S 3094 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUD,)ING-ELECTRICAL I'E 1IT NO.
BUILDING DIVISION APPLICATION/PERMIT 1'LUMI{ING-MECHANICAL 3094
BUILDING PROJECT IDENTIFICATION,
BUILDING ADDRESS. SANITARY NO, APPLICAI ION SUBNUC1'AL DATE
toe
OWNIMlUHONiCON T1'OMrhe— _ 7Sp
1 NIC CONI'ROLp
RCIIRECT/ENGINEEk; LIC NO: )WjF'_tiS: L ElCl0
CON'fnC'T. PHONE: BUII,UINC PERMIT'INFO
❑ Consultant Fecs Paid by Applicant(Initial) B,.DG VLIiC9PLUM MIiCH
❑ ❑ ❑
LICENSED CONTRACTORS DECLARAI[ON QTY ELECTRIC PERMIT FEE
I hereby anlnn that l am licensed under onvlsionx at Chapter 9(ta ni nencing LOB DESCRIPTION
Oat with Section'lonnlnf D'odion3 of(lie Fummusand Protest s..code ondnty license is RESIDENTIAL;
❑100 wn //� PERMIT ISSUANCE
Fes.. Linins force and eR ❑ShDWI. ❑KITCHEN REMODEL
lUU 1.icatscC s Lic.p APPLIANCES-RESIDEN'I'I AL ❑ADDITION ❑PLUMBING BE PIPE
y�a Dme Commetor
ARCIII'I'ECPSDECLA ATION ❑MUI:T6UNIT ❑SIRUCTURAI.
,oar, PANELS MODIFICNI'ION
ZOonZmalcolandmy,litsshall bc.ved aspubl'a rectums
UP TO 200 AMPS
OZ—O 0INTIiR1OR El CHIMNEY REPAIR
F.HW Licensed Professional 201-1(M)AMPS IMPROVEMENT SWIMMING POOLS
4 sW 7. OWNER-BOLDER DECLARATION OVER 1000 AMPS El kAl'II REMODIiUREI'AIR Q DEMOLI"PION
1 hereby allium Ihut I nm exempt Gam the Cowman's License I.nw for the
OAU ❑oci I1:R
y followinguires a ouch t 9t3L5,r,omcss end improve,
demolish.
moll Code:Any city nr county SIGNS I?hliCfRICAI.
3 LL N which requires n permit ac wires the alter,improve,h parr
n t file
repair any structure a[.� r
<' ,done its issuance,nkat requires the applicant for such permit to fik vsigned smmment SPECIAL CIRCUTUMISC. �N2G4rt�
F y.] that he is I cemed pursuant m the provisions of the Contractor's License Low(Chapter 9
(co;nmm�cing with S tion700(l„f Division 3 oflhc Hmtn...and Profession,Core)nr 'I'I.MP�M Ii I'13R OR POLE INST. COMMERCIAL:
d d Oe a
Than he is exempt Ibetufrnm and the basis for the alleged exemp;in i.Any violation of ❑NEW BLDGIADDITION ❑DhMOLITION
6^m Section 70315 by any applicantfirtiocrmit suhjess the applicau to a civil pend,of POWER DEVICES El TENANT ❑FOOD SERVICE
y^} resnume than five hundred dollars(1500). MPROVEMENT
p ❑ I,as owner of the poown,nutty employees with wages as their sale compenomma. SWIMMING POOL ELECTRIC
HOTIIwill dothe work.nad(Ine,rucmed isomindial.nifeed lorsalosec.7044,Itu.vare,,
Isft
m and Prom
Professions Code Cmd etensa arot v
d,License Low dnonl 1. to owner oi' OUTLET'S-SWITCUES-FIXTURES
propewho builds pr improves thrown,and who Jets such work himself or through
his oo wn employeesprovided that such improvements are not intended or offered for NEW RESIDENTIAL IiLECTR SQ]
sale,It.however, he M1uilJing ar improvement iesnld within nncycnndmntpictinn,the SQ.FT.Ff.00R AREA USQ.FT.
