S 3860 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT N0.
BUILDING DIVISION C "—APPLICATION/PF,RMIT I'LUMRINC-MECHANICAL S 3860
1 7/BUILDING PeOJEC'[T IDENTIFICATION'(;l7f/.t)'f+ '
HUILDINGADDNESSO� � ' SANITARY NO. APPLICATI`N SUBMITTAL DATE
OWNIiR'S NA p PIIONE��W�CONTRACTOR"S NAME: VI -_3L4i NO:AA
NIC CONTROL��#
CIIITIiCT/I: .IC O: ADDRESS: ❑ I L / /
corv'rncr: PHONE: {;�tf0;'r;�''/7BUILDING PERMITINFO•" :
ngaltant Flues Paid by Applicant(Initial) BLDG ELECT- PLUI.9Y MEC
jUie
LI :N513D CONTRACTOR S D CI ARATION '"/ ' t j - -
1 hcreh f rent I am een.eJ d QTY r /.;LLI:&RIC PERMIT)", t 1 t(`bEH 1jj,
ya g ', -nrcnapmr9n.,m(commencing ) . ..e,. ar .,.1. II- A JOB DESCRIPTION
�QZ withs«tion 710#7 o[ on 3 tithe Bus'nessan my occurus -� RESIDENTIAL:
FLL� in full force and Ilkct PERMIT ISSUANCE
❑gl'DWL [I KITCHEN REMODEL.
�UU Lamm, x Lic.N APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING REPIPEF�u] Dae Commcmr
h L n shallN use DELI. RA []MULTI-UNIT El STRUCTURAL
PANELS
Z O y 1 understand my plain shall be used as public words MODIFICATION
OZ-0 - Ill'T02o0 AMPS []INTERIOR ❑CHJMN17Y REPAIR
FBF.,; Lucent Prn1,,sio ad 201-1MAMPS IMPROVEMENT ❑ OOLS
SWIMMING P
S�W f_1 OWNER-BUILDER DECLARATION
C wQ I hereby altimn that Ian,exempt Iran the Commons.Ll,cnse Law for the OVER)BIB AMPS ❑BATH REMODEL/REPAIR ❑DEMOLITION
P.94 U Rapmwing temnn.(Section 7031.5.Rosiness and Profesaionx Code:Any city inventory SIGNS ELECTRICAL LJOTHER
LL y which wmmi a permit to cnrrsaun,alter,improve,demolish,or repair anyxw atue
ft�1 prior In its isauancc,alai"arms,heappli,ml fmovh Permit m file it,,rodxamment SPECIALCIRCULDMISC.
f G N, that he is licensed pursuant to the provisions office Contractors License hw(Chapter r)
1=C0 (codnmencing with Section 711W1o(Divixion3 nT,h,Bmineas unJ Professions Codgor '1'EMP.ME1ERORPOLEI COMMERCIAL:
6 X c rL that he is exempt therefrom and the basis for the alleged exemption,Any violaion of NEW BLDG/ADDITION ❑DEMOLITION
_4• Section 7031.5 by any applicanlfor a pencil subjects We applicant to a civil Penalty of POWER DEVICES
LL m not more man Fee humlreddallars(S5W). TENANT Ll FOOD SERVICE,
F=6 1.as owner of the norm employees with woes as their,ole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
❑ grope Y yemp y g ,Ed..
y$� will Poetwork,andei he orre Coniisnnts License
eed nseLawdo offered fivot apply too an Nosiness ❑OTHER
Wa 3 and Professions ills o,The Cnmmcmr's Licenm Law does not apply In if owner of OUTLETS-SWITCHES-IlX'1'URFS
property who builds or improves that
thereon,and who does such work himself offered far
his Own employeese pmldong that such irrom is sold w t m not i earofJ or offered fm NEW RESIDENTIAL IiLECfR SQ PT
ale.If,howevw will
have In o burden
n of proving
it at he did n ore build
or improve fon,the SQ.fTJ100R ARBA $ISQ.Ff.
owner-builder will have the burden nl'proving that he did urn build or improve far pus- q
none r. l ). !/ � O �
❑ 1 ownerofproperty . va
exclusively fN
ng ' hceneeconnector,m gOTAI.
