S3340 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PESI I NO. 3340
BUILDING DIVISION APPLICA'I•IONA'ERMIT PLUMBING.MECHANICAL.
BUILDING PROJECT IDEN'HFIGAFION
BUILDING ADDRESS: SANII'ARYNO. APPLICATION SUHMII'1'AL DATE
OWN, E: PHONE'. C( KAC OR'S AML: IJCNO:
zz�f��� N/C GQNTRQI.k
. ARC111'fECT/F,NGINEER: LIC NO: )vS ia� /J El
CONTACT: PHONE: Y l/•//T7•''I i/J BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) LD ELECT PLUMB MECH
Li El ElLICENSE DCONTRACTOR S DTCI ARAI'ION QTY ELECTRIC PERMIT -FEE
I hclehy antro dit I Tc n cd d p ns of Chapter)( ...or m, JOB DESCRIPTION
DMZ alio Secfon] f1 3 enc Bun d fsoo a ylic se RESIDENTIAL,
f 1'ENMI l ISSUANCE
FWO in full Correa��urr t`T` ❑SFDWL ❑KITCHEN REMODEL
aUU Lice.c Cl�Lic.p AI'PLIANC6S-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
F Z ut Doe Common
rn¢y ❑MULTI-UNIT ❑STRUCTURAL
��,�. ARCHITECTS DE( O. / PANF.IS
Z O H Z 1 nem d,ley plans abaft M uusd z'public recur "� ' G MODIFICATION
OZ4/� UP'N 2O1AMP5 ❑INTERIOR NzgMNEY REPAIR
Liconsed Prarid000wl 201-I0C0AMPS IMPROVEMENT ElSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IWOAMPg ❑BATH REMODEUREPAIR L1 DEMOLITION
5 C Q I hereby affirm that I am exempt fru.the Conuamor i Liam Law err the
X 3 i U following reason.(Section 7031.5,Business and Pormes,ions Coda Any city or eounry SIGNS ELECTRICAL
L1 OTHER
u: a In which requires a permit to construct.alter,improve,demolish,or repair any structure
•F�OQ pdorm in issuance,also requires the applicant for such Permit file a signed statement SPECIALCIRCUITIMISC.
f T' that he is licensed pursuant to the provisions of the Commmor's License Los(Chapter9
�SrQ.,i (commencing with Section7YOnof Division 3 of The Business and Professions Code)or TEMRSHEFER OR POLE INST. COMMERCIAL'
y y y that he is exempt rbelefrons and the basis for The alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
all u
mhan five Section 7O3 IS by any applicant for a permit subjects the applicanta civil penalty of MOWER DEVICES ❑TENANT. ❑FOOD SERVICE
not more tve hundred dollars(5500} IMPROVEMENT
_� ❑T.asownerof the propeny,onnyem,loyeen with wages.,their sol,aomPensanion, SWIMMINGMIOLELECTRIC ❑OTHER
will clothe wink,and the structure is an,intended urmYcteJ for.vlc(Sec.70FL Business
W m and Professions Code:The Claimant's Liceme Ltw rimes ma aPIT,To as net of OUTLETS-SWITCHES- XTIIR
property who builds or improves thereon,and who dons such work himself or Through
his own employees,provided nutshell iagmvemenu arc not imcnded or offered fill NEW RESIDENT IAL EL . sQ IT.
sale If.however,the bmldingm improvement isudd so thinon,ye.rofasnnplatom.the SQ.FT AREA SQ.FT.
u-ner-budder will have h booders of forcing thth did not build or improvefor per. se D D
pus f. I ).
[1l a f the property, exclusivey controlling sv th licensed tractors to T
comiumuct theproject(Sec.7144 Business and Professions CW )The Contractors,1' MAY 1 91999
cause Udoes not apply to an owner ofp ,day who builds or improves duarcon.and QTY PLUMBING PERMIT 7FEE.
