S3105 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bm1.DING-ELECTRICAL PERNUTNO.
BUILDING DIVISION APPLICATION/PERMIT _ PLUS1ItINGMI?CunrvICAL S 3105
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. .\1'I'LICAt'ION SURhIOTAL DATE
19�v/ Ccr In4w Dek 7?N/6?
� /2-fir
1.
CON RACTVR'S IS IF e
CONfkOLnNIC
ARCHITFCTLNGINEER: I.ICNCF A
(/ •ILL�IL !Ac/ ❑
CONTACT. PHONE: f III'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL SUCH
MUCH
❑ ❑ L ❑
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that lam licensed tinder provisions of Chapter 91 oem ram, _ _ JOB DESCRIPTION
0"Z with Section 7000)it 3 fthe Run dP f,ou Cr day lienee is RESIDENTIAL:
WOp wt PERMIT ISSUANCE
¢ F to full force and e6'en. �SFDW'I. C KITCHEN REMODEL
UE- License Class Lic'N gpl'hIANCGS-RESIDLNTL\L El ADDITION L1 PLUMBING RE-PIPE
Fhiz
zW Dale—�� !!lT���rammn°r dE�Sn.
`�Qd gNCIi1TECT5 DECLARA I ElMULH-UNIT' CSIRULTURAL
PANELS MODIFICNI'[ON
Qzm Z 1 understand my plans shall be,used as public record..
-O His TO 100 AMPS El INTERIOR [I CHIMNEY REPAIR
F.�F"W Licensed Pmfe.csianal 201-1000AMPS IMPROVEM1iNT CSWIMMING POOLS
= 1 hereby aflinn NV OWNER
Tam BUILDER Dh:from Ne Commnor's Litems Law for the CLARATION OVRk 1000AMPS ❑BATH RE.MOUEIJREPAIR ❑DEMOLITION
U. following (Seri 9031.5 B c ll f Code: A y ty rcnunty SIGNS ELECI RICAL X10 HIiR/� �_,e
m¢ which q Perron trot t It improve,throttler. p. yshncture /J(%J�Q CD/TJ %� I
�-�0J prior n issuance,also q the applicant f hpe It rile a:g statementdSPECIAL Cl RCUIT/MISC.
�N} Ibut M1 I Ilursi It II p n. fd C 1' I L (Chapter 9
��n0 (commencing with Semon 7000)ofDtsion 3ofl he Rus'ne,sato Not c,irr,Cale)or 'I'LM It MCTI?It OR POLE IN ST. COMMERCIAL
a a e z
her he is exempt Nmfrmd th
eoume tua is for Ne alleged exempti.n.Any violation of ❑NEW BLDG/ADDITION ❑DI, OLITION
W-vi section 90315 by any applicant for a hicou t,object,the appream nt a civil penalty of POWER DEVICES
not oars into five hundred dollars 5500). C IMPROV C ItDDD SERVICE
( IMPROVEMENT
=C Q 1.itsthe work,the are oftic nemycmntendes with wages r Neonate70e-LB sines.on. SWIMMING POOL ELECTRIC i1:R
will do ac,iiak,and the he Contra for s lareed or offered for pply to an. weer of
W m and Pndcsi.ns Cade:The Contractors Llcen+c Law Jncn not apply to an owner of OUTLETS-SWITCIIIIS-FIXTURES
0'a-. propery no build,or improve,thereon,and who docs such work nimxdf or nhrnugh
his own employees,provided char such improvements am not intended or offered for NEW RESIDENTIAL ELECT R SQ FI'.
rde.It.however,the building or improvement is sold within one ycmorcounplerim,the SQ.FT FLOOR AREA S/SQ.Cr. I
covia,hudde,will lane the burden of....wing than he del no,build or Lnprove for pur-
pnm of sole.).
