S 3897 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPER'PINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONWERMITPLUMBING-MEC{TANICAL - S 3897
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION S U BMITTAL DATE
70290 FsfQ4LCdnrE Df,,, CuPG�eTi.�o� C.A �7sD/Sc /'y ^ -3 Cc
s
sO NER'S NAME: PHON}: CONTRACTOR'S NAME: LIC NO:
1v7,Pat Ast 9-S H[-1%1,&A6AVACc/' ViS"ArtagY NIC CONTROL#
qW ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: / PHONE - BUILDING PERMIT INFO
(//CL{AJ O 6j—�30S ❑ Con5u1Wn1 Fees Paid by Applicant(Initial) BLDG ELECT PLUMq_ MEN
LICF.NSIiDCONTRAC OR'S I)F.C1.ARATION QTY ELECTRIC PERMIT FEE zWrJ✓ L9
1 heresy alarm that I m++licensed undar prnvi.aors of chapter v(eommendng JOB DESCRIPTION
Ca7� with Section](KKpofDlvislon9nf the Business and lknfesslone Code.and my license is
WCO PERMIT ISSUANCE 3 RESIDENTIAL:
infullforceandcRmt.
0SFDWL 2hnrZHEN REMODEL
QUO Lmeme Class 1.ic.# APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
h Q W Date Contraere
ARCHITECTS DECLARATION []MULTI-UNIT ❑STRUCTURAL
OZ I to detsmnd my plans shall he used re lmblic rivulets MODIFICATION
UTT0200 AMPS MODIFICATION
1=�F-M ❑
LsenseJ Professional INTERIOR ❑CHIMNEY REPAIR
5p 201-100 AM1I PS IMPROVEMENT E]SWIMMING POOLS
y�-! OWNER-BUILDERDECLARATIONCIARATION OVER 1000 AMPS C BATH REMODEIIREPAIR [_I DEMOLITION
yy Q 1 nanny affirm that I am exempt s an the Contractor's License Law for the El OTHER _..y
Dd 3 d U following iresm.(Semon 7031.5,Business and Professions 1r,o Any shy or county SIGNS ELECTRICAL w +a C
II�A1 4 which regoi of a perms re conxwd,alto,improve,for such
demolish.or repair any swemre
,F.t� priottehsissuance,also regains the poorNme,of far Contractor's
orile a cense Lw(Chamcm SPECIAL CIRCUIT/ ( G
mn +hat he is licensed pursuanuotM1e provisions of the Cnmrucmr's License Law(Chapter
Iu�CO (commencing with Section]001)of Division 3 of the Business and Professions Cartel or TEMP.METER UK ST COMMERCIAL:
a a e K that he is exempt Nerefmm and the basis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
--y
Section 703).5 by any applicant for a era iisubjects the applicant to o civil penalty of POWER DEVICES
FX}
net are than five hundred doll ($500),
❑TENANT ❑FOODSERVICE
M 01,as owner of the property,or illy employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work.and the srumurc is nm imcndW or nlTemd fossalc(Sw.]fN4.Bosinnss 'y COTTER
W�' and Professions Code:The Contractors License Low dues not apply m an owner of /, OUTLETS-SWITCHES-FIXTURES
B'3 property who builds or impmvm thcreun,and who does such xork himself or through L toward, /',
his own employees,provided thin such imprms
nveemare not intended or offered for NEW RESIDENTIAL ELECfR SQ FT. ppp���
sale.Iwevec the Wildingurimprom
veem is sold sidualsi,yerndrimplelion,the 1Q. 1.FLOOR AREA $1
-builder will have the iamden of that he did not build nr improve `�
prmving p+usefmpur �r JUN 0319 9
E
ale.). T TAL
as owner of the progeny,um exclusively contracting with licensed contractors m f
construct the pmjcct(Sec.704,1,Business and Profusions Code:)The Comwnor's Li- f
ase Law,does not apply,.an mw net of properly who builds or improves thereon.and QTY. PLUMBING PERMIT FEE V
who Contrails for such projects with a contmcmrad licensed pursuanno the Contractor's
License Law. PF.RMII'ISSUANCE O �y
❑ I.am exmvpt Under Sea. R&I'C for this reason
ALTER-DRAIN&VEMT-WATER(BA)
Own - n,- T <C VALUATION
WORKER'SCOMPENATIONDECLARATION� BACK FLOW PROTECT.DEVICE
I hereby affirm under penahy of perjury one of the following declazotionz: C/ V
sC three and will andialnaCenificmeofConsen,.self-irmze for Wwier's Co.,.- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTgUCTION
cation, provided for by Section 3]00 of the l.uhur Cwle,for the performance oldie
work far
which this permit is issued. ! FIX TURES-PER TRAP 0N/
C 1 have and will ovid,for
Worker's ante of the w Insurance, h required by Section
MyWnke'sC. 'roatior thePerformance
cruaofihework for whichthis permit is issued. GAS-GA.SYSTEM-I INC.l OUTLETS C.GROUN APN
MyW'otkers Compensation Insurance carierand Policy number art: 3 3`? 70
Gartree Policy No.: GAS-EA.SYSTEM-OVER!(EA) O
CERTIFICCO MPE EXEMPTION ION FROM WORKERS' GRFASIVINDUSTRL WAS IT INTERCEPTOR
COMPENSATION he
INSURANCE BUILDING DIVISION FEES
(this section need not he completed ifihepm+it is[ornne hundred dollars($IIID) GREASE TRAP
or less.) PLANCHECK FEE
Imnify that the cryreaance of rder1.ls1.ork becoorwhich this Perthe il Walker,'
Cor shall SEWER-SANITARY-STORM EA.200 FT.
