S 3167 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. q
BUILDING DIVISION APPLICATION(PERMIT PLUMBING-MRCIIANICALS 316 7
BUILDING PROdECI'IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
10301 *41CASIRV8 4 '0R // i9 l
OWNER NAME: PHONE.: CONTRACIOR:SNAME: LIC NO�^�� N/C CON'TROLp
FJ Muisism 0 3c — 1l3�{ Nu'+S+rwo♦"PIo., I ❑
ARCHITECUENGINEIIR: LIC NO: ADDRESS:
e 11143 /CAnPBeL� CA Is-oil
CONTACT`. PHONE: BUILDING PERMIT INFO
❑ Consultant Feng Paid by Applicant(Initial) BLDG ELECT PLUMB kini
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY IiL-CTRICPF.RMI'I' FEE
I hash,affirm than 1 min licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
nwzwith St,U,..7100)of Do sion3oftire llisincss slid Professions Coat unJmy license is RESIDENTIAL
ENTIAL:
Fob in lull farce olid tRm, PERMIT ISSUANCE
µIF 0SFDWI, O KITCHEN REMODEL
�UU License Class LIe,M APPLIANCF,S-RIiSID13NT'IAL ❑ADDITION O PLUMBING RE Pi1R?
y z W Dane Contractor
ARCHITI=S DECLARATION ❑MULTIUNIT ❑STRUCTURAL.
-Z undemm nnJ my plans shall he used public records PANELS MODIFICATION
OZ=a UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
F.y.�W Licensed Pn It......I 201-10WAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER 1(Xp AMPS O BATH REMODEIJR17PAIR [ID17MOLUION
a Q 1 hereby affiran that 1 am exempt from the Control License Law for the
6 O G U following reason(Seined,7031.5,Business and Rnfessious Code:Any city or county SIGNS ELECTRICAL [I OTHER
I' which re,mres a permit In consaud,aIle,impmvq demolish,or repair any a mcwre
NW prior to its issuance,also requires the applicant for such permit to life a signed statement SPECIAL CIRCUIT/MISC.
5� that he is licensed pureanua the provisions oftb,Comntmm's License have(Chapter 9
W a�pO (asmmcncingwith Swtinn]IXXry,f Divisi,nJof tM1e Business and Rofessions Codc)nr TEMP.MITER OR POLE INST COMMERCIAL:
d y c that he is exempt therefrom anti the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION 0 DEMOIATION
µX1 m
Section 703 t,5 by any applicant for a permit subjects the applicant to a civil pemOty of POWER DEVICES
not more than five hundred dollurs(S5Wh 0'[M OV [I FOOD SERVICE
�Z> IM OVBMIIM'
6 MLothe work,
fine peanictor anyemployeeswithendforaile(Sm.co ,Business SWIMMING I'OOLQLECTRIC
F will doth,wons CdtheN Conturera tors Licerse Law dos not apply 1.a. Business ER
�{�d and .y whops Cndm The era a mora License Low Jon not apply to un owner,[ OUTLETS-SWITCHES-FIXTURES
his own who build,or improves thereon,and who does such work himself or through
hiss wt employees,provided that such mens ,menti are not inandW or offered for NEW RESIDEMfIAI.ELEC:R SQ Ir.
vlc�If,however,the huilding,rimpmvenrem is sold within line yenndannplmion,the SQ.PI'.FLOOR AREA 5/SQ.IT.
