S 3844 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
C FPY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 3844
BUILDING PROJI!CT IDEYI'IFICATION
ItUILDING ADDRESS: SANITARY NO. APPLICATIONSUUB/MITTTTTAALDAT
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OWNER'S NAh PHONE: COf"fRACIY)R'SN ME: LICIN'TO:
S S / NIC CONTROL
RCHITEC I'/IiNGINEER: LIC NO: ADDRESS. ,-� ❑
ONTACT: PHONE: y BUILDING PERh11T INFO
'101 Cam)
=P> ^(p01 ❑ Consultant Fees Paid by App.cant(Initial) LD G Ii1.liCT PLUMB EC
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT F88 � ❑
I hereby anion that 1 am licensed under provisions of chapter 9(reconnect ng JOB DESCRIPTION
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with
Senian l(Xp)o(DivixionJolthe Business and Professions Code,and myliccn,e is I RE.SIDIRNTIAL
.
' follferc and t PERMIT ISSUANCE
m— ' FDWL O KITCHEN REMODEL
aUU 1.icem� Lic.p APPLIANCES-RESIDENTIAL El ❑
ADDITION PLUMBING RIi.PIPE
Naa I CnnVa i L`—
F>vn ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [DSTRUCTURAL
viZ I understand my plan.shall M1e used as public records ` MODIFICATION
ZOZ�O UP TO NIOAMPS N�,Ili RIOR ❑CHIMNE REPAIR
W Licensed Prole,olnml 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
=C Q 1 hereby aTrm that;ER'BWmDERom the CounaOoh license Law fur the OVER I(g10 AMPS ❑RATH REMODEL/REPAIR [I DEMOLITION
L�aU tallow 6 .(S f 9031SB dI t Cd A '. aunty OTHER YJA1�C+•'• Lt.1li..ADtt7
xx Y Y SIGNS ELECTRICAL
W3LLy wFch c4 e, 11 cowlalt 1 demolish, rear Y.. court .ff�Pae QLQd
�j putt t ice al: req theapplicantf suchrapermit signed statement SPECIAL CIRCUI I'/MISC. T C
�y}
�a0pthat heul licensed pursuant 70the provisions ofthe ofte Burnes sLicenseta ICM1pter9 ��—
6'nnmsncing with Section 7000)nl'llivision3of.hC Business and Fntl'csxinns Codc)n, TEMP.METER OR POLE INST OhL�MFR�IAs
Z.a e C .hat he is exempt therefrom and the basis for.he alleged cacmpiion.Any violation of ❑NEW BLDGIADIII'TION ❑DEMOLITION
W:m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not marc than five hundrnl dollars(5500).
ASOQ Laxoe worwncrot the prospery,ornly employees with wage,as theirsole compensation, SWIMMING POOL ELECT C IMPROVEMENT
F.
will dothk.and theumearm is Pill intended oroOired l or sale(Sec.1613,Business ❑OTH17R
ohiglitil
W m anti Professions Calc:The Contractors License law does not apply to an owner of 7
OUTLIffS-SWITCHES- '
prapcny who builds or improves thenen,and who does such work himself m thmagh
Ws own auno,ces,prnvidm that welt ill,.ovcmena am not intended or offered for NEW RESIDENTIAL ELECTR Q Fr.
