S 3332 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFR"FINO BwLDING-ELECTRICAL PE lND.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL 3332
BUILDING PROJECT UMIN'I'IFuc JdTON
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITI'At.DAI'E
g
N. f- 9M 1//L C�1 l �z -8 -48
O 'N :SN 1E: PI{ONE: CO TRACTOR'S 'AME: EJC NO: NIC CONTROLM
ARCHITRCI'/13NGINI313R:
/� U LICNO: ADDRESS: ❑
CON'IACC PHONE: BUILDING PERMIT INFO
i; �'I Kg' [-IConsultantFees Paid by Applicant(Initial) BL❑UG ELECT PLUMB MECII
J7/\• LICFNSIiI )NIRA R:S DECLARATION Q'IY ELECTRIC PERMIT ELI% JOB DE$CRIPTInN
I hcrcby a111n t that[;at,license under....cions of Chapter 9(connneming
ca020 with Nation 71XII1Ld Ulvixinn3ofthc Busincaxand Pmfcxvicns COJc.and soy licence lx PERMIT ISSUANCE RESIDENTIAL'
C 1y� infullhmeandcdcO. ❑SFDWL ❑KI'I'C1113N RLM OlDFL
aUU License Claes Lic.N APPLIANCES-RESIDENTIAL ❑AUDITION ❑PLUMBING RE-1'11'1:
F z W Dam Conlmclar
to Qa ❑MULI'I"UNIT ❑STRUCTURAL
ARCHITECT'S DECLARATION
Fo)Z Iunduonndmy plane vleall be used m public record. E'ANI?IS MODIPICA'fION
O Z 4-M IIP TG 270 AMPS
[I INTERIOR ❑CHIMNEY REPAIR
F W Licensed Pnml Qonal 201-10s)AMPS IMPROVEMENT ❑SWIMNIING?Oohs
OWNER-BUILDER DECLARATION OVER IfNN1AMPS C BATH REMODEUREPAIR ❑DEMOLI'T[ON
C Q I hereby allirm that I am exempt foam the Contractor's Lireme Line,for the
,K35W,F- following reason.(Section 7031.5,Businevx and Professions Codc:Any city or county SIGNS ELECTRICAL ❑OTHER
m' p`ott which requires a peen it,construct,aller,Improve,demolish,or repair any structure
¢ primo its iswuana.ahn reclaim,he applicant for such permit to Glc a signed statement SPECIAL CIRCUIT/N115C.
04 that he is licensed punuanl In the provisions of the Contractor.Licrnxe Luw(Chapter 4
C�Q� (commencing with Section7000)of Division 3 oflhe Business and Profcs.iots Gruel or 'TEMP.METER OR POLE INST. COMMERCIAL:
W_pO
a a c that he ix exempt Inerefrom and the basis for due alleged exemption.Any violaion of ❑NEW BLDG/ADDITION DEMO1.1'HUN
Section 7031.5 by any applicant for a Permit.subjeas the applicants to a civil penaltyof POWER DEVICES PITF' NT ❑FGODSI:RVICE.
m than Bve hundred doll.,WOOLPR VE.
Sp Tux owner of'be propemY•or npemployecs with wages as loci,role asmpn.xaion, SWIMMING POOL ELECTRIC fro-OT
t: willdo Nework, ed Ne,micnem is not intended oroffered for vale(Sec.7011.Business
W 3 and Podossions Code:The Cnnaacon,License law docs not apply to an —net o1 OU DAN S-SWITCHES-FI%TURES
property who builds at improves thereon,and who docs such work himself at througlm
his own re,pluycen,provided thin such improvements am not intended or onbred for NEW RISIUIENTIAI.ELEC'fR SQ FI'.
,ale 11,hnorocr,lnc t ildingor i snprovcment is sold within one your of completion.the SQ.FT.FLOOR AREA SISQI'I'.
.
o
to fodder will hive the harden of proving but no did nal build of innpm a for pnr-
p�s
� t: t.Ill 'ta
). 'I OI'AI;
IT.I ml din l 1 q • ly tiltg w.In l
...... ttl ,ject(1 ts]IWSIt d Pride...or,Code'.IIh L t"t I-
w Law dose not apply I,,rot owner of property who builds or irepro ex thereon,and QTY. PLUMBING PERMIT FEE
who<mm,.ucts on-such post with a commctoo i)licensed pmeuantto the Contractors
License Law. PIERMI i'ISSUANCE
Ian exempt umm ler Ste, .H&1'C for this moon
ro
ALDER-DRAIN&VENT-WR'I'ER(EA) VALUATION
WORKE 'S COM of DECLA ION BACK FLOW PROTECT DEVICE
I hereby wriffai under soapy of pc Cory the ro wing Workc io o
0Ihave and will maintain aCenifcate of Canunun mlf-insure(or Worker's Compen- GRAINS-FLOOR,ROOF.AREA.COND. STORIES 'IYI'Ii CONSI'HIICI'ION
cation,as pmvidW for by Section 37M of the Labor Code,for the prforance of IM
work for which this peril is issued. FIS TURES-PER TRAP
1 have and will maintain Workers Compensation Insurance.as rcquird by Scaion
3700of the Lulea Cdc,for'be pedwr—eof the work far which'his permit is ixwd. GAS-En.$Y$TEM-I INC. OUTLETS (J FICC GROUP AITI
My Worker%Conmpen.salion Insurance carrier and Policy number am: GAS-EA.SYSTEM-OVER 4(EA)
Carer, Policy No.:
C;WjJiL AJ: (y ExaagRIR1V.iiRIM.WARKERS
: SAI'IONI .URAN - GRI?RSI%INDUSTRL WASTE 1NTERCEI'IUk BUILDING DIVISION l�liliS
CII �T
less.)
