S3327 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO 1 U 1'DIN(;-ELECTRICAL eBR HT No.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL 3327
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS T
/� SANITARY No APPLICAION Sl111MITl'AI,DATE
OW S NAME: t - - PHON . CONTRACIO 'S NAME: LIC NO:p
i"'t �l-�Sa L'\ ^/\A.[ SY32S NIC GQNTRQI.p
CHITECT)IiNGLN1iER: LIC No ADDRESS: ❑ .
CONTACT: ruorvr: ILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) RLI ELECT PLUMB MECH
A - ' 513-7 � P D� ED 1:1LICE\ Cfl CU\TRACTORS II ECLARATION QTY ELECTRIC PERMIT FEE
I hcom,affna that it,l used madc,p nznr Chapmr 9(courneriew, _ JOE DESCRIPTION
�aZ th Sccfun 9lNNJ)ofU - 1 Ohre Hus IP fcxnih hs Gla:rod nylc hm lx �j RESIDENTIAL;
WOO wh PERMIT ISSUANCE it, J
F��F
in force and R�fmtr Q7 '1 l ❑SFDWI, ❑KITCHENREMODEL
Q,ZU Incense Clain Liep� APPLIANCES-RESIDUN'rlAi. ❑ADDITION [_1 PLUMBING RE-PIPE
W Data Cormier
m Q r
kCII1TEC1'S DECLARATION El MULTI-UNIT El STRUCTURAL
A
PANELS MODIFICATION
Z Z l understand my plans shall be used us public records
OZ�O UP 10200ANIPS ❑INTERIOR El CHIMNEY REPAIR
[:-t?F'W Licensed Pndewional 201-ItxX)AMI'S LII.MPROVF_MENT E]SWIMMING POOLS
�Y J OWNER-BUILDER DECLARATION OVER MO AMPS ❑BATH REMODEL/REPN ❑
R DEMOLITION
C d 1 hereby affirm that 1.m exempt from the Comracmr'x License Law for the
d O d U fo lmoin (Nation]031.5.Bueiness and Profusions Code:Any cit Ont ❑OTHER
3 LL F 8 reams.(.ec inn Y m tomit, SIGNS ELF.CI RICAL
or
•� which requires u scant to comtmct.Tiler improve,demoli.,h,m meson any sa remrc
7,izfY .3
I )Ton pro,I"as issuance,aBonerion"the applicant for such peanut to rile u signed statement SPECIAL CIRCUI'1'IMISC.
42 1
f t,u�I that he is licensed pursuant o the provisiomoftbe Commucau's License law(Chapmr9
WE5 (commencing with Semina T)(XBuf Ed,mon3of@e Business road 11 [visitorsCade)to, TEMP.METER OR POLE INST COMMERCIAL:
d 10 C than be is exempt there a,and the basis fur tha alleged em.alec T.Any v,olalioa of ❑NEW BI.DG)ADDITION ❑DEMOI.I'IION
�'^,y Section]03 LS by any applicant fmapennit subjn¢the applicannoacivil penalty of POWIiR DEVICES ❑TENANT ❑FOODSERVICE
not mere than five hundred dollars($5(X1). IMPROVEMfiNf
El 1.as awnOr,,f the ma,uy,ormy cntpinycec wiW wn,u as In,,,ole congctuWin i, SWIMMING P1.11 ELECTRIC
t- will do the work.and themancture is not intended or offered lot sale(Sec.](Hi.Business ❑OTHER
a3 and profession.,Cale:'['he Canm¢mr's],it....c Law does not apply to an owner o OO"I LEIS-SWITCHES-FIXTURES e
progenbar ro
y who uilds impve,thereon,and who docs such work himself or thfough
his own employees,presided that%nab impmvehncros am not intended or offered for NEW RESIDENTIAL ELEC'!'R SQ Fr.
sale,IL however,the building or improvement is sold within one yearofcomplztion.the SQ.F1'.FLOOR AREA $tSQ.17..
