satisfy of POWER DEVICES ❑TENANT ❑FOOD SERVICE
over th:m Bve hundmd dollars($500).
IMPROVEMENT
Q E]Laso,work,the pm pertcome,,no,
treffe esas their sale comp ensation, SWIMMING POOL ELECTRIC
will doth slime,end the he Contractor's
la tot imcndM or Law
doscl not
apply 7044,weerIn of ❑ 1111 ' f
63 enJerty who ns Code:The Comrocrva Licemelaw Jcesnotapplytolf owner of OUTLET$-SWITCHES-FIXTORES
his own who builds or..Orales nsuch i and who docs such work himself on Ihmngh
his own however
the building than such mentis sol w arc nil intended or placed for NIiW RIiSIDEN'TIAp.IiLECTR- 5Q FI'.
sale.If.M1uweveq the building or improvement is sold within one year of completion,the SQ.FI'.FLOOR AREA 4/SQ.FT.
owner-builAcr will have the huNen of proving Ihm he did not build in flatfoot,for pun-
pose of salad.
1,as owner of the property,am exclusively contracting with licensed contractors m TOTAL:
Colon eel the project(See.7194,Husineiis and precisions Cale:)Tho Cannt¢Inr's 1,I.
cense law dMa nen apply m an owner of pmpeny his build,,,,improves thereon.and Q'T'Y. PLUMBING PER. FEE _
who cnnoans forslmh projects wimh a comrac,on,o Iicenwil punumt to tic Conlmmer'e
License taw. I'IiRMITISSUANCE
ElI am exempt under Sec. ,R&P C roc this..",a
Owner Date ALTER-DRAIN&VENT-WATER(EA) /j VALUATION '
WORKHR'S COMPENSATION DECLARATION RACK FLOW PROTECT'.DEVICE r7A �O
I hereby oflirm under penalty of perjury ane of the following declarations / 1/s
❑I have and will maintain a Certificate ofConsenuo self-mom for W'orker's Com DRAINS-FLOOR,ROOF,AREA, ND. Sri'(RIES 'I'YPEL'ONSO'RUCinal
aaliotr,as provided for by Section 9701 of the LahorC'ele,for the penfommnce of the
k for which this permit is issued. FIKFURES-PER TRAP
hove and will maintain Worker's Compensonkm Insurance,as rad ired by Seeion
.7011 of the labor Code.Ibn tNhe1 pcirI rmance of the work for w rich lis pemJl is issyuI CAG-EA SYSTEM A SYS I LM I INC.
C.G[(FA) pCC.GROUP APN
My workpl:Fq„ypgfgtlo/R e c crier and Policy /+ S
Carrier IS1wYY1[L.GG�IVV Yi rnliny Nn.:
CCR I'IFICA'I'E 017 EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIIINDUS'TRL WASTE INTERCEPH)It
BUILDING DIVISION FEES
(This section need urn bit completaliDhe permit is for one hundred dollars($1011 GREASE TRAP
err less) LANCHCCK IT!E
[cantly lhit in'he lanfonmancent lie wnrkfawlechdo,pern.to it issued,I shill SEWER-SANITARY-STORM EA.21k)FT.
not employ any person in any marine' oil,y>, �nn the Workers'Co.,.- IiNERGY HE
z ,Z, sation lawyer Ca fa )ere 11 WA'ITR IWATER W/VIiN'1'IEhIiC'I'li
Appli.m )I-n7 I - GRADING FEE
V) NOTICE TO APPLICANT:IL after making IN,Certificate of ExemPhon,you should WATER SYST iM/IREATING
a becrmm subject to the Workers Cod urce-lmsh
n pnrviovor
s ae Labor
Coda,you moll — SOILS H
7 E
W ronhwith comply with such provisions orthis permit shall he deemed invoked. WATER SERVICE
�. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.F'1'. PAID
U Ihcrewhich thi thonherei.wued(See,30 len ding agency ronM perfnmmnm of Dae ReceiplM
w the alI vonkfor which this permit is issued f$w.3097,Civ.C.)
Lenders NameTOTAL:
Wlenders Address 'LUTA L:
I cedify that have mod this application and sesta the,the above iofnrmount in BUILDING PF,Ii
M
correct.l agree to comply with all city and county ordinances andsae laws rdmingm QTY. MECIIANICALPERMIT ITE
U z building annsWginn,oma hcrcny innnoriee reprccmmives of,hix city mo entemm�n theI ISEISMICFER
shove-mentioned property for inspection pmgwes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep hamdesa the City of Cupertino against ELECTRIC PER
Ii11nilhics.judgnlenl. m'ardlexpenses which nmy In any way acerae against said City gla'CR OR ADD TO MECH.
in consequenceo grand el This permit. PLUMBING FEE
APPLICANT DER ND AND LL CO PLWITH ALL NON.POINO'
S N AIR HANDLING UNITOO IlI1X1(1 CPM7 MEClIANICALIEE
SOUHC� Ln7 S
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
HAZARDOUS MATERIALS DISCLOSURE
b t App Ume EXHAUST HOOD(W/DUC) HOUSING AID GATION ME
ROhandl
c, Willthe C applicantor future building e.Chapter
r 9.12,handle hmoNe and Safety HEATING UNIT(TO 101,IIBU H'1'U7
as defined by the Cupertino Municipal Code.Chapmr Y.11,and eche I Icalth and Safety
Code,Seclinn 15531(11)4 HHA'TING UNIT'(OVER IIp,gNI RTU)
❑Yee QNo PAID
VF.NTILA'T]ON FAN(SINGLE RESIDE Dec Receipt p
Will the applicant or future building claimed use equipment or devices which BOILER (JHP OR Igl,(IW BTU)
mit M1azardou.v air rnntaminen¢s.anrd by the Bay Area Air Quality Management TOO
C]yo, Na '
❑isvicm) ;No BOILER-COMP(OVER IOLNXI BTU)
r
AIR CONDITIONER
I have reel the M1v::Nous mal• 'rnnenus under Chapter Q95 of the Cali- ISSUANCE DATE
Timis Health&Safety, c,5 15 533 and 155311 ender old thus if tie NEW RESIDENTIAL MACH. SQ.IT
hndding doer. , have Ictmn6, na mY resptnnihililymnotify the anvpom -
m ? LLL
of are mil Id1 mu. he me missuanceofacl cat 'O cu
Owner m<d agent Date TOTAL: ISSUED BY: I v
FFICE