IINtI �uIor.1J p'f 'dhf'h kf nuiIts 'Ihi p,Imadtd!:IronA llsk 11 CHEASLTRAP
PLANCHECK FEE
noten
n I til ai 1 'Cu opens SEWER SANI FARY STORM EA.270 IT. ENERGY FEE
tat 11 v alr(n ... Ie
Z sutaml.awnol 1 'or ruoyw WAI'FR HEATERVJNENT/ELECIR GRAVING FEE
is. I
ALj
PPI'stmt
/z- ren NOI'IGi'TU I,LLICAN'I:II;a Ile,snaking do,CrdiGe I!enumsnn,You sI Id WA'1'I!R SYS'I'I?M?REATING
E
> 110111.11c xubjcof m(he Worker's Coutperoation pro slam of theLabor Coda you root SOILS PIA?
Da ,s Ibnhwitb cutnply taliJ xuch p ovkio i—,this pv7mit shall bed and rcvokcd, WATER SERVICE:L'ONS"fRUCI'ION LENDING AGENCY NEW RESIDENTIAL?LMB. SQ.1'f. PAID Date Receipts
U C) Ihereby affirm that here is a construction lending agency Gm'he p,loot-ore of
f 6 F' the work for which this peri'is issued(Sec,3057.Civ.C.)
Olender's Nume TQInL:
U Loiter',Addmxx TAI
Q. I certify that I c mad this appheithon and state that the above information is
BUILDING
F rq coral.l ogrceum comM1avply with all city and county ordinances and sfare rows relating to QTY MECHANICAL PERMIT FEE SEISMIC Ef:
U Z building cnnvruclion,and hereby au'boris reprexnmtives of'h's city mcmcr upmthc
atone mentioned property for inspeainn puryoms. PERMIT ISSUANCE s® ISLECfRIC E
(We)agree In save,indemnify and keep harmless the City of Cupertino eguinxt
liabilities judgntentx,cost.s and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMB ' ;EE,
in me,cnce of the pmnting of lni.-
APPLICAN'1'UNDERSndu I DWELL NIPLY WITH ALL NON-POINT AIR HANDLING UNIT 10.0110 CFMI MIECHA "ALIl'E
SOURCEBEGULA'ONS. _ �e^
UX AIR HANDLING UNIT(OVER I0.IXXICFM) CONSTRU610N TAX
S lgnoturtof npplican Cont or i'; Uulc US (EXHAUST HOLD(W/DUCT') HOUSING MI GATION ITT
IIAZAHDOdelis.RIALS DISCI )R'
Will lhe upplicunl or Guurc hnilding uctupam ntu¢arnu Ichu'eurdonx nuucrial IIHATING UNI'I'(TO I00h000 lfPlp
as dclined by the Calailloo Municipal Cade.Chapter 9.12,and the lb alth unit Safety
CoAq Section 25532po7 HEATING UNIT(OVER Illifyin if IT)
p Yes, ❑NnPAID
VIEN'1'11,.41DN hAN ISINGLIE RIESIUI Date RaciptM
Will the applic:mtu,more hailding saccup.or use equip.,.,or devices which
e BOII ER-COMP LIFE OR TOOJpn BI U)mit hatardo s air contaminants as defined by the Bay Arca Air Quality Management BOILER
District? BOILER-COME(OVER IIALLYgIPTU)
C3 Yrs No
I have mad the hmardors materials requirenenN oder Chapter h.95 of the Cul'" AIR CONDITIONER ISSUANCE,DATI',j
fond.Health&Safe,,Code,Sections 25505.25533 and 25531.1 udeNand thin if the NEW RESIDENTIAL MECIL SQ,IT.
bumbl ngdtcs rot emmully have a te......bar it my msponxibiliy to notify the occupant D
of the nNuiremenx which must be met prior m issuance of;Certificate of 0,eupancy.
Owner on umborimJ.gem
,am
TOTAL: ISSUED BY:
OFFICE