S 3184 '- - APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO DGII.)INC•ELECTRICAL PF.tl'f NO,
BUILDING DIVISION APPLICATION/PERMPP PLUMIfIN(:.MECHANICAL V 3184
' BUILDING P'ROJBCp ioitm1'IFICATION
RUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SNAME: PHO F.: C( �I'OR'g NAM1lgi: LIC NO:J
Q yon 41`,6 'Pi . CK �� ZS3 — NIC COMfHOLp
ARCHD'ECT/ENGINEER: LIC NO: AD RESS: ./ ❑
(D.SM
CONTACT: - PHONE: BUILDING PL'RMIT INFO
KAY H / 116 -'?M? ElCansultant Fccs Paid by Applicant(Initial) BLDG ELECT PLUMB STECCH//
1:1 1:1 1:1 LI
LICENSED CONTRACT'OR'S DECLARATION Q'I'Y ELECTRIC PERMIT FEE
G Z I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
with Section 70(finsf Division 3ofthe Busirmo al Pmfexams Cal my limnse is RESIDENTIAL:
O O PBRMIT ISSUANCE
n full force and eJ(eci. /
WUL^ LiccnscCIn `'�O �'361icp Z�3f ❑SfT)WL ❑KDCHF:N REMODEL
sc G ¢ APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE.
�QL nam /is' Contractor .
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
F 7 m 0 '7, I understand my plays shall he used nx public records PANELS MODIFICATION
OZ- UP TO 2IXtAMPS C:1 INTERIOR El CHIMNEY REPAIR
W Iectn,cd[Imfcsoard 201-10I0AMPS IMPROVEMENT [SWIMMING POOLS
OWNER-BUILDER PECLARAl'[ON OVER I000AMPS O BATH REMODEUREPAIR ❑DEMOLITION
1 lumby affirm that I um exempt Irani the Ci nlraaor's License Lrw for the
�F O 6 V following reemn.(Section 7031.5,Businmx mud Professions Code:Any city mentally SIGNS ELECTRICAL ❑OTHER
E0 y which requires a Permit to construct,alter,improve.demolish,or repair any mmetme
prior to its issuance,also requires me applicant list such Permit file a signed statement SPECIAL CIRCUIT/MISC.
} that he is licensed Pursuant o the provisions ofthe Communes License Law(Chapter 9
W..G CO (commencing with Section7")of Division3ofibe Business and Professions C,NC)nr TEMP,METER OR I'C11.IilN$T COMMERCIAL:
611 o yy thio he is exempt therefrom and the hash,guise allege)exempinn.Any violation of '❑NEW BLDG/ADDITION ❑DEMOLITION
❑TTiNANT ❑PIX)D SERVICE
not mo
,MN Stainn701 L5 by any applicant for a permit objects the applicant to a civil penalty of POWER DF.VICFS C
F m than rive hundred dollars IMPROVEMENT
1,as nwncr ofthc property,or my employees with wages as their sole compensation, SWIMMING POOL❑ ELECTRIC
C will do the wink,and thesuucmre is urn imeadedern0'cted fordo(See7044.Business THF.R
a and Prnfessione Gale:The Contras is License Law does not apply to an owner of OUTLETS-SWITCIII?S-FIX'fI11tE5 -
propcty who builds or imprnves Ihemnn,[send will)docs ovh work himself or through
his own empioyceI.provided Ilml such ilnp nIenmm.am urn intended nr nffcroA for NEW RESIDENTIAL FLECI'It SQ Ff.
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.Ff.FLOOR AREA VSQ.FT.
ter builder will have the burden of proving that he did not build or improve for pur-
isomIT'wlcd.
C] 1,as owner of the property,am exclusively contracting with licensed Orientation it)
TOTAL:
construct the project(Sm.70,D.Business and Professions Code:)The Central Li-
lease Law does not apply to an owner of property who but[&or intimoves thereson.and QTY, PLUMBING PERMIT
who commas for such projects with a rontrvctor(s)licensed pursuant to me Contractor s
License Ino.
