S 3878 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN0 BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING.MECHANICAL _ C 'j p'7 p
d'LfHJL,''BUILDINGPRDJF.TIDENI'IFICATI0Nlit'Iti:PS tlitl JO 10
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
pyo / fakes v
nWNEIf9fryAME: PHONE: CONTRACTOR'S NAME: LIC NO:
{,O / ��O is 2j O NIC CONTROL%
ARCHITEC,ENGINEER: LIC NO: AD RGSS: < ❑
S/
corrrAcr: rxarveILDING PHRMIT-INFO,115
2 C ❑ Consultant Fees Pard by Applicant(Initial) BLDG/ ELLE PLUMB MECH
LICENSED CONTRACTORS DECLARATION f f t 4 ' PERMIT, tf!) r (f I'(t M1 D I
TY '7' !ELECTRIC PERMIT)) r�{�
thereby uft tT 1 J 1 : rCM1aptu 9 Conncn B sQ 'u �,t ,�d.h.c' .... 4.'ttlsf .t '.-r`�ft- SiIEitFEE, �': ]OB DESCRIPTION
�R'Z with Seann]WO)of Division Sof the Fusne and Pn Rssdons Code and my licenseRESIDENTIAL:
WOO 1'F.RMI7 ISSUANCG
H in full force and ettee /, I
u]" 7 G ❑SPDWL ❑KITCHEN REMODEf.
�UV license CL.ss Lich APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMPING RE-PIPE
yaiDate�'T^r�� cnntfamnr
F>y ARCHITECTS DECLA ION PANELS ❑NUI-Th UNR DS'TRUCTURAI.
z0yzz IundnfslonA my pima shall Be used ax public reartJs MODIFICATION
/l eL uP'PO200AMPS El INTERIOR El CHIMNEY REPAIR
Q�F'u1Licemocchlorame,storril 301-IOfX)AMPS IMPROVEMENT [3 SWIMMING POOLS
0WNF.R,BUILDEROEheCoutCLARAIION 0VER1000AMPS DBATH REMODHUREPAIR DDE OLITION
CCCC hereby u('Snn that 1 1.5 exempt frons IM1e Cont..is C s License Law for the M
O follows squires. fruit
construct.
and improve,
demolish,
ore ind,soy or county SIGNS ELECTRICAL �DTHHR V'•'('�� �a !`{-gam
W3LLN whichrequiresnee also toarcores the alter,improve,h permits firepair adstate ent Fro f^{I �Ht
that heprior itsissuance.
pursuant tuire theapplicantfor Contractor
a Lice se Laced haptr1) SpBC1A1.CIRCUITIMISC. Ii1
2�(y that he lx licensed pursuant to the Pmvivions of the Contractor's License Loons Codmr9
W�QQ (commencingx'ith Scetion](Xp)of Oivision3ofthe Businessand l'mfesionx Csd0 or 'TEMP METER OR POLE INST COMMERCIAL:
d(�c C that he is exempt therefrom nonlife vois for ohe allege)exemption.Any violinum of ❑NEW BLDG/ADDITION ❑DEMOLITION
peyy
net me 7031.51,ch ndmlarann fora,Up)'u subjects ihunpplinmt to n civil penalty of POWER DEVICI?S ❑TENANT' DFOOD SERVICE
IMPROVEMENT
Sa ❑ 1,as ownerofoh<Propeny.nr my nnployees with sages as their cele rnmpcmation, SWIMMING POOLELECTRIC
�p.� will do the work.and lheslmcvtre is urn imenJal nroR rcd fur snle(Sec.]044,Uosinesn DOTHER
and Professions Code The Campaclofs License Luse fres not apply to an owner of OUTLhrS—SWITCHES-1'IXTUItIiS
13� pmpcny who builds or improves thereon.and who Jces such work htmulf nnlwugM1 � S
his own employees,provided that such improvements are not intended or offered for NEW RESIDENIAL ITLECTk SQ FT
xnle.11 however,the building orimpmvcmere ds,olJ whhin one year nfwmpldion,the SQ. !El, AREA /SQ.FT.
=nerbuilder will have the burden of proving that he did nm build or improve for par- I�'
enf.xale, I� JUN 031999
D I, er III P p ty l ly t I y with lice ued cnnvacmrs he
TOTAL
consumer tn project(S70,14 Business andl f..' n-Cods,)The Cnntmcror I „
estate Law does par apply t an f property who builds r Improves thereon d QTIYI 't' o !PLUMB C IT; 1 I I' i{ FEEL ;Ir
wbowunionsfor such projects with)contmckr(s)licensed pursuant n the Counselor's 44
License law. PERMIT ISSUANCE
D I am exempt under Sec. .B as P C for this reason
Owner Data Data ALTER—DRAIN&VENT—WATER(EA) VALUATION
WORKER'S C0MPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under Penalty of perjury one of the following declaration f
❑ Ihevmmdwllllnainminll Cenifeulcof Canvenito SClf-Insursfnr Worker's Compen- DRAINS—FLOOR,ROOF,AREA,GOND.
