S 3255 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, Putt NO
BUILDING DIVISION APPLICATIONIPERMIT - PLUMBING-MECHANICAL 3255
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRBSS.. SANII'ARYNO. APPLICATION SUBMITTAL DATE
OW'NERSNAMH: P PHONE. CON I"RAG70R'S NAME; IC NO:
1 ,JQ•� CONTROL k
A EHI'UFC'1'/HNGINF.ER: LIC NO: ADDRES` NN til" �N�� �O �.JJ� ❑
CONTACT PHorvQE: /^ / �I = , BUILDING PERMIT INFO'
4r ( 'P / ❑ Consultant Fees Paid by Applicant(Initial) BOG 13LO'I' PLUMB MECH
LICENSED CONTRACTORS DCCIARAII - QTY. ELEGTRIG PERMIT PEP, •
I n by o f that I 1 l a p f Cn pl ->(rnmm g JOB DESCRIPTION
QaZ ,uhS i 7000) fD Is 3uflhe Bus and Prof-sioseCd danylie
use, RESIDENTIAL'
Fin- in full I...c and effect PERMIT ISSUANCE,
�U� License Class C �� 'LiaIf V1 ❑SFDWL ❑KITCHEN REMODEL
gV APPLIANCES-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
y d u Dem-1-4—"t Comrvncr
W L ARCHITECT'S DECLARATION ❑MULTI-UNIT 0 S RUCfURAI.
F�N PANELS'
Z O m 1 under,mod my plane shall he ural ns Public wrNs MODIFICATIONPA
OZ•-i ❑P T02M AMPS
F.N. W Licensed Professiomd - El INTERIOR ❑CHIMNEY REPAIR
201-IOOOAMP5 IMPROVEMENT SWIMMING POOLS
CC OWNER-BUILDER DECLARATION OVER IOM AMPS ❑BATH RP:MOI3h:LIRI:PNR DEMOLITION{y ¢p],6 I hereby affirm than 1 um exempt front the Contmmer's License Law franc
31L U following rcnson.(Section 7031 5,Rosiness and Professions Cole:Any city or eounry SIGNS ELECTRICAL LICOURT
W fA which requires it permit to com,rand alter,improve,demolish,or repair any sanctions
Fi
O�Q pin,Ina"i"Guar,alsorequirestheappliedntforsurh permitm tile.signedstmemcm SPECIAL CIRCUIT/MISC.
malheislicensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(commencing with Section Il100)of Uivi,ion3o[tha Businessand Professions Code)or TEMP.METER OIL POLE INST, COMMERCIAL:
d{y C
but he is exempt therefrom and the basis for the alleged cxnnptien.Any violation of ❑NEW BLDG/ADD["ON ❑DI?MOIA910N
Section 7031.5 by any applievm fof a leant sulgm¢the applicant m a civil penally or POWER DEVICES ❑'ITNAN'I' [I FOOD SERVICE
not more than five hundred dollars(5500).
E] Lnuro
ownfthere
ppoay,mery employees with wages vslheirnnle compensation, SWIMMING POOL ELECT RIC IMPROVEMENT
2pr will do the work,and the structure is not intended or offered Ter sale(Sec.7044,Business O'IAFR
and Professions Cole:'rhe Contricam s License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improve,thereon,and he does such work himself or through
his ,on employees,provided that such Improvements are not immcded oroBcIel fur NEW RESIDENTIAL EL.ECTR SQ FT.
,ale,If,however,the building or improvement is sold wilhinone yearnfaimpliahon,the SQ.FT.FLOOR AREA $/SQ_EL
ei-Puilder will have the burden of proving that he did ant build or improve for pur-
pnsc of sole J.
❑I,as owner of the property,an,cminsivOy confraating with licensed v ulmcnns to TOTAL.
