S 3848 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERNTIT PLUMBING-MkS 3848
hl_UI,-fry=IRRUII.HINGPROJECLIDF.WIFICATION' !f' f/lma,dl
BUILDING ADDRESS: SANITARY NO. APPLE TION SUBMITTAL DATE
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OWNE NAMII: PIIONIi: COfJ'IRACfOR'S AMB: LI O:
-123/'f0 NIC CONTROL
ARCHITECT/ENGINEER: LIC NO: /' ❑
CONT Cf: PHONE, }(pjjf7if::'%1fBUILDING PERMFrJNFO'`I1:,,!/fl'1"
r r ❑ Consultant Fees Paid by Applicant(Initial) BL❑UC ELEcr PLUMB MEC1
IIIYYW�/// d1.i a L.d
LICENSED CONTRACTOR S DECLARATION 1(II r Iys ' 1_ �f
QTY I• I I 7 LLCCPRIC PERIA T'f „(I ( f�I,FLE ��
I hereby affirm that i licensed oder previsions of Chapter 9(commencing ) o . I t s f tt h t n.. t -JOB DESCRIPTION
WoZ msecron]Bro)ony _'om3onne Business aid Pro[esmore clbe.and my l'celnes 'RESIDENTIAL'
X00 WI PIiRMITISSUANCE
F�� n full force and cRccl, r Q NFDWI. El KITCHEN REMODEh
aVU hicensocClssAPPLIANCES-RESIDENTIAL []ADDITION ❑PhIlM61NG RE-PIPE
Onley
ARCHITECT'S DUCmh!
A ❑
PANELS MULT6UNIT El STRUCTURAL
Zpo�Z IunderxumnJ my plansshall he mWmss Publicrecords MODIFMODIPICATION
OZ—� UP T0200 Ah11'S ❑INTERIOR [I CHIMNEY REPAIR
F��'ad Licensed Profexsionel 201-10IMAMPS IMPROVEMENT [ISWIMMING POOLS
OWNER-BUILDER DECLARATION
C Y ; OVER 1(I(I(IAMPS ❑BATH REMODEDREPAIR ❑DEMOLITION
Q I hereby affirm that 1 am exempt from the Contractors License Lew for the
3 c.F fEJ ollowing rcaroNei ection]031.5.Business and Professions Gsm:Any city or county SIGNS ELECTRICAL
W C1 OTHER
ad O which 4 :' pe mm� I I all p d I.M1 p any
N pro I t iLsacquiresIn ppl'a- II hp I signedo iment SPRCIALCIRCIPHYMISC.
�} tholh 1 Ip su n U p fth C Ian 1' 1 [Chvpmr9
ly gm (cont ' g Ih Sect ]000)of0 ',' n3oflhe0 . td 141 CMe)or TEh1P.METER OR TOLE INST. e M -
a o e C that he Is exempt therefrom and the basis Enron,alleged exemption.Any violation of �O L)NEW PLDG/ADDITION [I DEMOLITION
so sons Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
I than rive hundred dollar, ❑TENANT ❑FOODSERVICE
E z Y nn more IMPROVEMENT
any-j, 1 rill property Y phy wage,a,the 1c Business SWIMMING IV)OI.ELECTRIC
o
O dld II k dths.l Iintended o IG:
ffr: l (See.](W4.Bu ❑OTHI?k
❑] and Protession,Code: I lie Contractors Law does mou apply to an askarT nl OUTLETS-SWITCHES FIXTURES
n' property who Wilds...impro a there n,and no t x such k hirreelt or gh
his own employees,provided that such improvements are not intended or offered for NEW RESIDIN GAL ELECTR SQ FT
sale If.however,the Irmidingorimp..coach,is sold within oneyearofcompleion.rhe SQ FLOOR AREA ASQ.Err
canar-latilder will have 0e burden of proving that he did not(wild or improve for purr
pose of sole k
❑ E,as owner of the properry,am exclusively contracting with licensed contractors to TO AL: r
construct thpoiject(S ID4i Business randProfessions C dc')The Contractor's I 1 1 ti i t-i t t ht,iY'.L.t 1 ( j
�QIYt J ( � UMBINGoPIiRMI'6 1'11141 s (I PH I+, I'�� �1
wh: t ri .:eL pct] t aWau nr r(s7liccnsed pu: II th Contra I r '- 1s � ) ,nl n + I I :s P., �
LicenseLaw. PERMI9ISSUANCH
❑1 am exempt under Sec ,B&P C for this reavm
AI.TER-DRAI WATER(EA) I 'jViol VVO.0
Owner Date
WORKER'SCOMI'17NSA'I'IONDECLARATION BACK FLOW P ECT. E
1 hereby aDirm under penalty of perlury one of the following declarations:
