S 3238 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-EL.ECI'RICAL Flat[I NO.
BUILDING DIVISION APPLICATIONWERMITPLUMBING-MECHANICAL 3238
BUILDING PROJECTIDENTIFTCA'I'[ON
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL,DATE
0 04C r. -t-OK 'IiR'S NA"B" •• i• ��'� Nli: CONTRACT I'OR'S NA B YI G• LIC NU:
FEE CONTROL#
Lae
�ARCIII'IT:CT/P.NGINIi•R: LICNO: ADDRESS: �""1u �,,�- gyp, ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLUG ELECT PLUMB MECH
A"61 CA 50 El1:1 ❑
LICENSED CONTR, OR;S iCLARNTION J QTY ELECPR IC PERM I I°EE
1 hereby affirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
al' Z with gradient IIpt)af Division 3o1lhe Budrue, od Ponswinns Csde.andmylicervcis RESIDENTIAL:
nI O p
faN—�Q—6 iUatee CnntmePERMISSUANCE
fllfrccf
❑SFDWL ❑KITCHENREMODEL
la .pncut APPLIANCES—RESIDENTLLL ❑ADDITION ❑PLUMBING RF-PIPEVU L
ARCIII'I ECPS DECIARATION ❑bluun-UNIT El STRUCTURAL
F h Z_ I understand m plans shall be least an public record. PANELS MODIFICATION'
OZN y pu UP TO 200 AMPS
ICL] Licensed Professional ❑INTERIOR [:I CHIMNEY REPAIR
aye" OWNIiR-Pl11LDIiR DECLARATION 201-IOOOAMPS IMPROVEMENT E]SWIMMING POOLS
C x Q I hereby affirm that I am eaetnpl from the Comracmr's License Law for the OVER 1000 AMPS ❑ TO REMODEDREI' IR ❑DEMO[ TI N
3 F following rea.on.(Setlon]131.5.Business and Profession,Cade:A,dory or enemy SIGNS ELECTRICAL OTHER �.. Jn�1,un.Ln
y which requires a Permit to nmseua,alter,improve,demolish or repair any structure _CP A'�gn-eyfF r
U.C) priorto its issuance,also requires the applicant larsuch priminn file a signed statement SPBCIALCIRCUIT/MISC.
In.,he islicensed p :u a the provisions al the Contractor License I' (Chapter9
` CCC�O (wm g 'INS v 900)of sir l ftM1 Business dProfessions Code)or TEMP.METER OR POLO I NS'f. COMMERCIAL:
y c C
he,he is esenme herthord aell the thavi,For thealfir,rd rsedrion.Any oolvio.of ❑NEW BLDG/ADDITION ❑DEMOLITION
kmto Scri 1 703I5by y PPI ll I Permi,subjects thet 1pm,li,of POWER DEVICES
W m TI:NANI C:1 FOOD SERVICE
nt mere than Ise hundred dollars($5 0).
FZY IM OVIWEN't
�ZQC ❑ fm t 1 rtY Y ply n .mS' f n, SWIMMING 1001.ELECTRIC
will do OM1 k ITh .I t' t J Ine
f Ie f a (S ]fW4,Business- LER
1i13� and Profession,Cotta I'heC n reruns License law dee, to apply esu-net ill OUTLET'S—SWI'CCHES HI%'IURCS
CC properly who huidds o nlpro r ficr nd who dov, ed,work hie OR or mraugh
I. own cntplayce,.Presided the such ilnplvwcmmas ale not intended or offered for NEW RESIDENTIAL.ELEC'1'R SQ Fir
Bald.IL howevea the hnilding or all owm..re, —old within oncycurofcontpleaion,Int, SQ.IT FLOOR AREA sold T.
