S 3836 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
Bull.@iNC UrvisioN APPLICATION/PERMIT PLUMBING-MECHANICAL S 3836
BUILDING PROJECT IDENTIFICATION
Y•UH.DINGADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE.
1 0 363 SAN FEQN APIDo AVE cupE(LT)NG CA ��-9T
aWNER'S NAME PIIONE: COM '
'RACIOR'S NAME: LIC NO:
A 11L0 f=QAF14 C-(J SEE NIC coMxol.a
II'IiGiENGINEER: LIC ND: ADDRESS: ❑ `'Y2z
m oa Go 4 $A¢NSp6L LT SJ si 7
CONTACT: PHONE: BUILDING PERMIT INTO
pTj ` �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
`I' O 1 6 —(O Q— E�--
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRICPERMIT EF JOB
I hereby affirm that I ata 1,,.,,d muter provisions of Chapter 9 Eommencing JOB DESCRIPTION
== Z with Scene,,700)ofDivision 3ofthe Bovines and Professions Cuda.ural my license is R'_Ip pRNT1AL:
Worn PERMIT ISSUANCE Sx5
Fly_ in full forceand effect. ❑SFDWL ❑KITCHEN REMODEL
QUU License Class Lia« APPLIANCES—RGSIDEN'1'[AL ❑ADDITION El PLUMBING RE-PIPE
NZW Date Contractor
ARCH] DECLARATION ❑MULT6UNIT ❑STRUCTURAL
~,aZ Im,dcrsumdo,yplati ,hull b,u¢daspublicrccvrd, PANELS MODIFICATION
OZ4—a UP TO20AMPS ❑IN'PERIOR C2 CHIMNEY REPAIR
Fa-~tw Licensed PmEssional 201.100AMPS IMPROVEMENT ❑SWIMMING POOLS
y sl�� OWNER-BUILDER DECLARATION OVER 1000 AMPS
C1 BATH REMODEUREPAIR [I DEMOLITION
1 C 6 I hereby aRrtn that 1 am exempt from the Commaors License Law for the N EIA.7 13-0 s4•�@
x 1 U following reason.(Section 7031.5,Business and Profession,Codc:Any cey or county SIGNS ELECTRICAL [I UTTER
W 3 a y which requires a Permit m constrva.altos improve,demolish,or repair any structure
f- e, prior to its issuance,also requires the applicantfor such pem,iuo file a signed statement SPECIAL CIRCUITIMISC.
E y Nm he is licensed pursuant to the prov,wa,of the Conancous Lweamu Law(Chapter 9
�IY?� (commencing with Section 7")of Division J ofthe Business and Professions CMc)or TENP.METERORPOLEINST. COMMERCIAL:
S X e Nat he is exempt thereBnm and the basic for the alleged u,emptlan.Any violmiun of ❑NF.W BLDG/ADDITION El DEMOLITION
�� Section703 I S by any applicant lista pcouil subjects the applicant o a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
at more than five hundred dollars(S50). IMPROVEMENT
E2�
FI 1,.s ownerofthepra,var,of my employees with wages auncir>olecompensmian, SWIMMING POOL ELECTRIC
will du the wirk.munic,nuoune is nutnnrndedmu(fd enfor,de(Set.7044,Business ❑OTT{P.R
{W—p..m and Professions Code:The Contractors License Law docs not apply in an owner of OUTLETS—SWITCHES—P1%'TUR 2
a 3 propeny who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not Intended nr offered for NEW RESIDENTIAL ELECfR SQ 19'.
sale If,however,the building or improvement is sold within one year ofeumplction.the ' SQ.FT.FLUOR AR — LSQ.FT
M1miwill have the burden en of proving that he did not build of improve for par- NG -x,32 Sir
Po oIc,. m ey Q� /y 1
weer of the Prnpeny,a xdusrvely comractin8 wish licensed contractors us X s(�7 T3 1 p
c .tructmeprujeet(Sec.7(M.Inv rc,andPrmcssiunsCndcpinc—ofvetnrsl.i- I j�
c clawdoes not applytonnawncrofmr,voywho buildsnrimpmvathemon.and QTY. PLUMBING PERMIT FEE LJ
who contracts for such projects with a contractor(s)licensed pursuant o the Contractor's JAN 6 2000
License law. IT
(]Icon except under Sec. .B&P C for this¢a son i'IERMITISSUANCE
Done
ALTER—DRAIN&VIiNT—WATER(CIA) ? VALUATION
WORKERS C 11ENSA'nON DECLARATION BACK FLOW PROTI .DEVICE 7
OVO
1 hereby affirm under penally of perjury one of We following declarations: .J J.