I haveond will mntintain o Cenificateol C...ucm to self-insure for Wiker'a Co.,,,,- DRAINS-FLOOR,ROOF,AREA, . D. f� "� ! RI1C9'ION
saiinn,as provided far by Section 37W of b
the labor Code,for Iha pdr entranueof Ibe FAV STGRH:S
work for which 0is permit is issued. FIXTURES—E'ER TRAP
❑I have and will maintain Workers Compensation Insurance,or,required by Section
3100 ofthe Labor Code.for she performance of the work for which this permit is issued GAS—EA.SYSTEM-I INC.J OUTLIifS OCC.GROUP APN
My Workers Contra,It�tion Insurance carrier and Policy.r.grl�R'3�: F4 GAS—EA.SYSTEM-OVER i(EA)
Comer /1O.d Policy O WOR ER w
CIiR'1'119CATEOFF.AIION1INN FROM WORKERS'
COMPENSATION INSIIRANCI! GREASEIINDf15'IRL WASTE INTIiRCLiYI'OR
(Thr,wr1inn need not be complemA if the permit is fonmchundredol,dauxl00) a IIUILDING-1)IVISIONPf:Es-
or
lc,,,) GREASE.TRAP PLANCHECK FEE
Icerify that in the peKormance of the work fur which this permit is issued.ishall SEWER-SANITARY-STORM PA.2IX1 FT,
not employ any I orron in any manner so as to became subject to the Workers'Compen- ENERGY FEE
Z sotion Laws of California.Date WATER HEAT ER WNENT/ELECI'R
Q Applicant GRADING FEE
rq NOTICE TO APPIJCAN'C If,after making his Certiricme of Exemption,you should WATER SYSTHM/TRP.ATING
become subject to the Worker.Cw i,creation us....ions of the Loux r Code,you mull SOILS PUT
WIOnhwish comnply with slmh provisinm nr Ihis permit shall be dcemal revoked. WATER SERVICE.
5 z CONSTRUCTION LENDINGpGI?NCY NEN'RF_SIDIiMfIAL PLA1R. SQ.Fr. PAID
V Iherehy allirm that isacnnmm�inn leWing agency fonhe performance of Receipt•
he work for which Ihis Pontin is issuedeo
(S .3097.Co,C.)
IL r. Lenders Name TOTAL:
V Leader,Address TOTAL
a ) s BUILDING PCE
I c ofl IL I I' d h prat J state that h l f m U h correct.I agreiticaurply zilh all cityand county ordimmuciand: s tat gt fk rM.IECF.rAsNICAtLz PP1 RM-I•I t II a~ ttt ' I tbuildingenvuctand hereby h ri�.representatives efthscty to enter upon theQ7 -ri1`'.jS TNNr''ui sr-
SEISMIC PER
above mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE Q
liabiliues,judgment costs an xpemes which may in anysay acerae against said City ALTER OR ADD TO SUCH.
in nsequence o e gr T of Ihis 4��_
PLUMBING FEE
APPLIC T DF DS ANL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO It"CPM) MECHANICAL FEE
SOURC
Alk HANDLING UNIT(OVER 111,1X)11 CFM) CONSTRUCTION TAX
Signmre of APPI nmacO Date • EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
EAZARDOUS hLVERIALS DISCLOSURE?
Will thea liconl or future buildin6ox,trem score or handle hazatJous material HEATING UNIT LTO I00,OW B'N)
us def re l by t Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Corr,Section 25532(u)? HEATING ONE(OVER I00,000 BTU)
❑Yes ❑No
VP,NTI I,ATION PAN ISI NGLF RES IDI PAID -
Date Rewim d
Will the applicant or future building occupant use equipmunl or devices which
emit hazardous air contaminants as defined by the Ray Area Air Quality Management BOILER-COMP DEEP OR I60,000 BTU)
TA
Uislrict?
El Yes EllenBOILER-COMP(OVER 100,000 BTU)
AIR CONDITIONER
io.mH
e the or
us an rick mryirmnems under Chapter 695 of the Cnll- ISSUANCE,DATE
h re,afe ,Sedionv 255 5,25533and25534. understandthatifthe NHWRESIDENTIALMECH. SQ.Friole Ihuvevrenunll m it is my responsibility hat notify Ilio uccupatu uel be est u:is. cum of Ocwpaney.
Owt r am m agent Date 'TOTAL: ISSUED BY:
OFFICE