S 3108 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL Pl-Rp11T NO. 3108
BUILDING DIVISION APPLICATION/PERMIT i'LUMBING-ME(MANICAL 5
IIUILDING PROJRCE IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATH
lozZ W l l/
OWNIiR'S/AML': - Shin �11ONI3:` O RACy� SN�ME: 1� I .NO: NIC CONTIiOLp
ARCHITECT'/ENGINEER:
LIC NO: ADDIt HSS' /W-1 /� ❑
CON1ACf: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid By Applicant(Initial) BLDG ELECT PLUMB/ MECH
ED El ® ❑
LICENSEDCONTRAC'IOICS DECLARATIONQTy ELECTRIC PERMIT FEE
1 hereby affirm that I um licensed under prnvisimns of Ch:mtcr 9(commencing JOB DESCRIPTION
Offcz th$ectinn]ll(ggof Divisiun9 of the Business-anJ 1'mfessions Cale andmyliccuuis T
€„x100 wt. PERMIT ISSUANCE!
1- in full force and elTcct.0 U/6 FDWi. 0 KITCHEN REMODEL.
�UU i"use Iuss {.r L10.X APPLIANCES-RESIDEN'I'IAI, ❑ADDI'PION ❑PLUMBING RE-PIPE.
N Q 6 Dale Cont actECL
AHCIIITIiCTS DECLARATI ❑MULTI-UNIT' ❑STRUCTURAL
zOyZ l understand my plans shall he used as public records PANUS MODIFICATION
Oz-o UP DO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
1=.4t�j Liccnscd Professional 201.1010AMPS IMPROVEMENT E]SWIMMING POOLS
�Y7_1 OWNER BUILDER DECLARATION OVER IWEAMPS ❑BATH REMODEL/REPAIR El DEMOLITION
yC 1 hereby affirm that I am exempt from the Contractor's License Low home
L?x�506 U following reason.(Section RDI S,Business and Professions Csdc:Any city nr county SIGNS ELECTRICAL V HEg/
W 3 WI- which m,uires a penult ,,ennsuva,whet improve,demolish,or mpir any strumb re SA1 C j2
KBO priortuits iks ..b,al......for,the upplicam for such perminn f lc a signed.%atcment SPECIAL CIRCUIT/MISC. s
yy that he is licensed pursuant to the provisions of the Commences License Law(Chice,9
IyaCC (commencing with Section 7")ofninsion H ofthe Business and Professions Code)or TEMP.ME EBB OR POLE INST. COMMERCIAL:
d a e Iv Choi he is exempt lherefmm and the basis lit the alleged exemption.Any violation of ❑NEW NLUG/ADDITION ❑DIiMOLI'I'ION
k• Section 7031.5 by any apprcnmt fan fiction subjects the applicant to a civil Penally of POWER DEVICES ❑TENANT [2 FOOD SERVICE
ml marc than five hundred dollars(1500), lip
�+ Q I] I.as owner of the property,or my employees with wages as their sole compensation. SWIMMING 11001.ELECTRIC IMPROVEMENT
"Sys will Jo the work,and the structure is not intended or offered frosale(Sec.AW,Business L1 OTHER
W m omit Professions Gale:The Com stor's License Law does our apply m an inner of DUE LETS-SWI'I'CH&S-FIXTURCS
6'w^ pmpeny who builds or impmves demon,and who dues Such work himself or through
sixic
his own employees,provided thin such improvements are not intended or offered for NEW RISIDENTIAI.1:1I'M R SQ IT.
sale.If.however.the building orimprovement is sold within one year of completion,the
I1.00R ARBA S/SQ.1§'.
invo,builder will have the burden of proving that he did not build or improve for put-
pose of axle.). 7
TOTAL:
1,as owner of rhe preprny,oro exclusively cmmctic,with licensed contractors it)
construct the project(Sea.7044,Business and Professions GrdcO The Correctors Li-
ccuse Law does not apply to air owner of property who builds or improves theme,=it QTY, PLUMBING PERMIT FEE
who sommm.Lor such pcircls will,a comcaemms)licensed mromm w the Contractor's
License Law, PERMIT ISSUANCE
Fl 1 am exempt under Sec. ,B&P C for Ibis reason
ALTI7R-DRAIN&VFNI'-WAITR(EA) VALUATION
Owner Date
WORKFR:S COMPUENSAI'ION DECLARATION BACK FLOW PROTECT.DEVICE
1 hueby,M.under penalty of perjury one of the following decNi inion,
❑ Ihave and will mainmine Cenifirmc of Conum mulGinsum forWmAcrs Grmpen- DRAINS-II.00R,R(IOIi AliEA,CONI). STORB: I'YPECONSTRUCTION
tion,as provided far by Secninn 9700 of me Letter Cale,for the pedurroaaoe of the D
Elwrch ibis ponnr is issued. FIXTURES-PHR'DAY 5 1998
hove and will maimoin Workers Cmnpensanion Insomoce u.s required by Section
- lofthe LiE ,Cde.far the pefuoname of the work far which this permit is issued. GAS-EA,SYSTEM-)INC.4 OUTLITS OCC.GR( APN
My C nWmlcr'x Cn fiensnity° ePrWil cY Na,:�ump¢�,y ,I �q
m LlLryeY�J l]T CAS-IiA.SYS TEM 4 OCO
CER IFICATF.OF EXHMPfION FROM WORKERS' C0.EASIlINDUSTRL WAST"INTERCEITO0.
