S 3213 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILTNG-ELECTRICAL PE TT NO, ^^
BUILDING DIVISION APPLICATION/PERMIT PI.UMRINf.-MkC11ANICAI. 1 K
-BUILDING PROJIi(YI'IDEN'1'IpIL'ATION - \\\!!!2NN`///
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATI
/007/ SAT/ffl• CL1M/F —
PHONEfN�SNAMi: 8
NIC COTpWryGDN3r�� � S• ���o�o o OO1,M
ARCHITECTIHISGINEER: LIC NO: ADDRESS:ZG c' w' � E32S
CONTACT: PITON]:: BUILDING PERMIT INTO
❑ Consultant Fees Paid by Applicant(Initial) BLDGPLUMB MECII
v T:LECf 32-ofo� ❑ � ❑ ❑
LICENSHI)CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby O inn that I am licemed not no loom,of Chapter 9(cmmmencts, JOE DESCRIPTION
0�'L with sadinn 7fxg])nfDivirion3ofine Business and Pro@ssinnsCsde,and mylicemeia RESIDENTIAL,
eeZ i PERMIT'ISSl1ANGli f
full noccond ctZ, 6 ❑ShDWL ❑KI'I'CIIEN RIiMOUI?I.
QUU License Chis V Lica s APPLIANCES-BESIDES'I[Al. ❑ADDITION ❑PLUMBING RI}I'IPE
rF Q 1 U:ne Commcnor
ARCHITECTS DECLARATION ❑h1ULT1-UNIT ❑S'I'kUCI'URAL
1"zb�z Iumdcrslnnd any ple,,smll lac u,ad as publloranrdn PANELS MODIFICATION
IJP DO OZ=� ❑INTERIOkC1 CHIMNEY REPAIR
Hat Licensed pmleseimad 201-10MAMP5 IMPROVEMENT EJ SWIMMING POOLS
y�Q �� OWNI!R-NUILDER DECLARATION OVER IRO AMPS ❑[IN[IT REMODELRF:PAIR ❑DEMOLITION
CL Q I hereby aurum mal I am e.mapt from floe Canlruulnrn Licensa Law lar'hu
x 3LLH following,canon.(Section 9031,5,Busirt and Prdcwious Rale:Any city or county SIGNS ELECTRICAL ❑(YCILER
H which requires a permit to curt alter,improve,Jmnolixh,or repair any umemre
W0Q prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
IZ,a••1 had he is liaacsedp'caut to'he Provisionsofthc CommemA License Low(Chapter9
..00 (commencing with Section 9000)of Divlsinn Sof mo llueincwmul Prot mreimts CndOor 'I'EMI'.METER Olt POLE INS, COMMERCIAL'
a ac C that be is exempt Iherefnno and the hasis for the alleged exentplion.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
Xm la- seen..7031.5 by any applicant fora permu mbjectsthe applicant to a ciAllMnalty of IIOW17R DEVICES -
W^H ❑IMPROV ❑FOOD SERVICE
mare m
an five hundred dollars(SSM).
Fq'�6 D m I,us owner of the pngmny,nr my employees wim wage.as their sole contpcnsalion, SWIMMING P001 P.hEC'I'ItIC OIHFR EMIiNT
AFC will do the work,and the.rtmclme is not intended(it offered fcrvulc(Sec.9014.Business ❑ T'HER
3 m and Professions Code I'm Contractor's License Law d«s not apply m an owner of OUTLET' S CHES-FIXTURES [
Property who builds or intprnvev flum nn,and who Jots such work himself or through
his own empluyaa,provided the,such inlpmvemmus ate nal intended ur olfered for NEW NE AL ELE SQ FT.
sale.ITIameveq the building orimprovement is sold within oneyearofcon,letion,the SQ.FII FLOOR AREA g1SQ,IT.
owner-M1uilder will have the Without proving thin he did not build or improve for par
pose of sale.). rc
❑ L as awn r of the propcny,am exclusively comnmting with licensed contractors m1 L:
mslrud the ponact(Ste 9144,Bneinae and Prnl'tesions Cado)'I he Q011Intelmr'IT,
cense law done not apply man nwnm
erofppeny who mild,o,improves lhercon,and QTY LI GrF FEE
who contracts for such projects with a conarcouns)licensed pursuant to the Contractor's
License Law. 1117RMI'IISSUANCE
❑ Iron Csen,1 undo,Stu. ,R N P C Int'Mlle raxnn
ALI ER-DRNN&VENT'- A :A) VALUATION
Owner Date
WORKER COMPENSATION DECLARATION RACK FLOW 1'ROTELT DEVIC
1 hwchy affirm under pendly of perjury one of the following declarad loo
❑ I have and will maintain a Certificate of Consent lr self insure for Worker.Cmmpen- DRAINS-FLOOR,ROOF,AREA,GOND.