msruct the p ject(Sce.7044,Business and Professions Codep The Cnntmcnr1 li-
nsoLaw due,delappiy ,,anownerofmopeny who buddsoa improve,thrned"and QTY. PLUMBINGPERMIT FEE
who contracts for.such projects with a eorvrucmr(.$)licensed pumudnl ,,the Contractor s
License Law. PERMIT ISSUANCE
❑I am exempt under See ,B Rr P C for fit s......n
owner Doe AMER-DRAIN de VENT-WA'T'ER IEA) VALUATION
WORKER'SCOMPENSA'HON DECLARATION BACK FLOW PROTECT DEVICE
40 I hereby vlTna ander penally of perjury one of the following declarations:
❑I have and will mmnlain a Certificate of Conscn to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,COND. 5'1'ORIHS TYPE CONSTRUCTION
,.tion,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER'1'RAP
❑ I havemm will mwmuin Wndera Cetnpensaron Insurance,as required by Section
37OOofthe Lahor Code,for the pmfonnance of the work rorwhich this permit is issued. GAS-EA.SYSTEM-]INC,4 OUTLETS OCC.GROUP APE
My Worker's Compensation Insurance carrier and Policy number arc:
Carrier: Policy Nn,; GAS-EA.SY STI3M{)V
CEBIIITICATG OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 'REASFIINI, .WAST' I TEIIC : a e + ,= I BUILDING DIVISIDII 17ili5�
(Thlnsmtionneed nolhecomplcted iftnepenou,,fionme hundreddollms($100) ^ ' - - -
or ca") : SET PLANCHECK FEE
1 comfy that in the performance of the work for which this permit is issued,I shot[
noun destroy .on in tiny mnnnersr as to beennm suhje0.ln the kers'Conpem °R-S TR - O 201 ENERGY PEE
Z cation La e 1 Ir rmaa Dal
Q 1 TER W ENT/ELECTR
_ 0 Appllcvmy GRADING FEE
y NOTICE TO APPLICANT.If,after making tIN Certificate of Exemption,you should ER SYSTEM(fREATING SOILS FEE
H hewme Subject to the Worker's Compensation provisions of theLabor Codc,you inusI S
forthwith comply with anch previsions mthispermit ufall bedcennedrevokeA.
Q
DCONSTRUCTION LENDING AGENCY NL+W KESIDENTIALPLM6. SQ.FT, PALO
1 harwh,Thanthat there isaccd(See 30 lending agency far Iheperformunceof ReceiPlH
W O the eni for which this pcnnit u issued lSm.309].CIv.CJ TOTAL:
O ULenders Nanta
Lender's Address TL:
r� a I certify than 1 have read this applicator unJ sole Thal the,More information, I 0 Blllh h
.H. m rorreo.I agree to to In,with d1 rely and enemy nrd rtmet,i 1,une haws relating to QTY. MECHANICAL PERMIT FEF,
U Z building construction,and hereby authorise representatives of this city to enter upon the SEISMI
dbnvo-mentioncd Pu ped,for impeetion purposes. PERMIT ISSUANCE
(Wo)after to save,indemnity and keep harmless the City of Cupeado against 13LBC'T 'PEG
liabilities,judgmenls,costsand expenses which may many way decade igt/mm staid City pCfER OR ADD TO MECH.
in sequence ofthe Starting ofthis permit. PLUM NG FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOURCE REGULATIAIR HANDLING UNIT(TO IU,0IHICPM) MECHA CAL Ini.E
ON1y�` (�
14a AIR HANDLING UNIT(OVER[QOM CIM) CONS'fRU 'PION TAX
Signamlc of Applirmr Condaoer Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Iheapplioant or Town building occupant,mrc nr handle hamNou,mmerial I[EATING UNIT LED 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Solely
Cede,Section 25532(x)^. Efil UNIT(OVER 100,000 BTU)
❑Yes d VENTILATION PAN(SINGLE RESIDI PAID ..
Dam Receiptir
/. Will the air marol or fmure bonding occupant use equipment of Maria which
emit hazardous air cnnwminant,ns defined by the Bey Area Air Quality Management BOILER-COMP(iHP ON 100,00E BTU)
Distinct TOTAL
�Y¢s BOILEk-COME(OVER 100,000 BTU)
I Lave read the hazardous materials requirements under Chafer 6.95 of the Cal l- AIR CONDITIONER
golrcr p ISSUANCE,DATE_
boldigit.,aila a.Snfcty Code,Oe a Sections 25505,25533 mad 25534.1 mdatify the
that ifthe NEW RESIDENTIAL MECH. SQ.PT. 7l`
of
ramocenotcaundillyswhich must le,mentor o ismy reOtoCilit ficate ifytheeecnpam 1- T
of the mquiremens which must he mm prier to issuance of u CenlBoam of Oeotpmncy. -
Owner m cellos i>ed agent .Dam TOTAL: ISSUED BY: �� v
OFFICE