S 3216 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY -
CITYOFCUPERTINO BUILDING-ELECTRICAL PEµ(�11IT NO. I� /'�q /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL J 216
6UILDING PROJECT IDENTIFICATION �/ V
BU DI A'V')
D E SANITARY , APPLICATION SUBMITTAL DATE
S NAMEON _ CONTRtTOR'$NAI�v E:_.1 LIC NO�
NIC CONTROL#
HIT✓\ECT/E (NEER. LIC NLOi^ ADDRESS:C'NI `9Jl- ❑
CONTACT: f, X51 PHONE: - BUILDING PERMIT INFO
I C�,r-l_� I p Aqc I e ����/^I/' ❑ Consultant Fees Paid by Applicant(Initial) BL
DG F.ILEE tCT�- PLUUMB_ MIEECCH�
KIIL,��I Vr f LY cL�f LS IST-
LICENSEDCONTRA OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 min licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
C�aZ with Section 9008 fDxi1mn3a1 1rthe Businessnnd Profession.Caeradmylicemeis RESIDENTIAL:
,00 wt PERMIT ISSUANCE,
y'W-. m full force and rllect ��t Q.`7/�r- e ❑SFDWL /yRl'1'CHBN REMODEL
QUU License Cl`, Can.. n /! APPLIANCES-RESIDENTIAL
E`�0. Dam Convn�a�� 1-1 ADDITION C1 PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT El STRUCTURAL
'Z O y PANELS
h 1 understand my plans shall be used av public records MODIFICATION
OZ- 0 UP TO 200 AMPS Z 0 El INTERIOR ❑CHIMNEY REPAIR
F�E"41 Licensed Professional
4 j 201-1100AMPS IMPROVEMENT
❑SWIMMING POOLS
r� OWNER-BUILDER DECLARATION OVER I(IW AMPS El BATH REMODEIJREPAIR D DEMOLITION
as d I hereby.. .dote that 1 oro exempt from iho Contractors License Law for the
O L U -hickfollowing
osamoson.(Section]BJLS,Business and so,de in demolish,
Code Any easy soman,county SIGNS BLP.CTRICAI. ❑OTHER
If
3 0.y which requires a permit tr co es et,alter,improve,demolish, fi repair euy m �I d
� priaoto,licets nsedpalsrrequiresthroviomapplicant fnrwchpermitoicimse aw(Chtemeni SPECIAL CIRCUIT/MISC. �✓
pr that he is licensed purxknm to the provhlonx of he Cnntranors License Isco(Chnpier9 -
�C (commencing with Seciion]BOU)of Division3nf tM1e Raciness and Professinre Crde)or TEMP.MBq'BR OR POI.EINST. COMMERCIAL,
d y m C that M1e is exempt therefrom and the basis for the alleged exemption.Any violation of [1 EW BLDG/ADDITION ❑DEMOLITION
W^m Section]03IS by any applicant for a permit subjects the applicant a civil pe natty of POWER DEVICES TENANT ❑FOOD SERVICE
]mare than five hundred dollar,($500). op
El 1,as owner of the property,or my employees with wages as their sole cmnpensztion, SWIMMING POOL ELECTRIC IMPROVEMENT
ff44WWW44WWWLLll11� will an the work and themrucmm is not intended proffered for sale(See 9(004,Business OTHER
and Professions Cable:The Conimctods License Law doe not apply to an owner of OUTLETS-SWITCHES-FIXTURES '
IE property,who builds or improves thereon,and who does such work himself or through
his awn employees,provided shat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ Fe
sale.If,howeverthe building or improvement is sold within one yearofeompletjrn, F.
the SQ.FT.FLOOR AREA $/SQ,F
owner-huilder will have the burden of loving that he did not build or improve for poo-
Post of sole.).
