S 3345 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL 3345
NOERING PROJECT IDENTIFICATION
BUILUINGAUU BSS: t tSANITARY APPLICATION SUBMITTAL DATE7-li--9p HONE: C RACTO NAML: LIC NO:G �� CONTROL#ARCHITECTIE EER: LIC NO: A F.SS:
CONTACT: PHONE: - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) ZSFDWL
ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�aZ with section"IBItJJlpfl i�3nime Bwvmexrpd P�ofgyyppSCpb.andmy Fcenre is � I L:
ia0 kyr _�-f�JC17f`� PERMIT ISSUANCE
F W in full forced
&a W-1 ❑KITCHEN REMODEL
�UU Licen LiaN APPLIANCES-kF,SIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
bo st U e to �Cnmla��a� �.i�
ARCHIIECTSDE AR IO ❑MULTI-UNIT ❑STRUCTURAL
ZFO�z 1 understand my plans shall he used as public records 'f�n` PANELS ODIFICATION
OZ4O - UPTO 200 AMPS E3 INTERIOR /JcnPINEY REPAIR
FsQF l Licensed Professional 201-IOOOAMPS IMPROVEMENT f L]SWIMMING POOLS
"'1 OWNER-BUILDER DECLARATION [I BATH REMODELBEPAIR ❑DEMOLITION
% I hereby affirm that I am exempt from he Contractor's License Law for to OVER I000AMPS
Li�gyS 0 E U following reason.(Section 7031.5,Business and Nofmstons Cadc Any city of..only SIGNS ELECTRICAL ❑OTHER
which y ' apermit I I,alter,improve,dionalads,in mpairmyvudure
1"�O tial I t 'I req 'm.m tint tf hue a fleo.'6 d'r mment SPECIAL CIRCUIT/MISC.
N mmh I tip s n lh p :'i . ImeC vat L I' (Chapder9
� JC) (commencing with Section?000)of Division 3 ofma Business and Professions Code)it HEMP.METER OR POLE INST. COMMERCIAL,
0.y oa that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
XmN
Section 7031.5 by any xGgiom fora pormir subjects the applkanl dna civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W not mom than five hundred dollars($5(111).
IMPROVEMENT
a�d0 �1,vsownerof the progeny,nr my employrev with wages as theirs ole cohmmaotion, SWIMMING POOL ELECTRIC ❑OTHER
will do the work,and that structure is not intended oroffered for sale Fmc."1044,Business
da� and Prnfessions Code:The Convacmr's License Law does not apply to an owner of OUTLETS-SWITCHES-PIX9
iblij
propeay who builds or improves thareom and who doessuchweak himself or through
his awn employee,provided that such improvemems are hot intended or offered Por NEW RESIDF.N I JAL ELECTR S
sale if howevu.Ihe huilding orimprovctnent issold within one year of completion.the '�f EA � fy '�'
ser-huilder will have the burden of proving that he did not build or improve Bottom " U
arsala). JUL 1 2
❑ 1,as owner of the property,am exclusively contracting with beamed enmmctnfs Ice TOTAL: 1999
construct the project(Sec.7044,Business and Professions Code.)The Contractor's Li-
cause Law Jaws nm apply in an owner of property who huilds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts forsach projects wish a eonttaaboubd licensed piamom to the Contractor's pp
License Law. PERMIT ISSUANCE Oy
❑ 1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dote
WORKER'S COMPENSATION DFCLARA'1'ION BACK FLOW PROTECT.DEVICE //PF40 ��
I nearby affirm under penally or perjury ane of me following declarations ^j
❑ [have and will maintain a Certificate of Convent to sell-insurafor Wader's Gsmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the performance of the ^
w far which his permit is issued. FIXTURES-PER TRAP
e and will maintain Workers Compensation Insurance,as required by Section
00 of the labor Code,for the perfnrmt ace ofthe wor
My k far which this d. GAS-EA.SYSTEM-]INC.4 OUTLETS OCGGkOUP APN
Worke rel "y'ydf.�
CurrieryN. CAN-EA.SYSTEM-OVER 4(EA): �F+IIENnLe
CERTIFICATE F EXEMPTION FROM WORKERS' GREASFJINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES _
(Thixsechon need not be completed ifthe Permit is fortune hundreddollam($IW) GREASETRAP
or less) PLANCHRCK FEE
I realty that in the performance aflhe work forwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT
not employ any person In any manner so as m become subject mm,Warkern'Camper- ENERGY PEE
OZ cation Laws of California.Date WATER HEATER WVENIVELECTR GRADING PEE
12 Applicant
I,,, NOTICE TO APPLICAN'L If,after making this Ceaificate of Exemption,you should WATER SYSTIPNVI'SEATING
accurate subject m the Workers Compensation provisions of the LaMar Gude,you most SOILS FEE
Lala forthwith comply with such provisions nr this pemtil,hall be deemedrevoked. WATER SERVICE
Q
CONSTRUC'T'ION LENDING AGENCY NEW RESIDENTIAL PLATE. SQ.t•1'. PAID
Z" Thereby afGmt that mere pa curchniction lending agency for the performance of Date RecaiplN
U� the work for which this pennitra issued(Sea 3097,Civ.C.) -
u' TOTAL:
Lenders Name
U Lcuders Address TOTAL:
BUILDING HE
1 amity thatI have arced this application and state that the above infortion is
N comet.1 as.m comply with all city and county mEmmem and stale laws renting to QTY. MECHANICAL PERMIT FEE
U'7, building construction,and herebyauthoriurepresemmives ofthis city to emanation the SEISMIC FEE
above-mealioned property for inspersion'utpases, PERMIT ISSUANCE
(We)agree to save,'mm
demry and keep harmless the City of Cupertino agaiml ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City AITFRORAUDTOMECU
unsequenceofthumoratingo hisperntil. PLUMBING FEE
APPLICA INDERSTA' AND WILL COMPLY WITH ALL NON-POINT AIR HANDLINGUNIT(TO I0,0J(CFM) MECHANICAL FEE
SOURCE 1
yf/ •7/ AIR HANDLING UNIT(OVER IO,OW CPM) CONSTRUCTION TAX
jgfWure of Applici Conttar Dam EXHAUST HOOD(WIDUCC) HOUSING MITIGATION FEE
HAZAR OUS MATERIALS DISCLOSURE
Will he oEdicnm or fare huildingcwcupint store or handle araneus matuiil HEATING ON IT"TO I00,000 BTU)
m defined by the Cupmtino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532a)? HEATING UNIT(OVER 1(10.000 BTU)
[D Yes o VENTILATION FAN(SINGLE RESID) PAID Dote Rereiptk
_ Will the untilroad nr uture building occupant use equipment nr devices which Bfq BTU - n
I hanuNous air comemi a is u: entad by the Bny Aran Air Quality Management BOILER-COMP(3HPOR KB ) TOTAL'. /
District' BOILER-COMP(OVER I WENT)BTO)
❑Yes n
i have read aha hm, lous imtlerials requirements under Chapter fi 95 of mo Cali- AIR CONDITIONER ISSUANCE DATE
furore Henit afcty C de,Section 5505,25533 and 25534.1 understand tbm if the NEW RESIDENTIAL MECH. SQ.PT.
M1uildin trendy hove mal.that it is my mspansibility to t{�otiry th eupam
rot lh dor to isc ofaC� fa
i
O er rat o ems Dte TOTAL ISSUED BY:
OFFICE