S 3284 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERp1IT NO. 3284
BUILDING DIVISION APPLICATIONIPERMIT
PLUMBING.�AIF.CHANICAI. ICJ
INILUINO 1'ROJRC'T IUEN'I'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
10/ ti Cilk, HWIODr ke-, /_ 3--9�
OW ER:S NAME: PHONE: COM�L'OR'S NAME: LICnNO:
h ' TAI) % lU N/C CONTROLp
• ARCHITECI'/ENGINEER: LIC NO: ADDRESS. 9 ❑
/J 7 S Q.&Z-, t.I- t
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
S3-04 i$ ❑ ❑ �.
LICENSED CONrRACITIR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that Into Beensednude,prozoo e m Chapter 9 mommene;ng JOB DESCRIPTION
O�Z with stttion]0(IIB nrDivision3oftne Business and Nnfessi...Code,mamYBcenseis RESIDENTIAL
.
LL O O PERMIT ISSUANCE
F U.. in full lane and elFca. ❑NFOWL ❑KITCHEN REMODEL
aUV License Class Lica APPLIANCES-RESIDENTIAL ❑ADDITION E3PG LING RE-PIPE
F+�W Dam Costco,
N 6 ❑MULTh UNIT ❑MODIFI STRUCTURAL
ARCHITECTS Im.,oi DEC blit records ON
PANELS MODIFICATION
y Z 1 understand my plans shall he and us public recmm>
UI'"f021N)AMPS OZ=`S EJ INTERIOR OSWCHIMNEY
MING REPAIR
1=.��a1 Licensed Professional 2f11-IgN1AMPS IMPROVEMENT OSWIMMING POOLS
Cw , OWNER-BUILDER DECLARATION OVER 1000AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
C W Q I herehy affirm that 1 em exempt from the Conlmaors License law for the
px,O W U following reason.(Section]0315,Business and Professions Code:Any city or county SIGNS ELECTRICAL 0OTHER
41�+LL y which requires o permit to construct,aIle,,improve.demolish,m repair any streclure
.F.�Oar prior m its Issuance,also requites the applicant for such permino file asignodatatemenl SPECIAL CIRCUTTIMISC.
V, Inst M as licensed Punuum lm the provisions of the Comredors License law(Chnp¢19
LLCO (nnnmendng with SecTLn]aq))n[Divisinn3of the Pusinesx and Professions Gde)ar T'I?Mp.METOR OR POLE REST COMMERCIAL
a a�a e os Ihm he is exempt thcrefmm and the by is fur the alleged excmptian.Any viulmion of ❑NEW BLDGMDDITION ❑DEMOLITION
WIto Section 70315 by any upplicnm forapemtitsanjeets lhcapplicamm scoil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
FZi not more than five hundred dollars(S500). IMPROVEMENT'
q5p ❑ 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL EL[CT0.IC ❑OTHER
02 will do The work,and lheslructure is sol intended motored for Uda(S..7m14.Brsinev
and Professions Code:The Contmaors License law fres not apply to an owner of OUTLE1:S-SWITCHES-VIM URES
property who builds or improves thereon,and who does such work himself or tnnmgh or
his own employees,provided that such imprecisions are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the building or improvement is sold within one year of completion the Q.Ff.FLOOR AREA SISQ.FT.
owner-builder will have the human of peeving that he did not build or improve far pur-
pose of sale.)
