S 3378 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.Ei.ECTRICAL Pfitrr NO 3378
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL
BUILDING PROJDCT BEEN'1'IF'ICA'1'ION BUILDING ADDRESS: SANITARY NO. AI'I'hICA'I'ION SUBMITTAL DATE
OWNERS NAMIi: ^� I'llON CO CIOR'S NAM&' ��µ� LIC NO: NIC CONTROL Of
1 7� V
ZI
AkCHI IECT/F.NGINLEK: I.IC NO: ADDRESS:I J ❑
402T7 5'' 6W4 i
CONTACT: PHONE: BUILDING PERMIT INFO
: ❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
I -obi ❑ ❑ C---❑
L[C17.N SEDCONfRAC'I'OR'S DFCLARAI'ION - QTY ELIiCPRIC PERMIT PEE
I hereby affirm that I am licensed under provisions of Chapter 9lanmmcncing JOB DESCRIPTION
OCy with Scnion]000 nfUivision9oCthc ltnsinessand l'mfessinnx Cade,and nrylicenwis - RESIDENTIAL,
OW O p 1'ENMI'T ISSUANCIi
in lid,lora unJ effat. DSPDWL ❑KITCHEN REMODEL
aU License Clens LiCA APPLIANCIS.RESIDENTIAL DADDI'TION B4hBF6R`LG RE-PIPIT
07yL Dam Comnclor
¢R y ARCHITECTS DECLARATION PANELS ❑MUFTI-UNIT ❑STRUCTURAL
Ftp I mrdersumd my shall In used us public recomix MODIFICATION
OZ— UP YP plans pct UP T020B AMPS
❑INTERIOR ❑CHIMNEY REPAIR
F N„FW Licensed Professional 201-1000AMPS IMPROVEMENT DSWIMMING POOLS
OWNER-BUILDER DECLARATION OVI7R 10N0AMPS - 'D HATH REMODEUREPAIR L1 DEMOLITION
tY 6 I hereby of ori Ihm 1 am exempt from the Cmdracmrs License Law mount,
�d Oa U following hinu n.(Scown 703 1.5,Business and Pr^ressinns Code:Any city o,wanly SIGNS EL17C'I'BICAL El OTHER
1+131+,N which requires a permit to construct,alter,improve,demolish,or repair tiny structure
CIC"1�'1O1nn� prinnoilpermit oi...aspecdo requires theapplicant forsuch permiopic a signed statement SPECIAL CIRCUIT/MISC,
A y that he is licensed pursuant the prockinmironhe Contmemr's License Law(Chapmr9
^�� (commencing wish Sectinn]0p)of Division 3nf me Rusinws and lhnfessions Crwle)or TEMIIMETERORPOLEINST. COMMERCIAL
dy m Units,is csampt thercfmm and line buxis for the alleged exemption.Any violation of D NEW BLDG/ADDITION D DEMOLITION
% Section 703 IS by onyopplieovt fora furronsubjems the apph.to11,ac,,it penalty of POWER DEVICES CTENANT El FOOD SERVICE
�Yw mmnmm than five hundlcddelMrs(5500). IMPROVIiM1iNT'
t E] 1.as owner of the properly,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC DOTFIER
p. will do the wmkans
dum uture is not imendedoroffered a
for sale(SJ(W1.Business
µj3 and Prat"eWor,Cote:The Counn,moicedais m
r's License Law not r,], sn owner of OUTLETS-SWITCHES-FIXTURES
S popmy who builds or improves thereon,and who dos tach work himself nr through
his an employees,provided that such Improvements ma nut intended or offered for NEW RESIDENTIAL,ELECTN SQ Cr
sale ll:however,the building or impmvcmem lx xvld within on<ywr nfamoflento the SQ.IT.FLOOR AREA 5/SQ.FC
tar-builder will have the burden of proving that he did not build or improve for pur-
pose of sole.).