STOltll;g TYI'Ii CONS'i'It0CT10N
sation,as provided for by Section 3700 of mLe aNur Code,for the perfommnce of the
work for a hich this permit is issued. FIXTURES-PER TRAP
I M1ove nn l will rum nuin Worker's Cnmpensminn Insurance,ns required by Section
3700ofinel.uhn,Code.fin,the prifunou cot it.wrd for which thispenult is ia,med GAS-17,ASYS'IT -1 INC.4OUTLETN OCC.GROUP AI'N
My W'orker's Con,vasation Insurance comer and Policy number am:
Comet: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GIRFASFJINDIISTRI,WAS]fi INTERCEPTOR
BUILDING UIVISION_P_RGS
(Thin¢dinn need not bn comPlned ifine ptl'mit isfor onehnndmJ dnllars($IIMI) GREASETRAY
nr la..) P1.ANCIfFCK IJ31i
I certify that in the terfiormarmeof the workforwhichthi.c permit is mucl,[,hall
P Y Y person in any manner moa SHWI!R-SANI PARY-S'1(1RM EA.200 FT.
potent Lt any t ¢' Ice bjcet nt oho Wmkcrs'Cnmpen. ENERGY FEE
,� Appli Laws of Colifc ¢ l WAFER UIiA'I'I!N W/VEN'lllihliCTR
Z Q Applicant u GRADING FEE
re
,�I y N(mrat,TO APPLICANT: Aafro,making this nd itim;of of I!xah o d you should WATER SYS'IiM?REA'I'INC SOILS FEE
W!-+ becomeh c...fi y Ibe Worker's Camlmosmion pmvi,hal of the labor Coke,you muss
� forthwith annply wim such provi.lonx nnhis pmntit shall he Atclned revukut WATER SERVICE
o.
U O CONST'RUCT'ION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Orr. PAID Due Hccci I M
I hereby ch thi thnmhcre is a summation 30 lending7,Cro agency for the perfitrmance of
P
i-1 Lha work fin which this permit i,.i,aucA(Ser.31197,Civ.CJ
U Lender's Addo T01'A L:
U Lander', as TOTAL:
;s• 0. I certify that I have read this application and nate that the above infornmtion is BUILDING rpli
oF"s rn cormO.l agree to comply wall all city and county ordlnanca lard atom law%rclarng to QTY MECH I,PER I ' PEI?
U Z holdingcolulrunion,and hereby omhoriu rcprcxvmativex nl'this tilym enmr Tim the SHISMICFEE
above-mentioned pmNny for inspection purpmwv. PPRN 11 'DANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC Igili
liuhllitica„judgments,ousts and expcnxuswhich lnayinanywayaccrueogainsOinid City MAN AD( ' R 1
1998
sequence of the gnddir,off itle...unit. PLUMBING Hit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR 1 DLING UNIT(TO IOI CFM1D
SOU TRF.GUL ONS. A11!CIIANICAI.FEE
/ / I V/ /i✓/J�a AIR NDLING UNIT I0.00d CFM) CONS'I'RUC I'ION TAX
Sggn^lmre mf Applicant/Contmdor Dam�r— (ixi1 I HOUSING MI'T'IGATION EEE
I IAlIARDOUS MATERIALS DISCLOSURi3
Will theo....Means,fuurel,aildingoccupantamremhandlehazanlnmmamUnl H HATING UNIT(TO I00.0M RTU)
as Jefired by the Cupminn soon .1 Cade,Chapter 9.12,and the Health and tial ty
Crile,S,cainn 25532(1)? I HIM ING UNIT'(OVER 11111,0(1011'11)
❑Yes PAID
VENTILATION FAN(SINGLE R[SID) Data RaeiptM
aid
'r WJI me upphc{{nl or none hailding oauryun use cquipmem or duviwe which
n.n humnlnns air modmminants ae d fined by the lmy Area Air Quality Mmwgmncnt 13011-Elt-CONI'(3HP OR IIXI,OM HTII)
md9 Y
❑Yes o BOILER-COMP(OVER IIIO,Ig10RTU)
I have rccJ the hmmolnus mane' a LEI
under Chuptm(x95 n1'lhe Cali- AIR CONDI'DONGR ISSUANCE DATE?
fnmia Health.@ Safer Crede//��enio 2550d 2553Y.I undemm�J that if the NEW RESIDENTIAL MECII. SQ.ELhuildingdlasnotancmIyaYcare unt. ponsibility to notify luta ry'ntordeec'mmucnts tN .her ep orafa( t (mss
Ownermaullmnu g, I Due TOTAL: ISSUED BY: / ay•
OFFICE