0 I,as owner of the property,am exclusively contracting with licensed contractors to 1 OTAL:
construct the project(Sea 7(44,Runness and Professions CedcJ The ContmctorI L.i-
censelawdocsnotapplytounownerofpropertywhobuildsorimprovesthercon.and QTY. PLU M B INC,MRM IT FEE
who contracts for such pro ac s with a con evensr(s)licensed pursuant to the Contractors
License Law. PERMI T ISSUANCE
I am exempt under Sec. .B&P C for this reason
AINER—DRAIN&VENT—WATER IF:A) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty Npenury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compact- DRAINS—FLOOR.0.00E AREA,COND. STORIES TVPE CONS'I'RUCfION
sation,as provided far by Section 37W of the Labor Code,for the perfnnnanec of the O
work for which Imo permit is issued. FIXTURES—PER]RAP
0 1 have and will maintain Workers Compensation Insurance,ns required by See ion 1
3700 of the Lubar Cole,for the perfotmunce of the work far which this Permit is issued. GAS—F:A.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Work Ca ets.tr mce ca ierand Policy nal
/` ns p L�1 GAS—I?A.SYSTEM-OVIiR 4(EA)
Comer. A Policy Nn.:
CER'TIFLLAI E Oh EXE PPION FROM ORKIiRS' GREASEANDUSTRI.WASTE IN'TERCEFH)R
COMPENSATION INSURANCE BUILDING DIVISION FP.fS
(This section.cednm beconipleted iflhepennit is for one hundred dollars($100) GREASETRAP
or IessJ PLANCHECK FEIi
IU,Kfy that In lheperfnrmance of the work far which this permit isi...ed.l shall SEWER—SANITARY—STORM EA.Nal FF. -
net employ any person in any manner..A m become subject 1.the Workers'Compact ^� ENERGY FEC
Z stria.Laws of Cidderain.Dam WATER HEATER W/VENT/ELELTH C)
Applicant is
GRADING ITE
NOTICE TO APPLICANT:If,after making this Cenificam of Exemption,you should WATER SYSTEM/TREATING
y SOILS FEE
F+ becameh comp y the Ankara Coons or this oodu ons al the labor Code,you muvt
forthwith comply with such provisions or this permit eM1all he deemed revoked. WATER SERVICE
Or CONSTRUCTION LENDING AGENCY NEW RP_SIDENTIAL PIAIB. SQ.FII PAID pate cigN
UO Werehyafar,that[,am is.ornstrocdon andiagngency forme pedarianceaf
LL H the work(nr which tris permit ie izsued(Sec.3119].Civ.C.)
Lenders Name O TOTAL:
U
W Ladders Address 1 TA.
1 comity that 1 have read this application and state mint the above information is BUILDING ITE
i.. N mreet.l agreem comply with all city and county ordinances and sum laws relating to QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V building communion,a ad hereby man imrepresenmtives told,airy to emerupon the
above-mentioned property fur inspection p.Hwns. PERMIT ISSUANCE HLE0RIC FEE
(We).gree m save,indemnify it keep leamless the City of Caperton against
aabilities,judgments,s.,I and expenses which may in any way uc.c.gmrel aid Cay ALTER OR ADD TO M ITCH. PLUMBING I:
in consequence of the granting of this permit.
APPLICA :RST )S AN ILL COMPLY WITH ALL NON-POINT AIR HANDLING wmtm, MECHANICAL 'F:F.
REGI I'
�•-/3 -9� AIR HANDLING CONSTRUCTION TAX
SI re.c of slicanUCo Dam EXI IAUST 11001tPA!ID -
Data
;t G MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buidingeacupa.I store orhandle haamous material HEATING UNITdef J by the Capetian,Municipal Code,Chapter 9.12,andTne Heath and SafetyCode,Section 2.5532(a)? HEATING UNIT �
Oyes VENTILATION. ID. NGLE RESID) Receipts
WII The applicant or future building neeupat use eyuipnenl or devices which BOILER-COMP(3HPOR 100.00tl BTU) -
chat haramous air cnmamimants ss d�e(wM by the Bay Area Air Qualify Management TOTAL
Dioucl? BOILER-COMP(OVER 100,0001I1'U)
❑Yes ON.
I have dead the on, ak anuimmemm under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Sarin[leaps k Sa ode,S• a, 255 . 25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
Inildingdoes n0y ha at m it is my icsrymsdilily to amity The occupant i
ofthercq 'etre ichm It In, ' ruissuance aC is roof u nay
all
Owner or nuthorieedda i Ilate TOTAL: ISSUED BY:
OFFICE