D1,as owner of the property,am exclusively contracting with licensed cunnacton to TOTAL:
Construct the project(See.7044,Budness and Profession,CodCO The C.nnnam,'s Li-
Cem6Lawdoesnun apply to an ownerol'property who builds or improves mereo^,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a Contractor s)licensed pursuant o the Contractors
Lion+,law. PLRMI'IISSUANCE
❑ I am eaemPl under SIC .B&PC fits this Cession
ALTER-DRAIN&VENT-WA'I'US(BA) VALUATION
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby off rm under penally of perjury one of the fullewing declarations:
❑ I have and will maintain aCeniBcate of Consenttoself-insure for Worker's Compcn- DRAINS-FLOOR.ROOF ARE A,GOND' ST RS 'TYPE CONSTRUCTION
,miun,as providarl for by Section 37(X)of the Laren Code,In,the perfunn:me,of the
work for whichthis permit is issued a FIXTURES-PER[RAP �•
❑ 1 have and will maintain Workers Compensation Insurance,ac required by Section
3700ol fin L.bor Code,linthe pcifonnanaeol'ihc work forwh,,h thispermit is Maned. GAS-LA.SYS'CEM ANCA OU'I'LEfS " OCC. ' APN
My Wo 91'C p sat n+. ince ca,br vnd Policy n r�1 2 1
Carrie CI:RTIF .ATE OP EXIT IONy FROM n"opCa/ GAS-EA.SYSTEMGVHR 4 HIM �.W (R
COMPENSATION INSURANCE GREASUINDUST RL WASTE INTERCEPTOR Itl11LDINC DI VI'ION FEES
This section need not M cvampleled it permit is for ane hundred dol hors(51(10) OREASETRAP
or lets.) `1 PWNCItI!C
I coni ly J,,o imine gcrounia a of the work rnr which this wori n in i.ened,In hal I SEWER-SANITARY-STORM ITA,200 FT. I
not employ any Person in any manner so as to become subject to the Wnrkcrd Compen- IiRGY PER
OZ radonwLe ..of California.Dune WA'I'I!R HLA'1'I!R W/VENT/F[.F.CI'It GRADING PEE
Z 2 Applies.,
y N0110ETO APPLICANT:If,after making this Cenifieme of Exemption,you should WATER SYSTEMUREATING
F be,, nest,b]al In nine Workers Compenwbon prvlai0ns..i he Lebo,Code,ran naso SOILS FEE
r forthwith comply with such provisions or this permit+hall bedeemcd revoked. WATER SERVICE
Q
CONSTRUCTION LENDINGAGENCY NEW RIiSIDI!NTIAI.PLMB. SQ.NI'. PAID
U Z at RccciplM
V lfr loch hisonherc isocom ce.30[ending agency for the performance of
'he work for which nhix penult is ixwul ISea 3007,Clv.CJ
v" Isnder's Nene TOTAL:
L) Lenders Address TO 1
L.t I certify that 1 have read mis application and situ mm the above information iBUILDIN('F
s
h enrrcm.l agree mormply with all city and county oNinanwv unit sem laws relating m QTY. MIiCBANICAI.PERMIT FIiF
building coratrudimy sail hereby author Ge representatives of mlxcily to enlarupauho - SEISMIC
above-mentioned progeny for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and kap homdeos the City of Cupertino agninst ELHCI'RIC HE
liabilities.judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD'I'0 MECH.
m consequence Ofine gninfr,of this penal.to SER f
APPLICAN'I'UNLESS'I'ANDS AND WILL COM I'LY W IT[]ALL NON-POINT AIR HANDLING UNI'1'(TO 10.000 CFM) MECHANICAkrEE
SOURCE REGULATIONS.
AIR HANDLING ON['T(OVER 10.000 CITM) CONSTRUCTION TAX
Signmutn of ApplicanUContne., Done EXHAUSTHOOD IW/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MAE ERIA1 S DISCLOSURE
Will the applicem or future building occupant more or handle hazallous malerial IIEATING UNIT(TO 100,00)BUD
as dinned by,ho Copenlno Mon oiled Code,Chapter 9.12,and the I Iwl nh unit Softly
Coda Section 25532(x)^ IIHATING UNIT(OVER 101,0010 RTU)
El Yr, E]No VENTILATION PAN(SINGLE RESI D) PAID '
• .Date Receipt If .
Will the air 111(m or fmlarc building occupant use equipment or device which.
corn District? e`is sur wm,nnnneO Ns ddinedh nine Ba Arco Air Quality Mnnagemcnl HOlhlili-CDMP(311P OIt IIX1,00ui{TII) .
Y Y TOYA L:
El
1{OILER-COMP(OVER 100,000 BTU) -
AIR CONDITIONER
I have report tine havallous rhalerials nquimme.0 tinder Chapter 6.95 of,he Cali- ISSUANCr-DATE
[coni^HC.1,h&Sm C,y C I Sec'nu 25505,25533 it 25534.1 understand ohm if the NI!W RESIDENTIAL MF.CI I. SQ.EL
huilAing doe cu Oy ha amJhm it i.v my mMnihiliD mnudfy line ocwpam ` (_ Z (
yui' hiG c n nonssuana aCcniOwm of Ocyptpvney.
^r0
nzcJ
Date TOTAL: ISSUED BY:
OFFICE