S 3311 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PLV IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. l- 3311
Q1 1.'1
BUILDING PROJECT IDENTIFICATION - v
BUILDING ADDRESS: _ SANITARYNO. APPIACAT ION SUBMITTAL DATE
a K tic / ;N . 12--(— ? f
OWNER'S NAME: PHO COPORACIORIVINAME LIC NO:
NIC - CONTROL#
ARCHITECT/ENGINEGR: LIC NO: ADD FSS: �kt"O ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ CunsBltant Aces Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
00 ❑ ❑ 11/ ❑
LICENSED COVI RACTOR'S DEC RATIOry QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under preenouns of Chamm
pter 9(coencing JOB DESCRIPTION
Wool with Seetinn9000)af Division 3ofine PusinrssanJ Professiaa Code,andnrylicensib, RESIDENTIAL•
Fw infullfoceand a ��,.�f PERMIT ISSUANCE Licensc Class -' Lie.NQQJ—[_(L ❑SFDWL ❑KITCHEN REMODEL
rF�WM'Date Contactor APPLIANCES-RESIDENTIAL ❑ADDITION C1 PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
0 2 4 l undusmnd my plans aM1ull he used ve public records MODIFICATION
UPT02MAMPS
�[Q�lid0 Lrmensed Notessmnal 201-HIW AMPS ❑INTERIOR ❑CHIMNEY REPAIR
.t
OWNER-BUILDER CLARATIMPROVEMENT E]SWIMMING POOLS
C�Q 1 hereby affirm that I am exempt form
the C.mmdmr's License Law for the OVER 11x111 AMTS ❑BATH REMODEVREPAIR ElDEMOLDEMOLITION
a U fallowing reason.(Section 70313,Bneimss and Professions Gde:Any city or county ❑OTHER
{yj 3 y,F SIGNS ELECTRICAL
0 whichitsissuance,
requires permit re tt(mwd,ppee improve,demolish,ar repair any alrnemre
qq m that heor sli,coedProt so requires the applicant for Cha PermiOLrile aicense Lav,
statement SPECIAL CIRCUIT/MISC.
2 y that he is licensed pursuunuoThe provisions of the Character's License la(w(Chapter9
C� Go (commencing with Sol'..7000)of Di vision 3 of the Business and Pruresinous Code)or TEMP.METER OR POLE INST. COMMERCIAL'
TY q 1 ys that he is exempt therefrom mad the basis for the alleged exemption.Any violation of C1 NEW BLDG/ADDITION ❑DEMOLITION
�I Swelian 9031.5 Flury applicumfor a pormitsubjeas lheappliaman,a civil penal(yof POWER DEVICES
F, y not more than Five hundred dollars X501p. OTENANT ❑FOOD SERVICE
q ❑ Los owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do(hc wok,i nd da mot a m.is ma intended.coffered formic(Sts.7044,Business ❑OTHER
�,3 m and Professions Code:The Contractor's License Law does not apply m ne
an owr of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or m cnida
his own employees,provided that such impmvemeas to not intended or offered for NEW RESIDENTIAL BLECIR SQ FT.
sale.If,however,the building nr improvement issold within aneyear of cnmplction,the SQ.FT.FLOOR AREA $/SQ,FT,
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of pale.).
❑ 1,as owner of The property,am exclusively contracting with licensed contractors m TOTAL:
construct Ibe project(Sec.9044,Business and Professions Code:)The Grmractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT /
who contracts for such Project'will'a omtmemr(s)licensed pursuvntTo the Conhvanrs L/
License Law.
❑ m a
Isexmnpt title,Sec. ,B&P C forthis rePERMIT ISSUANCEason r.
OwnerDale ALTER-DRAIN&VENT-WATER(Ep) VALUATION
WORKER'S COMPENSATION DECLARATION
I herebyffrzm under BACK FLOW PROTECT DEVICE
v penalty of perjury one of the following declarations:
❑Ihaveand will mainmina Cetiriwleof C.menl to sell'-immure for Worker9 Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND,
nation,as provided for by Section 9701 of the Luber Coda for the performance of the a STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PERTRAP (�
❑ 1 have and will maintain Workers Compensation Insum rr,as required by Section
3710afthe Lahar Cole,for theperfiammncpppfffoflheavrkhn which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP qPN
My Workers oml ensmionI mmmc rand Policynu
Cartier Policy No n GAS-EA.SYSTEM-OVER 4(EA)
CERO�CATE OF EXE PTION FROM R ERS'
COMPENSATION INSURANCE GREASE/INDUSTRI.WASTE INTERCEPTOR
(This section need not Is,completed iflhe Aconitic formic hundred dollars(SIM) BUILDING DIVISION FRES _
or leas,) GRE sSE TRAP PLANCHECK FEE
Loy any thain many
the work Por sults to the Wokesued,Ishall ER-S ITARY RM EA.200 FT
and employ any person in vDa manner so as nt became subjen to the Waders'C ENERGY PEE
zz Applicant
Luwwf California.Dae
O Applicata t R HF.A .R WN ECTR
GRADING FEE
Loi h NOTICE TO APPLICANT:11',after making cis Cenifcae of ExemPtioo,yo J WATER 'Y F. I
JA
C•^, y� became subjwt m IM1e Wnrker6 Compansaion provisinns of the Labor Code,y l SOILS FEE
FWG �y forthwith comply with such provisions or this permit shall be deemed revoked IDS p ,R tRVICE
Q
CONSTRUCTION LENDING AGENCY
z I hereby Mirm tbm there is a constmmion lending agency f the NEW RESIDHNTIAI.PLMB. SQ.PI', PAID A.
U 0 6 ,)my or perfonI of Dole Rmcipt#
W u the work for which this permit is issued(Seo.3097,Civ.CJ
Q F Lender's Name TOTAL:
H yV Lender's Address T A
1 artily that i have lead this application and slate that the obnve information is BUILDING FB
W corteet.I agree to comply with all city and county ordinances and state lawn relating to QTY. MECHANICALPERMIT FEE
L) Z building communion,and hereby p.mnrize reprrsemmwes of this city,.corer upon the SEISMIC FEE
shove-nremi.ned property,for inspection purposes.
(We)agree to save,Indemnify suit kap harmless the City M Cupenm a
igainst PERMIT ISSUANCE ELECTRIC FEE
liabili(ies,judgmenta,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. D ,O
in consequence of the gaming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CPM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10.000CFM) CONSTRUCTION TAX
Signature ofA,licanVCentador Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION TEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or furore buildingseculsnl store or handle hazardous motorial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)9 HEA'L'ING UNIT(OVER 100,000 BTU)
❑Yes ❑Nn'
• VP,NTILA""CION PAN(SINGLE RP.SID) PAID _
Will the air contaminants
or future building occupant use equipment or Marra which
Date Recarmif
emitrict? nus air contaminants as defined by the Bay Area Air Quality Managentcnt BOILP.R-COMP(3HPOR 1(10,000 BTU)
District? BOILER-COMP(OVER 100.000 BTU) �A
El Yes ❑Nn
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
Main Health&Safety Code,Sections 25505,25533 and 25534.1 understand mTI
al if the NEW RESIDENAL.MECH. SQ,FT. U
building does not currently have a loran.that it is my responsibility to notify the aeect om
of the requirements which mus(be Fact Pror to issuance of a Cendicate of Occupancy.
Owner or authorized agent Date TOTAL: I �1
ISSUED BY:
OFFICE