civerser-bulder will have the burden of parting that he did not build or improve for pur-
1,as owner of the pm,.,am exclusively comment,with licensed nalim crs 1. TOTAL'
resumer the project(Sec.7044,Business end Ro t,,si,ns Cale:)Tam Commctor's Li-
museLawdnexnotapplytoanownerofpmlenywhohandsorimprovesthemon,and QTY. PLUMBING PERMIT FEE
who commas for mch projects with a mard.lons)licensed pec uum in the Comostun's
License Law, PERMIT ISSUANCEr
0 1 an seraph under Sec. B&P C for this muton
O -1 g11L_ pALTER-DRAIN&VENT-WATTR(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 Illunion under penult,of perjury one of the fallowing declarations:
E]I have and will maintain a Cenificnm of Cilin self-insure for Wnrkeea Conmem DRAINS-FLOOR,ROOF,AREA.GOND, STORIES TYPE CONSTRUCTION
satin,,as provided for by Section 3701,E the"No Code,for she performance m the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will maintain Workers Compensation hotor at,as ne me d by Satinn
3]1X1 nfthe LuMu Cwk,loose perbmmunce,l the work lar whicM1 thin permit is issued. GAS-EA.SYS'TEM-I INCAOUTLETS OCC GROUT' AIN
My Workers Campensution Insumnce comer and Policy number are:
Careen Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE. GREASMNDUSfRLWASTC INTERCEPTOR BUILDIN(1 DIVISION FEES _
('Dissection need not ed completed!if the permit is for one hundred dollms($1 W) GREASETRAI'
' or less.)('Dissection
FFai
Icenifythat in the performance ufhe work for which this permit missuwL lx hall SITWER-SANITARY-STORM F.A.21X1 FT.
rs
not employ any peon in any manner so as lit become subjeci m the Workers'Cmnpen- HNERGY FEE/I Lall
Oz mica laws of California.Date WATER IlHATER W/VENT/1TTC1'R
z ApplicantGRADING F'E
r/4 NOTICETO APPLICANT:If,after making this Ccnifc lc of Exemption,you should WATER SYSTEM/TREATING
I✓ hommm subject so the WorkerFE"A
Compensation provisons of the Labor Code,you must SOILS F
Wsr fail hwilh comply with such provisions or his permit still]M deenmd revoked. WATER SERVICE
Ci Q
vO CUGOONLENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID i
1 hereby affirm thanatthe.there construction umi,n lending agency for tM1e perl' w
nrnncc of i to IteceFt4
the work for which this permit is named(Sec.3(19],Civ.C.1
OLender's Name O TOTAL:
�s U Lemlefs Address T T
µ. 1 certify Nm st
I have read this application and state that the ave information is BUILDIN'ItiQ
.yT4/l mrrccLingmc to usmplywith all cityunA entntyonlinumes and stem lows relwingm QTY. MECHANICAL PERM ' FEE'
V z building construction,and hereby autharim,representatives of this city to enter upon the SEISMIC F'E
ade vementioned property for inspection purposes. PERMIT ISSUANCE
(We)agree motive,indemnify and keep harmless the City of Cupertino ogainn I_LECTRIG TV
liabilities,judgments,costs and expenses which may in any way active again,said City ALTER OR ADD TO MECH.
in ocinence t he grating of Ibis pemoil PLUMBING FEE n
s
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLI NO ON I'ITO 10,M)CFM)
Sou 1:REGULATIONS. MECHANICAL FcE
ILaI,_1 /} ,,� �_��— II/19/9d AIR HANDLING ON]T(OVER10,(XxfCFM) CONSTRUCfION TAX
.Wundra of Applicunl/Cnnwem Dnk, EXHAUST thwi)(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Or.,,licam,r hame buildia,metpunt store or handle hanurdovs material HEATING UNIT(To IW(100 BTU)
as shined by the Cmanino Municipal Cale,Chapter 9.12,and the Health:and Safety
Cala.Section 2 532(0'! HEATING UNIT(OVER IIN,gX)BTU)
❑Yes 7 N vwrii.A'TION FAN(SINGLE RESIO) PAID pure RecciptN
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,W0 BTU)
emit haterdous air contaminants as defined by the Bay Arca Air Quality Management Lc
District, BOILER-COMI'(OV ER I(X,,ppd ItT(1)
El Yes F1 No O
AIR CONDITIONER
� I have read the Wooden,materials rcquircments alder Chapter fi 95 of the Cl ISSUANCE DATE
Earn,Health&Safety Code,Sections 25505,25533 olid 25534.1 understand that it the NEW RESIDENTIAL MECH. SQ.FL
budding doss not currently base a tenant,that it is try resPonibili it)notify the occupant o
ill'@c requirements which must In met prior to issuance oft Cenirtcme of Occupancy.
1 Owner or uulhoriud agent Date TOTAL: ISSUED BY:
OFFICE