❑h as owner of the property,am exclusively contracting with licensed contractors to A
construct the project(Sec.]044,Business and Professions Code:.The CnnN tars.... -
aAnse Law does not apply to an owner of property who builds or imprmes thereon,and QTY. PLUMBING PERMIT FEE
who amtreeas for such pronates with a contra torts)licensed pursuant to the Contractor's ['�
Lice me exam
PERMIT ISSUANCE '3T V I f/
El 1 nm eexempt under Sec. ,B&P C(a,this rwsnn
AUPER-DRAIN&VENT-WATER TOG VALUATION
per Date 7 ^D
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE S
I hereby affirm under penalty
neperjury one ofthe following mk1r`1Co
❑ Ihaveraid Imsidel maintains Certificate of the La...Code,fare far Workersce of the
DRAINS-FLOOR.ROOF,AREA,COND. STORI . '1'YPBCONS'I'RUCTION
smirk,as provided for by Section 3700 at the Labor Code,far the perfnnnnnce of the O
wok for which this.it,,issued. 12IFIXTORES-PER TRAP
❑ 1 have and will ode,fon Worker's ence of
he w insurance, h requiredbySermon
37071 of the Lahr Code,for performance of the work for which this permit asxueA. GAS-EA.SYSTEM-I INC.4OUTLETS OCC GROUP APE
���
My WrrkevLff pp �N rrElall PalicY pym1AQ�9, /
Gorier d/ IN IpR yNo: 4L v GAS'-EASYS'TBM-(]VHR4(BA) r'InI
CERTIFICATE FEXEMPTIONFROOVIYC
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEES
(Thil,wel m need not be completed ifthe peolit is for one hundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performance adds,work l'or whichthixpermitixlwsued.lxhall SEWER-SANITARY-STORM EA.2101 FT
not employ any pers,,n in any manna m as to become subject m the Workers'Compen-
sation Laws of California.Date
Q Applicant WATER IIEA'F[R WNENT/ELECI'R G FEE '
z NOTICE TO APPLICANT:If,after makiii this Conilien a of Fxem tion,you should
6 l WATER SYSTEM/TREATINO In
become subject to the Worker's Compensation provisions b the Labor Cale,you most SOILS FF,E
Fail r�.t forthwith comply with such provisiorrs or this permit shall be accused revoked. WATER SERVICE
Q1999
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PUMPS. SQ.IT PAID
I hereby affirm that there is a consmmtion lending agency for the performance at Dom R• pi#
the work for which this permit is issued(Sce.3097.Civ.C.)
0 U Lender's Name TOTAL'.
Ixnders Address TOTA
Ha 1 certify shot 1 have read this application and state that the above information is BUILDING FEE O
fA comet.I agree to comply with all city and county ordinances and state laws relining m QTY ' MECHANICAL PERMIT FEE
building crnstmmion,and hereby authorize representatives of this city to enter upon the SEISMIC
above-nmmioved property for import apa-pows.
(We)agree to save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE y FLFCTRIC
IInbllrarapdgmena,coats and expenses which may in any way aerneagainst said City / ALTER OR ADD TO MUCH. Z a Zfl PWM E L
in rmonfor ace rf the granting of this ta,mah. I
fiOl11RC ANT UNDERST 9 AN WIL1.COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,B10CFM) MEC LFEE e O
AIR HANDLING UNIT(OVER 10,000CFM) CON ION TAX
.,rrImxof Appl rc A`ontmpro' - Date EXHAUST HOOD(W/DUCT) HO MITIGATION FEE
HAZARDOUS MATE ALS DISCLOSURE
Will the applicam rr fmurebuildin accupam lime nrhandle hnmNous motmlal HBATINO UNIT(Tri 100,!X0 RTU)
as defined by the Cupeninn Munici ul Cnde,Chapter 9.12,and the Hench and Suety
Code,Ser inn L5532ma HEATING UNIT(OVER 100,000 BTU)
El Yes No VEN FILABON PAN(SINGLE RESID) PAID --
Uma ReceiPb
Will the applicant or future buildingoccupantthe B use equipment or device,which BOILER-COMP LHIP OR 100,00 BTU)
.nit hazardous air comaminunte ns teed by the Bay Area Air Quality Management AL r
District? BOILER-COME(OVER 100,000 BTU)
EI Yrs
I have need the M
mentsunder Chapter 695 of the Cali- AIRCONDDIONER ISSUANCE DATE
fomin Health&Safety33 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FP.
buildingdersnot_weventyresponsi6 ty mnntify theoceupant /
ofthe N,.iN.c wh' once of a t O �
/ �(
Ownerminithorjz agent 1 Date OTA f 0 ISSUF.DBY: