S 3256 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL P1i IT NO
BUILDING DIVISION APPLICATIONMERMIT PLUMBING.-MECHANICAL 3256
tlUILDING PROJECT IDEN'T'IFICATION
BUII.DING ADDRF;SS: SANITARY NO. APPLICATION S U B M ITTAL DATE
/to I
0 ITR' N E: Y PLIONF.: CDN OR'S NAME: LIC NO:
�f / NIC CON I'kOL#
ARCIT PECTIENGINEINT LIGi ADD ESS: ❑
CON'T'ACT: PHONE: BUILDING PERMIT INFO
❑ Cunsllt int Fees Paid by Applicant(Initial) BLIIG ELECT PLUMB MECH)
Cts L� ❑
LICENSED CONTRACTOR S DECLARATION QTY ', 'ELECTRIC PERMIT FEE
I hereby affirm shot I a lion nNof err pr x or Chapter 9(eon ne irm - _ JOB DESCRIPTION
oaZ with Suion700n.ID I(he Ban dP fessioas Cmdedndmylce c RESIDENTIAL:
WOO PERMIT ISSUANCE 'J ❑tarim. CHEN REMODEL.
F W In fi II forty anJ comet.
�UVLicense Class Lie.Ad APPLIANCES-RESIDENTIAL ❑ADDITION Cl PLUMBING RF:-PIPE
yZ W Dote Gmlractor
F¢y ARCH It i?CTIS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCI'URAI.
Z O rn 7W I understand try plans shall be used as public records MODIFICATION
UP TO 200 AMPS
OZ-, C1 INTERIOR EJ CHIMNEY REPAIR
F+(:_W Licensed Professional 201-IWBANT'S IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION
'.d .W.l OVEN INXIAMPS 71 BATH REMODF.IJREPAIR (]DEMOLITION
fG Q I hereby u(Sect on I nm exempt from the Conan,C License Law for the
xdx O L U Hollowing reacna(Section]oma et.olue, and Prof ions Code:Any shy or county SIGNS ELECHIICAL -]OTHER
W a W h whim Tequircc a permit ro coastruet.zher,improve,dcmrrit I,on,a oir any sdumarc
0Q prit he it'iysueamicamor m onfincloe the oufcre fad Conarrecon,Blcasi Low
r9 SPECIAL CIRCUIT/MISC.
j..1 thatheinciml it purmtm 10th)prmlslomof Wm Conrtanssa trema ....N Code)I,
0�0
that
is ngrld Section 7000)and tie basis for oDheeged w meat Professions lenc)ol' '[EMP METER OR POLE INS'E COMMERCIAL:
W p� tett he is IIS b therefrom end the basis for the alleged exemption.Any violence of ❑NEW BLDNADDITION ❑DEMOLITION
W`"m Senlnn III IS by any
undredidoll ro($500) hsuhjeete the nppliwm moelvil ltenulry of 1'OWGIt UHVICF.S ❑TENANT ❑FOOD SERVICE
1„�Zy y tam than five hundred d011tm IS500). IMPROVEMENT
iQp tYJ 1,oc owner ofthe propcny,nr my employees with wage as tM1cireolccompensntinn, SWIMMING POOL ELECT RIC
H will dr the work,and th)smnnreis nm ittendetl or offcruf for sale(Sec.9044,Bneiness ❑OTHER
a w and P..F..ons Cade:The Contactors License Low doe,art apply lm on owner of OUTLETS-SWITCHES-FIX'THat
RES
property who toodds ocimpmvm Thereon,and wen does such work himself onI Odi
disown employees,provided that such imp mvemems me nm Intended or offered ler NEW RCSIDEN'LIAL ELFCTR SQ PL
sde.ILhowever.dee buifdingorimpmvementls sold within one ynumfmntplenna Om SQ.FC FLOOR AREA S/SQ.Fr
or-builder will have the burden of proving that he did not build or Improve for par-
lent,
ar- Ple sof sated,
El1,Its own«of We pm(w'ry,oro exclnsivdy cnmmning wins IlentsW condarmm to Torn L:
construct the project(Sea 9844,Business and Professions Code:)TheContmclers Li
ceaseo an 'JAN 8 RECrD'
Law does net apply tminor of property who builds or enproves mcrcon,and QTY. PLUMBINO PERMIT FEE,
whomoderns forsuch projecs with a comm c)licensed pursuant to l he Gowoors
Laterite,Low. - PERMIT ISSUANCE
❑Tare a:5pt under sea _ ,B&PC for reason UI_IY vh I.Ui-Cnl11Vl,
ALTER-DRAIN&VENT-WATER UCG VALUATION
Owner r AR Olde
WOknderPCOMPENSATION UIi RATION IiACK FLOW PROTECT.DEVICE
I Thereby affirm under penalty of perjurymnme, to following dedumlimns: -
❑ I have and will mainmin t CertifieareofCositoself-nxure for Worker's Cont pen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPECONS'FRUC'HON
senior,as provided for by Section 300 of the Luen,Code.far lee performance of the
work for whom this permit is issued / FIXTURES-PER TRAP
❑ I have and will maintain Workers Co npertminn Inslnmce ns rnryired by Section
3700 of the Occur Car,for the performance of the work for which(his permit is issued. GAS-EA.SYSTEM-I INC.4 OU'ILET'S OCC.GROUP APN
My Worker's Compensation Insurance carrier end Policy number are.