Oiklal.
rive and will maintain a Ceilticum ofConscat nuelf-arurc for Worker's Conpen- DRAINS—FLOOR.R(OF RPDA,COND. STORIES TYVECONSTRUCTION as provided for by Section JFM club,Lahr Cada,for the pero munce ofthe
work for which this permit is issued. FIX TURES—PERT CGQ
m ✓/
I have and will maintain he surf r arec o flat w rk for hi h required by Section
)70 of Om LxharCale,for the performvncc of the work for shish this Mnnit is lamed, GAS—EA.SYS lEh1-IINCq GIS 'OCC.GROUT' APN
My W'orker's Compensation Insurance emrief and Policy number arc'.
Cam" Policy No: GAS—EA.SYSTGh1-0VF,R4(EA) 3157-IZ 3
CEERTIEICATE OP EXEMPTION FROM WORKERS' OR WASTE INT EPTO
COMPENS/O]ON INSURANCE BUILDING DIVISION FEES
(-I'hlssmtiom need nnI se,moneted iOhe permit is foram,hundred dollars($100 GREASETRAP
or lest) 1'LnNCHECK FEE �'6•
I eenify that in the penfon,mnce oftne work for which this permit is ismcd,I shall SEWER—SANITARY—STORM EA,200 IT.
not employ any porsm,in my manner so as,,bee ane subject u,the Workcr,Camped- ENERGY FEE 53 Ss ZO
Z. satins Lawsof Califom,Doc wgrER11EA'IERWNCNVE[.F.CB
Z�_ Applicant GRADING FEE
Z
NOTICE TD APPLICAN P.IL after making this Cenificme of Exemption,you ehauld WATER SYSTEM/TREATING
FN SOILS FEE
that subject to the Workerm
Workers Compensation provisions of the Lahur Cale,you must
a 7 forthwiW comply win.such pnrvisiuns or Chia permit shall Fc fine ined revoked. WATER SERVICE
19
6PAID a07
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. Dat, Receipt«
U O 1 hereby affirm that there is a nmarvmion lending agency far the perfamwna of
the work liar which this fiction is issued(See.3097.On,C.)
Lender's Name �/ 'TOTAL:
Wlender's Address TOTAL: Cg pD
y I certify that 1 have read this application and state Boothe above information is BUILDING FEC a Q(
F^y correct.I agree to comply with allcity and county ordinances and state laws relating m. UTY. MECHANICAL PERMIT FEE �SC`/
U Z building construction.and hereby uu,hariesen
c repretuti ves of this city to enter moon the SCISMIC FEE 00
nbnvennemloned"u'ry,for inspection purpose" PERM IT ISSUANCE ELECTRIC PER �. d
(We)agree to save,indemnify and keep hurodcss the City of Cupertino against
1 I'mbllbics,judgmcros,cows and u.spe,r,which may in any way vccmc.,mmit said City
ALTER OR ADD TO MECH. PLUMPING knt
in ne of the granting of this Wit.
i APPLICANTICANTUNDERSTANDS ANOD WILL COMPLY WITH AL1.NON-POINT Ai1t HANDLING UNIT('rO IQ(NO CPM) MF,CHA I FE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,0X)CPM) CGNSTRU PION TAX
ri,murc ofAPPlicunVConuunor Date EXHAUST BOOD(WIDUC) HOUSI MITIGAT)ON FEE 3HAZARDOUS MAI HRIAIS DISCLOSURE
Will the applicant it future building occupant store m handle hazardous mmcrad HEATING UNIT(TO 10(1,001 BTU)
cOncal sty the Cupertino Municipal Calc,Chapter 912,and the Health and Safety
e.Section 25512(a)7 HEATING UNIT(OVER 10X1.000 BTU)
L3 Ye, ❑Na PAID -
VIiNTILAI'[ON FAN(SINGLE RES IU) Dam Rcceiptp
Will the applicant or future Wilding occupant use equipment or deWocs which BOILER—COS1P fJHP OR 10,000 BTU)
ezafdous air cumaminants as defined by the Bay Area Air Quality Management TOTAL:
n1OP1I BOILER—COMP(OVER I0.000BTU)
❑Yes
El No Q
I have read the hazardous macriul.s requirements under Chapter 6.95 ofthe Cali AIR CONDITIONER /f+-ISSUANCE DATE O
forma health&Safety Cede,Sections 25505,25577 cord 25530.1 understand that if die NEW RESIDENTIAL MECH. SQ.FR f/- 6S— 2—o o Q
boldo,docsnotcurrcn0y n u it cal that it is my rc,$)mibility m cooly thePam fY'
I'tncrego Jcnion—h d, Moen Priorm icsuvnee oraeenificufe r��``uupartcy. ��
4�� 0 /�/�— TOC /� 7
manses ae t Dte TOTAL: 2C �D Essuru BY:
OFFICE