own -Milder will have the burden of proving that he did not build or imprn a for pti
pose of sole^). v v
E] I.as f of the property,am exclusively contracting with licensed contractors to IOTA
onorudihe ,,,j,,,(Sea 9044.RuWncsaand pool ksioas Code:I The Contr.cmr's I J-
cerise law dos not apply man Owner ofpmperty who builds Or improves mcmon.and QTY. PLUMBING PERMIT FEE
who convects for such projects with a contractions)licensed pursuant o the Contractor's
Lieenn Law. PERMIT ISSUANCE
El 1 ton exempt under Soo .R&1'C far this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Done
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE 'l y O
I hereby affirm under penalty or perjury ane of the fallowing declarations: 2- L" P
J lhuvennJwillmuinwinnCcrtifcawnfCunn<mmszlf-insurvfur Wo.m"Compcn- DRAINS-FLOOR.ROOF.ARBA,COND, STORIES TYPECONS'I'RUCHON
--.moon,as provided fur try Section 3901)ul'the LvMm Cala,for the pcdnmhance Of the
work for which Nis permit is issued. MIXTURES-PER TRAP
❑ I have and will nwiumin Wurkcrs Gnnpenvudnn Inmmnme,ax rctluired by Section
3](I0of t¢Labor
hChcalc,fnrthe Nnformuneeof hhc work for whichthi5 peonit is issued. GAS-17A-SYSTEM-I INC,J OU'TLGTS OCC CROUP APN
by W., an ny/<mCAmie Pahldy N'h)'WMb�.rµc3 ZS GAS-EA.SYSTEM-OVER EA)
Can'mc, ti7�bj�l C q
�TI .pC( XLOMPENSyH AI'I'ION INSURAN
CE/ ��1`_ GRIASFJINDUSTRI,WASTE LYTERCIiYfOR
('T his sect ion aced not he completed if the pernut is tit one hundred dol lurs(S1WI BUILDING DIVISION FF.IS
or leu.) GREASETRAP I'I,ANCIIILCI ill
1 ' -I coni l y that in the perbnnao,of the work for which thispcanit is i.ssued.I shall SEWER-SANITARY-STORhI PA.200 FT.
.-/
not pal yy nth Y .0 as 1 0.' :object th W m
Worker,Co ,n- ENERGY i
Ze, sari fa ICITie Dt WAI FR HEN FR WNEN I/gLECTR
Applicant GRA jk6 'E
NOI ICE TO APPLICANT-11after makin,th:C it ca e of EiTualption.you should WAFER SYS TEMOTREATING
dtmmme subject to the Worker,Compematron pawkinns d the Labor Codr.you mum S( KI
PP
r futbwith comply with such powrainxar this permit shall he deemed revoked WAIER SERVICE
CONS'I'RUCTION LEND INC AGENCY NEW RES[DENTIN l,1'I,MH. SQ.FI'.
I
UQ thereby affirm that there is a construction lending agency for the puranen of Data Rc'iptU
W H theworktoo,which this permit is i.... (ST 319].Civ.C.) - ,10
OU Lender's Naas
Loader's Address TOTAL: li ILDING PET.
Q. I cmify that I have real this application and shute lhm the above information is
.�. h curmct.l agreememnply with ell city rad cowry nrdinancesand santelaws reliningnh Q'ly.. MECHANICALPERMIT FEE
U Z building construction,and hereby authorize mporworatives of this city to enter upon the SIDS. IC I'IiF, is
L(t7
abase-memioned property for inspection purposes. PERM]IT ISSUANCE(We).gree I save,indemnify mn1 kap hurmlea dw Co,of Cupertino n,uiaxt ELF. IC FEE:
Iisbilities,jidgmems,cousand expenses which may many..yawrueagaimm said City gllTfiR OR ADD TO MECH,
PLUMBING IEE
consequencein ofthe ' g thispermit.
APIhICANTI''UNDERSIANyS
ANIS WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIC(TO IIIJNN)CFM)
MECHANICAL ITiIi
SOURCE REGULATIONS.
AIR HANDLING UNI'I'(OVER I0.010 CFM) CONSTRUCDON'fAX
3rgnatura of AppEcautfiContmctor Due EXHAUS91 IOOD(WIDUCI) HOUSING MITICA'i'ION ITeE
HAZARDOUS MATERIALS DISCLOSURE
( ;
WIII,Im,,lior or tlimre bur along act,,; t mora or handle haranlmmomtrrirl HEATING UNIT 0 O I(DONX)BTU)
as defined by be Cupertino Mumeipul fide,Chapter 9.12.and the Health and Safety
Cod,Seer..25532(x)? HEAl1NG UNIT(OVER 100.000 BTU)
p Yc, E]No PAID
VIiN'TILA'IlON FAN(SINGLL'RESIU) Unto Recciptp
Will the applicant or future building occupant use equipment or dcvicas which
mit h.zudans air cnnimninumn ax Acfined by the Bay Arca Air Quality Managenmm BOILER-COMP(311P OR 100.000HIND 'TOTAL:
A1111111 BOILER-COME(OV ER 10X1100 It FU)
❑Yes ❑No
I have read the I J aiWl,.,mmarromesunt Charam,6.95 of Culi AIR CONDI I]ON FIR ISSUANCE DATE �f
fusion Health&Safety Code.Section,3505 25531 ad 25534.L miderootrad,hatt if the NEW RESIDENTIAL MECH. SQ.EL o Y
building d thotlyhave emm.thtf: y :ryhnsib Ttyt Blythe occupant
of the requirmnrnu which must be met prior to issuance of a Cenmerm of oeenpaney.
Ossr,ao uuthnfbed again Date TOTAL ISSUED BY:
OFFICE