sale.ILhowcvm,the buildingorintprovement N,old within one year of nvnpinlon the SQ.PT.P ( RIiA IT
owner Wilder will have the burden of proving that he did not Wild or improve for put- D D
purse vital).). / n
❑ L as owner of the pngsrny,am exclusively contracting with licensed contractors to TO GN
nnnmct The project(See.1114,Business and Porvs a s Ctde:)'I he Contractor's Li- JUL — 9 1999
cense Law does not apply to an owner of property who builds or improves Thm ar.and QTY. PLUMBING P I
who contracts far such projeco with a comracmr(sl licensed purmanuo the Contmctuts
License Law. PERMIT ISSUANCE
I am exempt made,Sec. ,B&P C for do....a. s
ALTER-DRAIN&VENT-WATER(EA)
Owns Date
WOR
mund under
PENSA'Iy[ON
in DECLARATION PACK PLOW 1'R(YI'F.CT.DEVICE 'l
Ihereby affirmunder penalty to perjuryenc ofthe in,mr,far decWorkers T ChJ
Ihavc and will far by Se Certificate if he Ul000Code for the Workers Co.,.-CopRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPO:CONSTRUCTION
av provided fur by Section 3100 of.M1e Lvbor Code.tali the Ierformantt of.M1e
for whish this peon!.is!,Lund. FIX'1'l1RF,5-PER TRAP
have and will maintain Workers Compensation Insurance,as required by Steelton
3]W of the labor Cards.for prodmmnce of me work fgqor.rywhicchr�h this permit is issuM. GAS-EA.SYSTEM-I INCA DUTL•' (KC.GROUP APN
-nine, Compu salon insurance carnal ul icy Nv 1-' brl� GAS-EA.SYSTEM OVER 4(E
ERT114'ATE OI'HXEMPDON FROM WORKERS'
COMPENSATION INSURANCE GRFASPIINDUSTRL WAST M'F:RCEPI'OR BUILDING DIVISION IETES
(This section need not W completed ifthe permit is for one hundred dollars(SIM) GREASE TRAP
nr lass.) PLANCHECK FEE
I unify Tho nine penbnnenva,idhe work fnrwhiehtno,scrout isolated.l shall SEWER-SAN)PA/-STORM EA.2W FT.
flat employ any person in any manner so as to Wcome subject m the Worker!Compen- IiNERGY FEE
� Z sation LawsofCulifomia.Dam WATER HEAT WNENI'/ELECM GRADING FEE
Z O Applicata
NCHCETO APPLICANT.If,after making this Cenilicam of Exemption,you should WATER S THM/1'RF,ATING
F" N become euhjen to the Workers Compensmil a provisions of the Labor Code.You must SOILS FEEfonM1with c....,Y ss'itX such powixiaae of this permit shall W deemed revoked. WATT SERVICE:
a. Q CONSTRUCT ION LENDING AGENCY I N RESIDENTIAL PLN It SQ.t1'. PAID
U O I hereby affirm that there its a construction lending agency for the per(ennnnw of Bit#
(-t the work far which this permit is!,sand(Scat 3097,Civ.C.)
17' lenders Nanta TOTAL:
L) Lender's Address 'fOq'AL:
y I ccnify Nm 1 have mail this application and state That the above orientation is BUILDING FEE
AnZ
.F. h correct.I agree to comply with all city and emmry ordinances.and slate lawxrelating m QTY. MECHANICAL PERMIT FEE ILO
U Z buildingcmtstmction,and herebyaul oom representatives of this city to cn.erupon the SEISMIC 1:17F,
above mentioned property for inspection purpnes. PERMIT ISSUANCE J' O
(We)agree 70 save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
habil hies,judgments,costs and expenses which may In any way accrual against said City All ER OR ADD'POM ECH.
PLUMBING FEE
in ,sequence oftc ngranting of t this permi
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,00)CI'M)
MECHANICAL FEB.
SOURCE REGULATIONS.
AIR HANDLING UNH'(OVER IgIXp CFM) CONSTRUCTION TAX
Slgnata,cof Appllc.mrCommcan Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE )
Will the applicant or future Xnilding occupant store or handle httardous mammal HEATING ON['1'(TO 100.0011 BTU) �•p0
roc defined by.he Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532mG HEATING UNIT(OVER I00.00)BTU) yrs
❑Tics No PAID
VENTILATION FAN(SINGLE RESID)
Will thea Meant or fu um bulldni t axe c t or devices which
Date eccipt p
pp 8by the
Area
Qu BOILER-COMP(3GPOR IW,(XX)BTU)
emit Xa>allous air contaminants as defined by tM Ray Arca Air Quality Managcmen. TATA
istria^ BOILER-COME(OVER IW.000 BTU)
❑Ycx No
I have read the haeardous materials requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SO PIT,
building doe,not curm..ly haven)nam,that It is my rcsp....mility to nerfy themeapm r,
of the requirements which mus inn pnonoissuanc nl'a Cenilicum of Xeu a icy
Own olio thorn agent Da TOTAL: .
49 ISSUED BY:
OFFICE
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