who contracts for such project with a cmmraeon(,)licensed pursuant to the Contractor's
Licenre Law. PERMIT ISSUANCE f�
1 am exempt under Sec. .B A to C for this reason B
ALLER-DRAIN As VENT-WATER WA)
Owner Oat,
WOR KERS COMPENSATION DECLA RATION HACK FLOW PROTECT.DEVICE 22[�
I half,chiral under pennityotporjury one of the tollowing declarations: ✓J`' r
I have and will maimain a Cenilinuc of Cn loan,..self-,neuro for Worker's Cmmpe. DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
9,W
s provided for by Section 39100 of the LaMn Code,for the performance of the
'h M1th:p T J FIXTURES—PER TRAP
J will a t Worker's C p ,' 1 : i I by S Yon o•[�
h LM CoA Th pu nnmc Rh workbassinet du%pcnl ' seri GAS IA SYSTEM I INC'.401JTLETS OCC GROUP APN
ywhe o1JyNny nor T--71—
Caner L l / / CAS TA SYSII?M OVER4(HA) 3�q
CERTIFICA'HOF EXEMPT ION PROM WORKERS GHIIASI%INUIISTHI.WAS'I'IiiMTERCEPTON o2 �
COMPENSA'I]ON INSURANCE BUILDING DI V ISCkl FEES
(I'h-whionnadnot hecum.pinuJiftire Pam,,is lbrmmbandreAdollarx(SIW) GIl17ASl1'fRAP
or Ic,z.) PIANCHECK PEE
I anify than in theperfnnnmee or the work for which misper mitis issued.I shall ShWFIt-SANI'T'ARY-S'I IRM EA.2fA)FT
.at hondoy tiny peso In any Tam e,,o m(o haomrc suh'lect w the WorkerCon,pco- ENERGY FEE
,Z a much Law,lelCalifornia.Don WA'I'IiRIE7 TIdRW/VHN'DELEC'TR
O Applicant t GRADING FEE
NOTICE TO AI'PLICANT:If,ale,nuking this Ccnifcaln of Eseu don,you sbodd WATER SYSTENIT RHA'IINC.
SOILS FEE
F became attbjeol to Tire Wilted,Co„yre,.odon pro'kit,ax..life lath...Code,y,,.otat
Woub,rdr comply wim.neh m'o,kion,or dd,p,rout shall be de en,ad revoked. WATER SERVICE
Q
CONSTRUCTION LENDING ager NI1W HHSIDIiN'TIAI.PLMIi, SQ.Ff. PAID
O Iherehy affirm that lhttoiea emstnmllnn lading
agencyy PIT lisrli
pe . nc
nnc of Date He,clp,a
LL, F the work lin wnlch,hi,panni,is—mad(Scd.3099,Civ.C.)
Lender',Name TOTAL
IU U Lc d All 'TOTAL:
I ccif,,hrt I have it This'ppl'aI t d.ithat th 'h i s' BUILDING FEB
�. h a ,.I agrcemdonmly w'mall city and n,y tnTwnaun l:rm Ltws ell ngm QTY MECHANICAL PERMIT FEE SEISMIC FEE
U Z miliin.cnnswealth.and hereby vumrni'�e rcprcxdnunivcn of Ibis city manses uprm,b,
abw,radammed property for inspection pu,ryxacs. PERMIT ISSUANCE ELECTRIC FEE
(we)agree to ome,inAamady and keep hanalcss,he City ol'Cupertino again,,
habAaar,,judgmenu,costs and exP:nus which stay In any way scat,againaxaill Cal ACI'ER OR ADD'TO MECH. PLUMPING FEE
in mmequence of the gmnTing of this penord.
APPLICANT UNDERSTANDS AND WILL COMPLY Willi Aid,NON-POINT AI R DANDLING U NT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR I IANDII NO UNI('(OVER 10.00 CFM) CONSTRUCT ION TAX
Signa ms of A Iplio,im Cmaraanr Dan, EXHAUST FOOD(WIDUC) HOUSING MITIGATION FEE
HA9.ARDOUS MATERIALS DISCLOSURE
Will the applicant or]little tads ing uceupatn msec ter handle bw.atduuv mmml.l IIITAI'INC,Fish F(IT)100.100 B I Or
as defined by The CUPenim M - . Code.Chapter 9.12,xnJ the Heuhn and Safety Coda Section 25532(n)p HEATING UNIT(OVER 100,00 IT IU) �� /
❑Yes F No VEN9'ILATIONFAN(SINGLERESID) PAID D e Receipt p/�
Will rhe applicant a more building swcopunt me cquiprom,ler devices Is Idea TOILER-COME'CHIP OR I(0B(0 BTUI
mi,hazvdota air cnntami ms' ,fined by The Hay Area Air Quality Management TOTAL'
Dwal BOILER-COMP(OVER 8O.1O0BTU)
❑YesSo 1.
I have read,he haz o materials teyu;mandrils under Chapter 6.95 of dw Cal;- AIH CONDITIONER ISSUANCE DATE
from cam. Safety Code.Seainns 255O5,25533 and,5511.1 understand That it The NEW Rp_SIDENT1Al,MECH. SQ.CE
IN it grind, a 1. -'vnyn'+1"'miha n"', Lily t heyyyyrrrryyyy'''' T -
t tech mod epdtams. oranfa � u, ,
ncr or tut mz agcm
Ua,c TOTAL: ISSUED BY:
OFFICE