S 3366 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PN ITNO
BUILDING DIVISION APPIACATION/PERMIT PLUMBING-MECIIANICAI, � 3366
BUILDING PROJECT IDENTII+ICA'1'ION
BUILDING ADDRESS: SANITARY NO. APPLICAIION SUBMITTAL DATE
;110 S ON 2-/G•-4
OW F, 'S AME: PHONE: 1 "TTT CI :SNAp1E: LIC N(
VA U 11V\ Y NIC CONINOha
ARCHTHKI'IENGINEER. L1CNO FtiR V ❑
CONTACT: PHONnE: BUILDING PERMIT INFO
�V /�t ❑ Consultant Fees Paid by Applicant(initial) BOG ELFCT PLUMBS ME❑CH
El
Z 'm full fI hereby
i ended F.DCfcensed order
OUCLARAI Chapter
QTY. I;LECfRIC PERMIT FEE (TIO
NTRA"I OR
1 nereny arum mal 1 am licensed a.aer pmvixiam.c nr enapmr 9ldmnmed=ins JOB DESCRIPTION
,h 5ectinn 1f100)af Dlvision3 of dPmfc,am,Citic. Ylicerm i. RMIDENTIAI:
1+10 0 in ^� �f ZpaCL� PERMIT ISSUANCE.
[—W•• — �''� 3 / J7 J ❑SFDWI. [I KITCHEN REMODGI.
Pzwl.iccns Lic.M X APPLIANCES—RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
h<i Oac Cnmmmnr
ARCHITECTS DECLA ATION ❑MULTI-UNIT ❑STRUCICAT[O
F y Z I undeoland.a I PANELS
OZ—� Ypnnt shall he usul ns puhLe annds MQDII'1CATION
U1'T02110 AMPS ❑INTERIOR ❑CHIMN17Y REPAIR
W Licensed Professional 201-100AMPS IMPROVEMENT SWIMMING POOLS
OWNER BUILDER DECLARATION OVER Half AMPS [I BATH RCh10DE1JN1iPAIR ❑DEMOLITION
6`C I hcrchy afOnn that I mm exempt fmm the Cnntruemr's License Law for the
�Oi" following rcmon.IScmion 9lD L5,Business vnJ Prnl'cesionc Code Any city nr county SIGNS ELECI'RICAC ❑(YTHER
3 LL y which requires a permh m co.,mi after.impmve.demoLsh,or repair any stmcmrc
O /
priormil.si....ace,ulsorequims the applicant mrsuch permit,,Elea signedstatement SPECIAL CIRCUFUMISC.
that he is licensed pursumn to the provisions of the Conauctur's lama,,Low(Chdpmr9
X00 (commencing with Sealion]01N)of Division3 allied Business and Nofemions Cade)o, I IMP ME117R OR POLIS INS'1'. L'
d 6 e C that he is exempt therefrom and the basic for me alleged exemption.Any violation of Q NEW BLDG/ADDII ON ❑DEMOLITION
Second 7031.5 byany appli...If..a permit subjects the applied.,„s civil penalty of POWER DEVICES ❑TENAMr ❑FOOD SERVICE
y'Z
n mom Ihun me In died dollars($5001, OTHERVIiMENT
5Q ❑Laahemoowner ofthe property,
esmarter myemployeeswith wages
rsale(sole cmrpematinn, SWIMMING POOL ELECT
will dome work.aide The mreltno,s License Law
os for sale iply to anommcas ❑OTHIiR
{ai1"m nnA Prolexcions CnJe.The Contractor's License Low dues urn apply,o an owner of OIITLCTS—SWl'I CITES_FIXTURES
property who hops.or Impmvex thereon,and who rams such work himself nr mango
his adv employees,provided that such improvements are not intended or o2mr!for NEW RESIDENTIAL I;I.EC1'R SQ
sale,If,however,the ImAdingorimpmvement L.sold within one yearefcmnpletion,,lie SQ,FN FLOOR AREA $I$Q.IT.
er-hail icr will hove the btudem of paving that he did a.,huild or improve
p rc of sale.). TOTAL:
❑1,as mare,of property, it,exclusively contmming c en. untmm
mstrvm the Project(Sec.1011.Ilusincts rail Prof Cala:) be���lttfactin L
se Lttwdoes amnpplyman owner of ywnnhtgany hereon. TY. PLUMBING PERMIT FEE
who denten forsuch Pmlutswand ntrmgx)lic , mImflcC:mlram
License law. ((��RI PERMIT ISSUANCE
❑I on excmp,under See
. .y s(I�C11S�1_rs tY"cam
Owner
ALIER—DRAIN&VHN1'—WA'I'IIR(EA) VALUATION
Dulc
WORKER'S COMPENSON Of CLARA'1'ION BACK FLOW PROILCI'.DEVICE
I hcrchy affirm under penalty of Perj eofinef,,llmvingdcclanam,
Ihavumdwill mnintainaCeniG, 7. =rat wsclf-inauie for W. ry✓ DRAINS—FLOOR,HOOF,AREA,CON D. S'1'ORWS TYPO CONSTRUCT ION
smion,os provided for by Section 3900o1'Il L.Mir`ICrile,f nonce of me
k far w r which,bis permit is issued. B] FIXTURES—PER TRAP
I] I ho1 0 will maintain Wmkde Contpcnx sdmnca'as required by Section �1�
3700 of the Labor Code, rmcicH,,rmmceol hewn,k far whichmis pconillnissacd. GAS—IIA.SYSTEM-I INC.
