S 3394 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO IDA n.pING-ELECTRICAL PHtII No.
BUILDING DIVISION APPLICATION/PERMIT PLUMItING-MECHANICAL - �J 3394
t_. 'IILIII,DINOPROJECTIDENTTFICATION' "
SUILDINGADI)RE55: _ D SANITARY NO. APPLICATION SUBMITTAL DATE
OWNEI' AME:: p PHONE:IPHONE: CON'ONIIRACIOk'S NAMD: LIC NO: T
/lJ N/C CONTROL#
AR rF.0/E NEER: LIC NO: ADDRESS: ❑ .
G
pNTACT: PHONE
BUILDING PERMIT INFO
DI/I TW)ffy /--17(/ 00 ❑.Consultant Fees Paid by Applicant(initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRA(2TO0,7)I.CLAFrATION QTY. ELGCTRIC PL•RMIT FEE
1 hereby lift,n mn I am licensed ander provisions of chapter 9(am,nnliving JON DESCRIPTION
QWZ With Section 70)(D.Onvision 3.Ohe Bearmssnnd Professions Code, license is RESIDENTIAL,
F W is full force and effect, /ll 1/ '-^,� 1'I?RMI'(IStil1ANCN
aUV licence Class Lic.p Q-1/r/ ❑SFDWL ❑KITCHEN REMODEL
rF7a Dae Conlowler APPLIANCES-RESIDENTIAL OADDITION C1 PLUMBING RE-PITH
FOm ARCHITECTS DECLARATION PANELS CMULTI-UNIT ❑STRUCTURAL
Z O y Z I understand my plans shall ba need as public maords MODIFICATION
O Z-.O UPT0200AM1'S El INTERIOR ❑CHIMNEY REPAIR
F4t:w Larread Prof esshall yf; 201-IIXNtAMYS IMPROVEMENT ❑SWIMMING POOLS
� OWNER-BUILDER DF.CLARA'HON
d a'W Q I hereby affirm mat I am exempt from the Commoner's License Law for the OVER EXXIAMRS ❑BATH REMODEUREPAIR ❑DEMOLITION
x 3Q.U following....(Section 7031.5,Bmirl and Professions Cale:Any city or county SIGNS ELECTRICAL 0 GOT R
W O He which requires a permit to ttmstmat,alter.improve,demolish,or repair any stmcnrc
prior,.its issuance,a],.ma oestheapplicann Bacilli permiuo fileusi,pasLmnneat
SPECIAL CIRCDR/AMSC.
Ste} that he is licensed pursimat mthe powisionsof,he Contractor's Liceue Law(Chapter l
a IYOO (commencing wish Seai.n]IXXB of DivisionJnf the ltusiness and l'nNessiom Cssle)or 't HMR METER OR POLE LNST COMMERCIAL:
6 x e¢ ,hat he is exempt therefrom and the basis fur the alleged eaentption.Any vinitim n of EJ NEW BLDG/ADDITION ❑DEMOLITION
caMN Sec ..7031.5 hyanyapplicam fora pernanwbjec,.vtheapplicannna civil penalty of POWER DEVICES
t more than five hundred dollars lS500). EI TENANT ❑FOOD SERVICE
�0 01,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the amoral is no,intended oroffered for sale(SecJnl4.Business ❑OTHER
W
3 m and Professions Cole:The Contractor's License Law does not apply in an owner of OUTLETS-SWITCHES-FIX'TUBES
property who builds or Improves thereon,and who doss such work himself or through
his own employees,provided thn such improvements arc not intended nr offered for NEW RESIDENTIAL F.I.FCfR SQ FT.
sale.IL however,the building or improvement is sold within one year ofonmpletion.the SQ.FT FLOOR AREA MQ.FT.
pter-builder will have the burden of proving that he did not build or improve far pur-
ose of sale.).