COMPENSATION INSURANCE G DIVISION PERS
(I his sectotvmed not be complmN ifthe permit isforonebundreJdollan($100 GREAS17TRAP
or lnse) I PLANCIIFCK FFG
1¢nify than in the perfurnuce oflhe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.2x1 FT.
mol employ any person m any manner so ax m became subject m the WarAcn.'Coni SEW FEE
Oz sation Laws of California.Due
Q Applicant WAT'IiR IIEA'1'EH WIVI3MI'/ELF,CI'R GRADING FEE
z
7 NOTICE TO APPLICANT.If,am,-making this Catitlewe of Exemption,you should WgILR SYSI'FM/1'REATINC
alacomesnbieO to the Workers Cumpenwlino prockinn,of lire LaM,Code,you must SOILS FfiE
W ti fonhwiNcorridy with such previsions nr this permit shall hedeemed revoked. WATHR SERVICE
0. 0
UO CONS'TRUCE ION LENDING AGENCY NEW RESIDP.NUAL PLMB. SQ.PT. PAID Dam NecciP1X
I hereby nffirncu
i that mer,is u constram lending agency for the Performance of
the work for which this permit is issued(Sac.3007,Civ.CJ
u" Lenders Name TOTAL:
L) Lendct's Address TOTAL: 0
W / BUILDING Il3E
1 eerily that I have"outdo,llilyund .rc end drum that the above information is
Zi amem.ingrmmimn,ad comply withaltoilwcoemum,wfwi ,o f,hidmaoi,mwuming he QTY. MECTIANICAI.PERMIT PF.E
V4 building constrvaion,anA hereby auNoriee represemmives of oris city mentor ngnt the SEISMIC FEE
alxrvc-memlaned pmpeny lot inspection purposes. PERMIT ISSUANCE
(We).,me m nooc.indemnify and keep hmmlcxs the City of Cupertino against ELECTRIC FEE
Iinhiiide,judgmenu.costs and expenses which may in any wayacervc against said City ALTER OR ADD TO MECH.
in nsespmnee of he gorming of Nis permiL F'UMH IN 1131!
APPLICANT UNDERS'T'ANDS AND Will.COMPLY WITH ALL NON-P(IIN'T AIR HANDLING UNITC O IB.000 CFMI
SOURCE REGULATIONS. MECHANICAL I4eE
AIR HANDLING UNIT(OVER 10,01)CFM) CONST RUCTION TAX
Sigmamreof Ap,hemVComrvcmr Date EK I iq US'IA 100D(W/DMC1') HOUSING MITIGATION FEE
j HAZARDOUS MATERIALS DISCLOSURE
Will the appliemt a,lat..building occupant oaten,handle havannus material HEATING UNIT(TO 100.000 RTU)
as de@med by the Cupeni no Municipal Code,Chapter 9.12,and Ne Health and Safety
Cale.Section 25532(.)p I(EATING UNIT(OVER I00.(Nlo bi
❑Yes Fl VENTILATION PAN(SINGLE RESIDE PAID
,f• Will thea licunt or future buildin m use e m or devices which Date Receipt X
pfi lby he .Airne BOILER-COMP(311P OR 100,000 IIT U)
f emit hmmdoue air cnnmminants ns JefineJ by the Ray Arcu Air Quality Management D
Distncf! L:
E3 Yen FI No BOILER-COMP(OVER I0 ,000 BTU)
Alit CONDE I IONER
I have rant the haeunlous nwmriula raquircmm�rs sealer Chanter 6.95 of the Cal, AIR DATE
fools Heahh&Saeo,Cade,Sections 2550-5,25593 and 25594.1 anderslatW that it Na NEW RESIDENTIAL MI!CI1. SQ.IT.
huildm ,us�nm cunT ply has,.temnb that it is my restow,holbym notify thco,,,ar
of the r n i�cEn crus M oet Friar m issuance of a Cceirlcate—/ y(p�� ✓ f
I
Owren eJ agent Date TOTAL: ISSUED BY:
OFFICE