1,ae r of the property,a exclusively concerting with licensed contractors m 'TOTAL:
mxmuu,thprnjca(See.7044,Baeincse and Professions Ctdc:)no Connector's Li-
elaw duennot.ppl,hean ownerof property who builds or improve Hereon,and QTY. -PLUMBING PERMIT, FEE
wnocomma,forsuch projects withucantractonq Imenoed pursuant notheCoutiontors
License Law. PERMIT ISSUANCE
I:un exempt undef Sm. .R&I'C for,hie reason If� 0
Owner Dno ALTER-DRAIN&VCN'f-WATER(EA) III VAII 1)
WORKER'S COMPENSATION DECLARATIONHACK FLOW PROI'E:Cf.DF.VICF, T677
C(l
I hereby akirm under Penalty of lakjuryonenrtne following declaration, I J EC Q
LI I have and will maintain a Certificate of Conxm to self-insure for Worker's Contrive- DRAINS-FLOOR,ROOF.ARCA.COND. (� STORAS" TYI'F.CONSTRUCI'I(lN
tion,us provided for ny Section 3]IXI of the Lahr Code,f.r,he pciforrearcr of the 1
irtw rel"Ii,prone,isissued FIXTURES-['FBI RAP
iLill
ehave and will maintain Workers Compensation Insurance,an required by Section �/
3700afthe labor Gde,forNe performance of Ne work for which this sepaut in issued. GAS-EA.SYSTEM-I I.NC.4 OU'RETS _t-'J {JGLfnn APES
My Wako, eros-. I suepc5�,taierund Pnli.y n_ _qlg pr sae'�T.�� GAS-EA.SYS"FIXI-0VER4(EA)
Currier Pnhey No_ JW♦A d
CEI IFIIATIOF EXEMPTION PROM WORKT:RS' GREASF/INDUSTRh H'ASTIi IM1TERCH ITYR
COMPENSAFION INSURANCE BUILDING DIVISION ISES
(I hix,vdin i need nal b,tar,lcmd f0upermnl.Rnonc hnndreddolk...S10(0 GREASE'I'RAP
or Ica.) I'LANCIIIiCK FEE
I ecrify that in the performance ofthe work forwhich this permit is issued.I shall SEWER-SANITARY-STORM EA-NEED TT.
no,employ any person in any mhnncr,o rte m become vab,ct to the Workers'C.,n,a- ENERGY FEE
Z cation Luwsnf California.Du¢ WAIER11HAIERWIVE T/EI.E(,TR
z ER Applicata GRADING FEE
.N. NOTICE TO APPLICANE:If,after making chis Certificate of Exemption,y.0 should WAFER SYSTEMOFUTATING
besot c,tEje" ,,the Wnrkern Cnuy"e'abar pro Sion.of the Lahur Cade,you must SOILS FEE
fonhxlith comply
simmer Powi,aro,this permit Shull N donned revoked. WATER S17RVICE
CONS"TRULTION LENDING AGENCY NEW RESIDENTIALPLMH. SQ,FT. PAID
INrcby nl'lirm that thuro isacomamninn lending ugnmy for the perl'onnunec of Dane Receipt p'
F' the work fee which this Note,is issued(See.3097,Civ.C.1 TOTAL
Q U Lender's Name T
L1J Lcndcrs AJArcx, TOTAL. S�V BUILDING FEE
y 1 cerify Than 1 have read this applicanon and state that the above infnrnation is
F' tq comet l agree to comply with all city and county ordinances and sate laws miming to Qty. MFCHANICAL PERMIT FEE
U Z building construction.and hereby mthorim repot.eoenives.f Ni.city winter uMadic SEISMIC PEE
mu'u-mentioned property for inapenlan pug....... 1'lilt Mlt'ISSUANCI3 ELECTRIC FEE(We)agree to save,indemnify and keep hnntlesn the City of Cupertino against
liabiliticn,judgmcnns,emu mdexKnzee which may in any way accrue againa hood City ALTER OR ADD TO MECLPIAin MHING
/
¢...ence of he gruuing.('his permit. FEL
APPLICANT UNIIERS'I'ANDS AND WILL COMPLY WITH ALL NON-POINTAIR HANDLING UNI'I'(TO 10,IN)1C17M)
MECHANICAL I:
SOURCE REGl1LAT10N5.
AIR HANDLING ONE I,'(OVER 111000 CIM) CONS'T'RUCTION TAX
Signa—of A,dicaMCmapi r One EXHAUST'HOOD(WIDUC'O I IOUSING MI'I MAT ION FEE
HAZARDOUS MATBRIAI S DISCLOSURE
Willthe:gtplicamurfmurx buildingaccurymtan¢no handle hazardous....mind HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Cole,Chupmr 9.12.:md the Health and Safety
Code.Section 25532(x)' HEATING ON]F(OVER 103.00 BTU)
C]Yee ILLVa PAID -
VLNTILAfION FAN(SING LIiBEEF U) Dae Rccep,#
Will the applicant or future building occupant ase equipmnn or devices which
,mil Earned...air c.ntarnnmm as defined by the Bay Area Air Quality Management ItO1LER-COMP 1311P OR IINLUIXI RTLA
Dion"?
E]yes -VNn ItOILER-COMI'(OVER IIM4IXYJ BTU)
I have mad the nrmill mumnals requirements under Chapter 6,95 of the Cali- AIR CONDITIONER ISSUANCE.DATE
form.Health&Safety Cale,Seniums 255115,2.5533 and 25534.1 undemand Nat d the NI7W RESIDENTIAL.SUCH SQ.121. �.
building does not cumn0y have a etnant.that in is my rexpmsibilily to notify the occupant 2-
oftherayeM1p � tustNmet prior to I"--ofa Cenilica �I( a p 1
OwnerF1'/Gthorn oga `1C� Il:nc TOTAL: ISSUED I3Y.
OFFICE