fa4 Gt1'TLBTS l (/ OCC.GROUP MIN
My Workers Compensation Insurance carrier and Policy number ore:
CerticC Policy No.: GAS—F.A.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' II
COMPENSATION INS GREASPIINDUS'I'; WAS'GI I PP`IOkEl M
BUILDING DIYIMGN FIZI!S
isseni,,ni
it IN mm et,iIthe 'I is l'orom undreA dollars 1$1(X11 GREA51i TRAP
LF
or Ie .) PLANCHECK FEE
rertifythm io the arfurnwnce that kit hichth' •ani,iv lxnunl,ISNuII 5 SEWER—SANIT ST01 MIy1. NI I'.
nut emp any p...... any. t 'the Worked Gimped- ENERGY THE
O z xauon l.aw. fC: its.D WATER HEA'TF. VF.NT/ELIiCTR TRADING PEE
7 0 Applicant t
q y NOTICIi'TO APPLICANT'.11'all tnoAin i.v CerliEm a H emp,iun,you shouhl WATER SYSTEM/ tHA'I'INC.
E✓ bwome subject to the Worker'. . "".l....
m sinnc of Ibe Lahor Cotle,you mural pp SOILS h'HII
W 'mmwi,hc�mplywithsuchpn nnhis rmitnM1allMdecirteJrcvnkeJ. WATERSERVR:q Oy
a Q imis
CONS'1'ItUCTI ' LNG AGENCY NI?W RESIDENTIA1,FLMH. My F1', PAID
VRemipl q
1 hereby aflirt i that there ie s ed(See 30 lending agency for the prlinmance of
H Leader,fur which,his permit is issued(Sec.109],Civ.C.)
u" LenJcr's Nwnc '1'OTAh:
O V Lender's Address TOT
�+ � r BUILDING P.
I certify mm 1 have reed this applicmion and.arae mat the above informminn is
.F.t UJ comet.I agree na daintily with all city and county eminences and nate laws relating to QTY MECHANICAL PERMIT FEF
C.77. building,dr,mctiun,and hereby mdanir.e representatives oftlescity memter upon the SEISMIC PEI(
above mentioned pmpeny for inspection purposes. 11I7RMIT ISSUANCE
We)agree to.ova bad and keep harnlcss the City of Cupertino against IJ.IiCTRIC I iii
iabilitics,'mgments, miles, which may many way acerae against said City AL'fEk ON ADD TO MUCH.
sego ¢ linin ispermlt. PLUMBING PP.E 1
I
APPL"' T I 'I S'A AND WIf.I.COMPLY WITH ALL XON-POINT AIR HANDLING UNIT(TO 10,000CFM7
u MIiCHANICAL PGI(
SOU HERE If NS.
AIN HANDLING UNIT(OVER I11,000 Clip C(INSTRUCTION'PA%
Signature of Ap no mmcmr Tmhk EXHAU STI 1001)(W/DUCT) HOUSING M ITIGA'I ION FEE
IA RDOUSMATERIALSOISCLOSURE
WdIthenpplld l a retain building occupant more or handl=hazardous material IIHATING UNIT ITO 100.010 It'[Of
na defined by the Cope i Municipal Cuda,Chnpmr 9,12,dad the Health and Sant,
Code,Section 955321a)Y HEATING UNIT(OVER 100,04)BTU)
E]yet C]No VENTILATION FAN(SINGLE RISID) PAID
Will thea liedin or Linda,huildin ... f use mo or d....cs which Date Reecip ll
pp 6 Pat' Ana
BOLLEN—LGMP I3HP OR IfM1,INX)B'TU)
emit ied? us air communications as defined by the Bay Area Air Quality Management T AI
Uismn4
EJ Yet 0N BOILER—COMP(OVER 100.000 BTU)
AIR CONDITIONER
I have read the hazmdou,material.,mini emems ander CImpter 695 of me Cali- ISSUANCE DATE
humid Health&Safety Coda,Sections 255115,25533 and 25534.1 understand thin If the NEW RESIDENTIAL MECH, M.IT.
building dnex not curmndy have a mmmnd,dtat if is my ra.pnneinia,to are fY meow., t G I/
of the requirements which must be met prior to issnunce of a Certificate of Occupancy.
Owne,tnaumnri,edagent Dae TOTAL ISSUED BY:
OFFICE