Cavin: Policy No: GAS-EA.SYSTEM-(OVER 4 LOG
CEID H ICATE OF EXEMPTION FROM WORKERS'
COMPENSA'T'ION INSURANCE GREASE/INDUSTRL WASTE INTERCEPTOR BUT I,DING DOLMON PEES.
CTM1isNullnn need urn Menmplcmd ifthepermit is fnrmnc hundred delta,,y100) GREASETRAP
ar IessJ PLANCHECK P19E
I certify that in the performance efthe work forwhich lluspermit is issued,Nuill SEWER-SANITARY-STORM EA.200 FT.
not employ any man
paon in y nonce s0 as m fee urme wbject m the Workes'rCompcn- ENERGY FEE
,Z Nation Laws of Caledonia.Date WATER HEATER WNP,NTAILECTR
Applicant GRADING FEE
y NOTICE TO APPLICANT:TI;after making this Certificate or Exemption,you should mlm ) usl WAITER SYSTEMlfRRATING
becoeabjeO the Worker's Compensation provision,of Labor CoAyoumSOILS FEE
!� forthwith comply with such provisions or this permit shall ler deemed revoked. WATER SERVICE
p Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL 1'LMB. SQ.FT. PAID Date Recei t#
I herebyaffirm
noritrcisown(Set,30 leading7, N.agency for the pnhormance of p
U O Fa hweaker,for which eels permit is issued(Sec.909],civ.C)
u' Lenders Nano TOTAL:
y�U Lender's Address TOTAL:
er
[' W 1 certify M1St I have fwd his epplicmien lmtl now Ihut the above information Is - � BUILDING FEE
wort.l agree m comNy with all city and county on inlmces and slide laws relating m QTY. MECHANICAL PERMIT FEE
(J 7
building cmnmrurnioq anA hereby aulhnrLc rcprecouativas of this city mantes upon the SEISMIC FEB
««77 above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Wei agree m save indemnify and keep harml)cc the City of Cupertino against P.LP.CTRIC PCE
Ithat lilies,judgments,cosis:md expenses which may In any way acme against .,it City ALTER OR ADD TO MECH.
in consequence ofthe granting mfthis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SO�UI/(�E REGULATION. MECHANICAL PEE
I AIR HANDLING UNIT(OVER 10,(XIOCPM) CONSTRUCTION'FAX
STIondtenf ApplicRgConmanor Dow EXHAUST FOOD(WNUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the spplicanter fume building rectification)or handle lo,ohdmuanmterfaf HEATING UNIT(TO I ho'neo B'TU)
as defined by ilio Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cede,Section 25532(a)P HEATING UNIT(OVER 11X0,000 BTI!)
(]Ye, o VENTILATION PAN(SINGLE RESID) PAID
Dale Receipt#
Will the applfcont or future building ocament use equipment or devices which
craftmM ........haons air contaminants as defied by the Buy Arco Air Quality M
ent BOILER-COMP CLIP OR I00,W0 B'fU)
TOTAL:
DiNlrin^ J
L-]Yes t.9 nvo HOLLER-COMP(OVER 100,00013'I'U)
,
I have mxd WC M1arordmus nwtennlsre to under Cha -fi.95 nC lac Culi- AIRCONDIGONER ISSUANCE DATE
fnmiu &SSections 225593end25534.I understand that ifhe NEW kHSIDFN'RAI,MECH.
builJinraidmcuannt,haovmnvnh()lot it is ay responsibility to notify
the occupant
of equicarms'threat Art petro"ulusiecrf a Centfnce,of Oropancy.
r
Own authorized again Dam TOTAL; ISSUED BY:
OFFICE