pocrhuilder will have the harden of proving That he did not hudd er imp mwe for Poo-
se of
❑ 1,as tosider
of the property,a exclwisely eontrar'ting with licensed era
odcmis m 'RYl'AL:
rnHm f thepmjel(See 7014,Iio,Inee,..,it Frefd,sion,Colld)'Fte Cotta.......Li-
,.,d Law does not aPPlYm ano,sner of property who builds or...vooveatheeme.and QTY. PLUMBING PERMIT FLEE
who ame:eta far such projects with a,manacte(al licensed Pat...lo m the Contractors
License La, PERMIT ISSUANCE
❑I am exempt under See. ,B&P C for this reams
Owner DateALTER—DRAIN&VENT—WATER HRA) VALUATION
WOH COPDECLARATION uBACK FLOW PROTECTDFVICIi C
1 hereby afrat add,pcnl,.1perBryoneofhe following Jcdurtion.: •
�❑ l heveend willmainminaCenihdatc of Can¢nnoselGinsure for Wmker',Cmn,m- DRAINS—FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
tion,as provided fill by Section 3700 of the Latin Cited.fertile m
e perfnradev of the
for which this permit is issued. FIXTURES—PER TRAP
ave
and will maintain Worker's Compensation m ensation Insurance, required by Station
3]W lbs lrb,rGde.(nnhc pdr(onnmme al the worA for wM1ich lhrs permit .issued GAS—EA.SYSTEM-I INCAOUTLETS OCC.GROUP ANN
My Work pJ�rppcc9�, J Policy nyW�e�pr
Camra NR �r policy No.:VIJ�k'IA/o I OV GAS—F.A.SYSTR\LOVER i(EA)
CEGFIFICAT'E(lit EXEMPT]ON FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE:INTERCEPTOR
(This vection need not he completed tithe permit is Room,hundred dollars(51orI BUILDING DIVISION FEES
or less) GREASETRAP PLANCHECK PER
Loy anythatinthe anyfor nce former so
the work toneWhich this thePermitWroluds'C,lshe0 SEWER—SANITARY—STORM EA.20117.
i not employ any person in any mannermusmbecome subject to Worken'Campen- ENERGY PF:E
z scion Law,of Culibmali.Date
WATER HF.A'IER WNENT
z� Applicant GRADING GRADING LORE
ZI NOTICE TO APPLICAT:If,after making this C,dinicea of E,emplion,you ahnnld WATER SYSTEM/IREATING
a > became aobject Io the Woked Compe.,alion pro,kiu is of the Labor Cele,you mea SOILS PEE
fathw'inc,orady wimsuch pro,kima nr his p marif shall M Jeered revoked WATER SERVICE
CL
oz CONS'TRUCI'[ON LENDING AG17NCY NEW RESIDENTIAL PLMB. SO.IT. PAID
V O 1 hereby affirm that here is a c ndraction lending agency for the pcdnmmnce of Dead Rear IX
Fbework for which this ismoI,ia,awd(Sce.3(97,Civ.C.)
V Lender's Name
W Lender's Address - TOTA
F0. I emit,nuts I best,mad miv apphrel a;told d ae Ohm dm ubrvt,informtnien i, Itll 1 G FE1:
fn cometh.I after m cmnply ohall city i i,amay nr.hnuneu,Bad sate laws relating es QT'Y. MECHANICAL PERMIT FEE, - J
U z building com%anction,and hereby lumnriac rcprcnenhrlivca of this citymdnldr ulmn the SP. ;EBF
choset d m ip:ly f P I p T PERMIT ISSUANCE, (I
(W) b I slvol dy iIl I I.:0 City fC lar ging E ,,11lICIFF n J
hahilt ,f Ig Ise I 't Ivspur, whd nay to ally way acnuutg rstsall City AL'1'BR OR ADD TO ML'CIL
in,nuvqucnoc the gr' 'ngot Ill, t. I MING FI?I?
API'LICAN'1' ,NDE I' ND' WI WI'f11 ALL NON-POINT AIR HANDLING UNIT(1'O If),1101 CIrM)
I
SOURCE, ',ULA' -':
AIR HANDLING UNIT(OVER Hk0X1 CPM) CONSI'RUC'IION TA%
S.,atereol'ApplieuNCoolve^r Date EXHAUST HOLD(W/DUC'1) HOUSING,MI'GCATION FEE
Wilhite
MA'I'17RIALS'DISCLOSURE
Willite applicant....move building we am,tom of handle h...Neus material HEATING UNIT(TO I W,000 BTO)
.is defined by the Cupertino Municipal Cof Chapter 9.12,and the Health and Safety
Coda.Section 25532(a)'I HEATING UNIT(OVER 10k010 BTU)
E]Yes No
VENTILATION FAN(SINGLE RESHH PAID Do,. Reddy,X
emit h....Will the applicant or future brilding occupant use equipment or devices which
dous air conmmiwms as defined by me Buy Area Air Quality Management BOILER—COMP OHP OR 101.0X1 BTU) O
Ui,vim0 Yes ON. BOILER—COMP(OVER 100.010 BTU) AI
Iha%e read the byurdous nmfoials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomes Health&Safe,Cele,Seliom 25505.25533 and 255.1.1 understand Him if the NEW RESIDENTIAL MECH9
/Q
. SO.rE � ,-
building docs not currently have a tenant,that it is my reporsaddiny m notify the rcapam Z- 7
of the requifemems which roust be met prier m issuance of a Certificate of Occupancy.
Owner or authomcd agent Date TOTAL: ISSUED BY:
OFFICE