❑I,as owner of the property ant exclusively contracting with licensed contractors to TOTAL:
construct the project(Sec.]BJJ,Business and Professions Cole:)The Cenuucnsrs Li- -
enseLaw does not apply it)an owner of Employ who builds or improves themnn,and QTY. PLUMBING PERMIT FEE
who contract for such projects with it co mettnlsl licensed pursuant o the Contractor's
License Law. I'IiRMI"f ISSUANCE
El am exempt under Sec. ,It&P C formal,rea
s son
Owner pane AL'I ER-DRAIN&VL!NT-WATER EA) VALUATION
WORKER'S COMPENSATION DI!CLARATION BACK PLOW PR(YTF.CT.DEVICE
lie WORKER'S
hereby affirm tinder penalty ofperjury mm ol'me following declarations:
I have and will mnimvinvCeni,icnm nfCnnecnnn set Ginsurc Tnr Worker's Cnnupan- DRAINS_FLOOR,ROOF,AREA,CONE. STORIES 'TYPE CONSTRHC'I'ION
action,as provided for by Section 37(X1 of the Lamor Gale,for the pvrkarmanae of,he
work for which this permit is issued, TEXT LIKES-FEET RAP
El 1 have and will maiam.W..kre,Compemalloo Immune,.as mutated by Section
3700ofnhe Labor Gale,forthe perforectaccofthe work for which this prrma,.issued. GAS-17n.SYSTFEFI INC.q OUT11 FITOCC.GROUP AI'N
My Work•' Compensium anaecarriera Pt is room
Cartia, GAS-PA.SYS I'I:'-OVI?R 4(E
CE T PICATE : 'MPI ION P OorK
Gltl!ASIJINDUST'I B'fH 1 -'I!Ii`CEPOTOVR
I .,
FE AB)ILDI G91VISION
nrles. ORInSETRnP t19" _
—
\ PLANCHECK FEE
I certify that in the perfonnuna.M'me IssoomwhidNlir de,w is its C..... .... SP.WHR-SANI'PAR DOA HA.2(X1 Fr.
n.l employ any person In any munnc nn us m Ismmte subject w the Wurkern Conlpclt- ENERGY FEE
,'{ smion Laws f California Dut
z O
Applicant I' I f WAI Lai ALAI I?R W/ I, I/I LLCTR
- OR FEE
F-I h NOTICE TO APPLICANT:If afal Lha C 1 of I:xe t d n i y n ehutIE WATIat SYS hM/I'NI 1 ._
f~ H
become Ijc,1 It,the Wis Gal C P I filo tubo Colo you toes, - ^"""� SOILS PEE
w forthwith aonply withaad, one
p .r lh u
pnt ahtll ha daldalrevnkud. WA'I HR SERVICE
r
� z CONSTRUCTION LENDING AGENCY NI!W It IiSID1iNI'I AL PLM L SQ.1'1'. PAI,
L7 Iherehy affirm that mem iso ounstmcdat leading agency lin the pmfnnnlnnec til' Date Receipt
the work for which this proud is issacd(Sri.3097,Civ,C.)
U Lenders Name TOTAL
h GLenders Address '1'Dl'AL:
I all that 1 have read this application nntl slate that the above infatuation is BUILD]
IA correct.L agree to comply with all city and county ordinal and state laws ralntingto QTY MECf1ANICAI.PERMIT FEE
L) �-. alcove-mencommion.ert barely umtion Purposes. tiaras oi'nhis city to enter upon the t- SEISMIC FF:
abovemenion re property lied inspection purposes. PERMIT ISSUANCE
(We)agree to save indemnify and keep harmlces the City of CUlwninn llguinu ELECTRI EE
liabilities,judgments.mstsnndexpenseswhichlnvyinnnywaya,,ucagaindsaiJCity AITERORADDTOMECH,
1.&fAp,fiaaVC75Ea.,6l
nes of the granting of this permit. PLUMBING H
'1'UNOUR'ITANDS 'D WILL COMPLY WITH ALL NON-M)INT Alit HANDLING UNIT(TO IIhINX)CPAU
F ,SON MECHANICAL E
AIR HANDLING UNIT(OVER 10AX)CFM) CONS'T'RUCTION TAX
Det EXHAUST'HOOD(W/DUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the applicants future building occupant alone or handle hamohim,material III!ATING UNIT(11)100.0D0 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health anti Safety
- Code,Seat..25532(x)] HEATING UNIT(OVER 100.100 B'lll)
❑Yes ❑No
VENTILATION FAN(SINGLE RESIDE PAID
Dae Real#
Will the applicant or furore building racby he B use .Air entQw it Mum which COMP(INP OR 100,0100 BTU)
emit hazmdous air cnnmminan,s as JcfincA by,he Hay Amv Air Qmlity Manvgcmenn BOILER-
DisWn? T AL:
❑ P
Yes ❑Nn BOILER Haul
I have fund the hazardous materials rcquimmen,s under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fonds Health&Safety Cade,Sections 25505,25573 and 2353..1 understand that if,he NEW REST DWI[A].MECH. SQ.FT.
building does not currently have a tenant,that i,is my resrymsibibly to way the occupant / .., _ Q
of me requirements which must be met prim m iswamc of.Cmnanne of(kaupancy.
Ovmer m andurized agent Uvm TOTAL: ISSUED BY:
OFFICE