mCONtlon,a,provided for by Seinen 3708 cache labor Guk,far tue performance of the STORIES TYPE E C05STRUCT )N
work for which this pcmtit is issued. FI%1'IIkrS—P17R'TRAP
D I have and will nmlmain Worker's Compensation Insurance,as required by Section
3700of the Labor Code,for the performance of the work In,which this pemtit isionned. GAS—HA.SYSTEM-I INC.4 OU'I'I X IS OCC GROUT' APN
My Workers Compensation Insurance carrier and Policy number are:
Carrier Policy No.: GAS—EA.SYS'ITiM-OVER 4(EA)
CHRUGFICNI 1i OF EXEMPTION FROM WORKERS'
C0MPENSAII0N INSURANCE GREASE INDUSTRL WASTE INTERCEPTOk -
BUILDING DIVISION FEES
Phxe
Lsueom new urn IKcnnmlelw doim
he pex 1s far care hundred dollars ISI(pl
or lee") � GREASE'1'kAI' PLANCHECK FEE
I candyIhal in the peHotmamecof the work for which this permitsslsaucd.I dial SEWER—SANITARY—S'I ORM EA.200 FT.
antemployanypersaninanymannerso a cmc xubjenlolhe Workers Campem ENERGY
* Z, sat inn law,of califnmia,Date WATER IIEATHRW/VENT/ELECTN
z C) Applicant GRADING '
N NOTICE'TO AP .C T.IL afar looking This Certificate of F.xemplion,you should a WATER SYSTEM/TREATING SOILS^ Become subject m ohe W aker's Compcnsminn Provisions of the Labor Code,you muse
G hmb ith comply witheach Prevision,o,his prods shall be dwmw revoked. WATER SBRVICH
a �
UO CONSTRUCTION LENDINGAOIgNCY NEW RILSIDEYTIAL PLMIi. SQ.FT. PAI Date Rcaiptp
1 hernhy uHlmt Our Ian i is o l(Soo.construction0 lending agency lire the performanm of
Inc work I.,which IM1iv pel'tnll is ixsuw(Sec.3119],Civ.CJ
Leade N TOTAL:
V IsnA Address T(YIAL.
� 1 rtf but .ad his Iaf dtwltth hn r of BUILD FEE
r 'np ._ f.- , t df, ' II li! t'o,r1,r r iteltfP
to confect I B I ply 'm O ly d Y N eat I I ti gt QTY "y MECHANICALPI!
fj. FEF 0
V Z bolding construction and hereby authorize represented ves of this city to enter upon the .11 est 1 I ( , (� SEISMIC -.E
ubovC mmurmard property Inn....a,, npurpose,. PERMITISSUANCE
(We)agree lesave,indemnify and kmdesv Ince,hathe City nT Cupeninc against ELECTRIC PEE
liabilities,judgments,costs and expenses which nay in any way name again said City ALTER 0R ADD TO MECH.
In wn
wgttence of the gmit
maling of this per . PLUMBING PEE
SOURCE
REGULATIONS. AND WILL COMPLY WITH ALL NUN-POINT AIR HANDLING UNIT IT0IO,gXICFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,IID0 CFM) CONSTRUCTION TAX
Signature of Applicanl/Contranor Date EXHAUST HOGD(W/DUCT) HOUSING MITIGATION PER
HAZARDOUS MATERIALS DISCLOSURE
Will thuopplicamnr fuoure baild'mgocenpantslurcor handle factrlons material HEATING UNIT(TO 100,000 B-I'Of
as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safely
Code.Section 25532(x)? HEATING UNIT(OVER 10X1,000 BTU)
Yes
D *a VENTILATION FAN(SINGLE RESIU) PAID Date Receipt#
Will the applicant or future Building occupant use equipment or devices which
emit haor a m,air comtmmlnoms a defined by the Bay Area Air Quality Mawgemeat BOILER—COMP(3HP OR 100.0110 BTU)
District' T
DYes �n 9O1LER—C0MPf0VER 100.0011 R'TU)
LYC AIR CONDITIONER
I have rota the ha/111e Sections
255 5.255mentn under Chapter understand
of the if the /t !ISSUANCE DATE
Tessio Ucallh&Safety Calc,Sections 25505.25533 and 25534.I undercmnJ Thal if the NEW RESIDENTIAL MECH. SQ.FT. 3
building Joes sol currently lave],enanl.Ihato,wa cenfasCerfi ronotify theoccupam ( I/
of the rc,uioeiyate. icB nmsi be amt prionoissuonce uru Ceni Mu¢/gf(k^u��. _
Owner or amhodzcd agent Dale TOTAL: ISSUED BY:
OFFICE