not employ any perxnn in any manner so as m haome subject m the Workers'Compen- ENERGY FEE
,Z cation laws of Calif orris.Date
7� WATER 11EATER NNFNT/F.LECTR
O Applicant GRADING FEE
a fA NOTICE TO APPLICANT'.If,alter making this Certificate of Exen+ption,you should WATER SYSTEM/TREATING
C7 become subject to the Workers Compensation previsions of the Labor Cale,you must SOILS FEE '\
foMwiN comply with such previsions or this permit shell be dumeJ revoked. WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
LJp work for
thanhercisa.cd(Secconstruction lendis.agency for the per[ormancenf m Receipt If
U.OF thework farwhichthispermit's issue)(Sac.3097,Civ.C.) TOTAL:
Q U Lenders Name
Lenders Address TOTAL:
Imnify that 1 have read this application and ate that the eM+ve information i. BUIL FEE
Fol correct.I agree mcomPly with all City and county ordinances and state laws rebating v+ QT'Y. MECHANICAL PERMIT I FEE
building construction.and hereby authorize represanatives ofthiscity to cmerupun the SEISMt FEE
alae-mentioned property for inspcnion purposes.
(We)agree te save,indemnify send keep harmless the City of Cupertino against PERMIT ISSUANCE. ELE RIC reE
liabilities,judgmems.costs and expenses which may in anywayaceme against said City ALTER OR ADD TO MECH. PLUM NG FEE 0
in cunuquence of Bre granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM)SOU�C^E REGULATIONS. MECHA CAL FEE
V' AIR HANDLING UNIT(OVER 10,(MCFM) CONSTRUCTION TAX
Signature at ApplicanalContracmr .. Date EXHAUST IIOODDYMUCT) HOUSING MITIGATION FEEHAZARDO S MATERIALS DISCLOSURE
Will the applicant or future building wcupam atom orhandle hazallous material HEATING UNIT(TO IBB,BW BIL)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 255320)] HEATING UNIT(OVER 100.01))BTU)
❑Yes 0 N
�7 VENTILATION PAN(SINGLE RESID) PATO -
'
Will the applicant or future building occupant use equipmentData Receipt It
or devices which BOILER-COMP OHP OR 100,010 BTU)
.mit hazaNouz air conmminann as dcfinM by thehe Bay Area Air Quality Management TAL:
J Uumct]
L]Ves FIN. BOILER-COMP(OVER 100.001)BTU)
1 have read the hamNous rdern lls requirements under Chapter 6.05 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Heahh&Safety Code.Sections 25505,25533 and 25534.1 rudimental Not it the NEW RESIDENTIAL MECH. SQ.PT.
building does not curteady have a tenant,But it is my responsibility In notify the occupant
of theremcnn yNch must he met paw m' e f a Cenifiwm Uf c _�t
Ow r rutrouts.agate 0 ate TOTAL: ISSUED BY: Y
OFFICE
r �
ADDITIONAL PERMIT FEES
BU I LDINO PROJECT IDENTIFICATION J-(- VALUATION
RDO HA. HE
n°°ne n
awN R's 2
NAME
FEE SUMMARY
PHONE
NAIVE""CTOP s BUILDING
UC NO PLAN CHECK
CONTRACTOR S FEE
ADORE"
PHONE SEISMIC FEE
CITY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC 'L ZCIN
LIGHTING FIXTURES
PLUMBING
PPLIANCES-RESIDENTIAL
PANELS MECHANICAL
SIGNS
SIGNSTRANS. TOTAL 2-0
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VAUDATION
MOTORS SEE FEE SCH.
c SERVICE CHANGE
Z
F: ° TOTAL
CC ISSUANCE DATE
Lu > OTV. PLUMBING PERMIT FEE °L04 ELECT, PLG. MECN.
z ALTER-DRAIN&VENT-WATER(EA.)
V O BACKFLOW PROTECT.DEVICE
C w DRAINS-FLOOR,ROOF,AREA,COND.
} N FIXTURES-PER TRAP
f- z GAS-EA,SYSTEM-i INC.40UTLETS
() GAS-EA.SYSTEM-OVER 4(EA.)
INDUSTRIAL WASTE INTER.
LAWN SPRINKLERS-1 INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.2001t/
WATER HEATER W/VENT
WATER SYSTEM
WATER TREATING EQUIP.
TQT
OTY. MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
_ APPLIANCE
AIR HANDLING UNIT(TO 10,000C F M.)
AIR HANDLING UNIT IOVER 10,000C.FM.)
EXHAUST HOOD(WITH DUCTI
HEATING UNIT(TO 100,000 B.T.U.)
HEATING UNIT(OVER 100,000 B.TU,)
VENTILATION FAN(SINGLE)
_ BOILER-CDMP(3 H.P.or 700,000 B.T.U.)
BOILER-COMP Inrr,100,001)STU)SEE FEE SCH.
TOTAL