crhuilder will have the harden of proving that be did at build or improve lin pm-
povc of side),
❑I,in,owner of the phnpeny,.,it exclusively cn.ttmding with Encased commoners to 'TOTAL:
consumer the project(See BUT Business and professions Gs ht The Comme does Li-
neeLow does not apply munowner ofpropertywho builds(it improves tandn,and QTY PLUMBING PERMIT FEE
who contracts for such projects with v contractors)licenced,uourab a the Cnnimctrdv
License Law. PERMIT ISSUANCE
1 ton exempt under Sec. .1{&P C ter this reason
ALTEk-DRAIN&VENT WATER(IiA) VALUATION
Late
WORKER'S COM PENSATION DECLARATION RACK FLAW PROTECT.DEVICE
1 nearby ofthan under penalty of per janyone of the following declarations:
I have and will maintain a Courfieale of Consent ntself-insure for WrTkcLu Coition- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTR UCTION
cation,av sided lin by Section 3700 of the l.aMm Cale,for the performance of the
Wm 'rwhich this pemnl is issued FIXTURES-PER TRAP
have and will ntaininin Wnder'n Com,eraninn[us...dec,ns required 1y Section
3700ut'the lahnr(:mle,fin theperfunnance of the work for whluh din,,.rutin is l,sued. CAS-I?A.SYSTEM-I INC.4OU'I'I.1?'I'S OCC.GROUT' AI'N
Camr:rkjsCom nsati_p� _,,n�,rany��croli Policy uunnbv Xrq N/��/)/ GAS-.EA.SYSTEM-OVER 4(EA)
�,NI/zl cam-- PolicyNn:olic r"aSo'1 JS
CER, PICATEOFEXEMPTION FROM WORKERS' GRF,ASPlINU115TRL WASTE INT[RCIiVI'OR
COMPENSATION INSURANCE. H JII.DING DIVISION FEES
hisaemlan noel nal ha co npla ed aILep unit is for one hundred dollam(51 W)
or less)fTGREASE'I'RAP 0 PL6CIIECN
I certify that in the pertomnutceofthe work for which this permit is issued.I shall SEWER-SANITARY-STORM EA.No
not employ any person in any reduce so as to became subject nt the Workers'Comport- ENERGY PC
O zsoler laws of C:lione t Date WATER II EATER W/VEN'UELECI'11 C I Ip t
y Q Applicant
q y NOUCI1'TO APPLICANT:14 vtcr making this Cenificam nl lixemption,yon nhould WATER SYSTEMG`RFATING
becumesubjecl In the WoAdev Compensation provisions of the],No Code,you mus SOILS PER
Fk7 forthwith comply with such provisions or this permit shall he deemed revoked, WATER SERVICE.
P
CONSI is it construction
L[IJDlNC AGENCY NEW It IiSIDENfIAh I'LM11. S .
V O Ihcrchy olEmnhat there isnamswninn lcnJing agency fnnheperfnrmmrveof Dote c a
Ube work for which this permit is I...ed(Sec.307,Civ.C)
D" F' Lender's Name ICTAL:
O L) Lenders Address TOTAL:
44 1 certdy Lha I have found Ibis a"Ireattno nand sham Ito n],..base ink;nnoiun is BUILDING FEE
come.)agreem comply with all city and county ordinances and state laws rclai ng to QTY. MECHANICAL PERMIT 'FEE
V Z building construdion.and hereby amhorim representatives ofthis city to enter upon the SEISMICITH
above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)agree to cava,indemnify and keep hnnnlesv the City of Cupertino against ELECTRIC FEE
Ii,lodiaiec adgmems,ensas andcxpcusa wIbehnoy in any way;....udaia,acnid City AETF.R OR ADDTO MITCH.
ad ncectimarot the granting of this permit. PLUMBING IEE O
APPLICANT�{INITAN 'AND W'l1.L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT fI'O IQ(IdU CRhD
AMI.IC RE iIs A' I S -P MECHANICAL FEE
AIR HANDLING UNIT(OVER loop CFM) CONSTRUCT ION TAX
Signature ApplieanVContr.nnr Tum/ EXHAUSTHOOD(W/DUCT) HOUSING So TIGAI ION FEE
HAZARDOUS MATERIALS DISCLOSUR17
Will lhevpplicnit nr farm building occup;mT ulna or hanAlc hazardous material HEATING UNITf70100,000 BTU)
as defined by the Cupertino Municipal Care,Chirpier 9.12,and the Health and Safety
Code,Section 25fi32bo! IIEA'I'ING UNIT(OVER 100.007 111111
E]Yes VENTILATION FAN(SINGLE RESID) PAID
Dale Receipt a
Will the applicant or future building weupom use equipment or devices which
Iran hamrdous air contaminants ax defined by the Bay Area Air Quality Management BOILER-COMP CHIP OR 100,00011'1'UI .1 T
Disn'ic,i
ElYes BOILER-COMPIOViiIt 100,000 H'fEl
I have real the horrendous materials hcyuiranems uhWer Cha,ter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE;
fomia Heath&Safety o e,Sections 25505.25533 and 25534,1 undehs.nd Ih:n if the NEW RESIDENTIAL MHCIL SQ.IT. //-
.11
>
mildingdor,aa ctvrem have,ener,,hatitlsmyreswnvihility to notify thosa'n,pml ( G
oflhe myuire Is �ti mu -nn"Timmi."TanceofaCmii�ul o;c hpn
Comforau oris `agent DocI TOTAL: ISSUED BY:
OFFICE