EU�I.TIS,SUANCEI am exempt under Sec. .B&P C for this reasonIN&VENTt
VALUATION
Owner Date r
)YORKER'S COMPENSATION DECLARATION PRO117CIL DIherebyaffinamelorpenaltyol'pe➢lrynneof thefndoi.%declarations:nmam.mlf-inorefmWmkersCnmpem UOR,ROOF, RIES 1'YPH CONSTRUCTION
tion,asprovidesforby Secdnn3700oftheLINITCode,forthepeflnuanceol'the 1sngyelk�r which this permit is i..ued. PER TRAP' ``,9�JO
i( have and will museum Worker's Compensation Insurance,as required by Section 37(0of the labor Code,for the pefformuncc of the work for which this petook is i,oed. GAS-EA.SYSTEM.I INCDEC.GROUP APN
My Workc sGuolfserymLnl e�/n pnlcY Policy T�6e"r. &0z,9S6 ton \I�; 'ECTION OcPARTh°�� Vr
Calricc 3 7Y+'T s'C 7 GAS-LA.SYSTEM OVTiR4(GA) ECTIO
CERTIFICATE OF EXEMPT ION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINUUSTRI.WASTE INfERCFPfOR
B IL I DIVISIONFEFS
(This section need nm Mcmmwns b
pleted dthe femat is for.. GREASETRAP
or less.) PIANCHECK FEE
I certify that in the perfnrmuneenf the week forwhich this permit is issued,[,bell SEWER-SANITARY-STORM PA.Vat Fri.
not employ any For on'm any mmner,o ns to brooms object to the Workers'Cnnlpen- ENERGY FEE
�. in a Laws of Cit.Date WATER HEATER WIVRN IDAKCI'R
7� O Applicant I GRADING FEE
G rj) NMICIi'f0 APPLICANT:If,after making this Cri ificvte of Eamna m.you should WATER SYSTEM/TRENDING
hecninc lubject to the Workers Compensation provisions of the Labor Cade,you must SOILS FEE
W0 fnnhwithmmply wimsvch provision,or this permit shall Ni,deemWrevoked. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMN. SQ.FT PAID Date xipip
U O Iherebyalftm am me.is.emi,tmction leadia,lim my for the performance of
E-' the work for which this permit is heaved(Sec.3097,Co.C.) TOTAL:
0 U
Lenders Name
Leadees Address TOTAL:
11 1 certire
reality that 1 have ad this application and state that the above information is BUILDING FEE
to correct.Ingrm to comply with all cityand county ordinances and sett laws relating to QTY. MECHANICAL PERMIT FEE
U huildingconxtruction,and hereby adbiriet representatives ofthiseny to cotrai the SEISMIC
alswamcntioned properly for inspection purpecs. PERMIT ISSUANCE 3 S
agree I., iadern all kap[seamless the City of Cupertino agairtt I?LP.CTRIC PE'
Wind' us,;lu gment"i nd ex ch may in any way accrue again,,said City ALTER OR ADD TO M ECI I,
On r nseque ..I the ingot h' ps 1 1I. PLUMRING� E
AT 'LICA I' ND' AND, ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO 10.000CFM)
727
S URCEI - ILA 1 NS.' MECHANICAL C
AIR HANDLING UNI'1'(OVER ItxuolICFMI CONSTRUCTIONTAX
ignmurc of ApplicantsCommnur Dae EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the...[Xoom,future buildiogorea,m mmi handle hazardous motorial ) ITIITING UNIT(TO 100.00k)BTU) 12--
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Code,Section 25532(a)7 HEATING UNIT(OVER 100,000[TTU)
Eyes 341 VENTILATION PAN(SINGLE REST[)) PAID
Dole Receipt p
Will the applicant or future huilUing nmupvm use equipment or dl'VICEM1 which
emir Intention,or conuminnnu as dafned bytha Bay Aro Air Quality Management BOILER-COME(311P OR 100,000 BTU) T
Dislricl" / BOILER-COMP(OVER IW,(X0111'U)
0 Yea [}Q
Ih V rdou, m,tial: mntr under Chapter fi.95 of he Cali- AIR CONDITIONER ISSUANCE DATE
to is Ileae,Sec, 2 5,11533and25534.1mMmgaN1Maifdu NEW RESIDENTIAL.MECIL SQ.Is.
iItingJ aveam n mit ismyresponsibilitymnrni Iheaco af the rust be or m ismarse ora Certif ataTice
nr uwhonzed agemm TOTAL: w ISSUED BY:
OFFICE n.