convince,m p ) t(S .70,14.Business addP Contractor's nlmum
t n ' e fp pnY h h Idor'mprnves theren aL
c s Lawdoex no,r,py nd QTY / PLUMBING PERMIT, . -.- FEE
who contends chpjcwth a eoearlicensed pursuant o the Commoner's
License
?3
❑ I am exempt under See ,It&PC faolok ,sea PERMIT ISSUANCE
Data ALTER-DRAIN&VENT-WA'T'ER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION HACK FLOW PROTECT.DEVICE 7,
I hereby affirm under penalty of perjury one of the follow)ng:leclaratim, 3
I have and will mai plain v Cenificde of Consent to self-insom for Worker's Canner- DRAINS-FLOOR,RODE AREA,COND' STORKS 'TYPE CONSTRUCTION
.cation,as provided for by Section 3703 of me hurt Code,forahe Jeff onn advance of[be
work for which this permit ix;,sued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as requirad.Ex,Section
3Il01ofineode.fmrlhe perfo one ' e work fns which 11, nit is ,odd,eGAS-EA.SYSq'EM-I INC, OUTLETS OCC GB0,, APN
My Worker o s roolod
Carrico GAS-CA.SYSTCMI)VER 4(EA)
Ch:Rq'IPIC OM
CO ' o GREASIYINDUSTRL WASTE INTERCEI'TOR
RUILDING DIVISION FEES
(Thio section n«d�rat/y�(�y� ta' t'sf'24 it
dollars(8103) GREASE TRAP
or less.) 1/��,I/ _/.re, 0 7, a, '2 PLANCHECK FEE
Icenify ton Ko fr , , permit isissocd.l ahall SEWER-SANITARY-STORM EA.2W FT.
x01 employ any person in any n anther an as to become objea e,the Workers'Conryan- ENERGY FEE -
O Z salon Laws of California.Dole WATER HEATER WNEN'T/ELECTR
Z Applicant GRADING FIE
.�. NO)[CE III APPLICAN'E If,dust making this Cen it of Exemption,you should WATEk SYSTEM/REG
E
' Mcome subject m the Workels Compenv,ion pms,isinns of the Ladm Cede,you must SOILS ITIE
W forthwith comply with such provisions or mis permit shall be deemed revoked. WA'IYR SERVICE
CONSTRUCTION LENDING AGENCY NEW RI-SI TIAL 1' H. ETOTAL
PAID
V Q Ihetcby uffrcnlhat there knwmhumion lending agency fordo,Perfornaaeamf Dam Receipt#
LA F' the work for which this permit is issued(See.3097,Civ.C.)
O V Lender's Name IDEAL:
ICI Lunda,Addrmx 1 n fym,1 ha J Job pplicat e d- t that h M f rmmmn is BUILDING FEEm wore t I y , on,ply th II cdy unJ ty rJ rs J.d d F :rda, ng m QTY r MECHANICAL PER !1 rtr PEP/tat
U ,7Z. larld g ., I n,and hereby a Ihoriu pre Wf ex offl c'lyt t ruponthe SEISMIC FEE O
ahove,nemioneJ progeny far Inspection purlwses. PERMIT ISSUANCE
,Wel agree a,save,indemnify and keep harmless,he Coy of Cupertino against ELECTRIC FEE 6
liahilitiesjudgarrai civinand expenses which may many wayaccmeagainasaid City ALT ER OR ADD TO MECH.
in consequence nI me granting of this permit. PLUMBING FEE
APPLIC 'UNDERSTANDS A I WILL COMPLY THE A L NON.POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
SOU E E,9U _
AIR HANDLING UNIT(OVER 10,000 CPM) CONSTRUCTION TAX 6
Sig of Applicant/Cnn racier to EXHAUS'I 11001)(W/DUCT) HOUSING MITIGATION FEE
I IAZARDOUS MATERIALS DISCLOSURE
WC10a,applicamarfuture building occupamsmu or handle hazalloms ma¢nal HEAPING UNIT(To 103,000 BTU)
a,defined by the Cupertino Municipal Code.Chupler 9.12,in d,he Health and Safety
Codq Semicon 25532(a)7 HEATING UNIT(OVER 100,001 CITU)
❑Yes No VENTILATION FAN(SINGLE.RESID) PAID
Date Receipt#
Will the anPlicvm m I. wilding occupant use equipment or devices which BOILER-COMP(3 HP OR 101,03(1 BTU)of harardous air commninams a,defined by me Buy Arca Air Quality Management IDEAL.
❑i.v'IricR ,
❑y« `rj," \ BOILER-COMP(OVER 101,00013'CU)
I
I have rc:al the hevwil mmemi requirements under Chapter 695 ofthe Cali- AIRCONDITIONER ISSUANCE DATE
Wpm He Safety Code.S«,inns 25505,25533 and^55311 un mnJ ,if the NEW RESIDENTIAL.MIiCH. SQ.IT.
h
hnlldln a 1I,I aurrcntlyhnvea¢m SLI it ie my ruponsibllityfy aenpvm
of,he quit t misauancc ore nil cy.
Own:. uuffiordied agent I I Date IOTA ' ISSUED BY:
OFFICE