S 3811 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECIIANICAL S 3811
'BUILDINGIrROJECTIDENI'IFICAT1ON.lt, r: ,t
BUILDING ADDRESS: SANITARY NO, APPLICATION S/ E.
UBBMITTAL DAT
OWNER AME: PH ,fi: CONTRACTOR'S NA LIC NO'. C Z " IT
N/C CUNIBOLp
Itr
• ARCHHECT/ENGI EER: LIC NO: A lR S.:� / ❑
CON] CT: NN PHONE: '/ I'-'" ' ',1 ' •'BUILDING PERMIT INFO ' l
t o;ouw A f 3`7 717 ❑ Consultant Fees Paid by Applicant(Initial) BLE ELE PLUMB MLCH�L/,I
LICENSED CONTRACTOR'S DECLARATION QTY ELECT RIC PERMIT " FEE
1 Thereby affirm Thai I licensed under provisions f chapter 9 mmnme m, _ . , t... �t JOB DESCRIPTION
paZ w;m tiee+i„r,9RtNn„m".non3r nn,.e,a ss enol rotes .ns Code,and rayl ecnse i. RESIDENTIAL
I�O O PERMIT ISSUANCE
F W� in full force an -e t s � - ❑SFDW L ❑KITCHEN REMODEL
QU$U~ L2t"t,Cass Lica APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RIS PIPE
0 d Lit Dntc Conlruclor
Fpy COO ECTS I)ECLAAATICTbf PANELS ❑MULTI-UNIT []STRUCTURALz O o z 1 understand my plans shall be used as public records MODIFICATION
O "z-r4INTERIOR ❑CHIMNEY REPAIR
W UPT0200AMPS ❑
[F�F' Licensed Pmfessi,,nal 201-UgX)AMPS IMPROVEMENT C]SWIMMING POOLS
qgQ,j '� OWNER-BUILDER DECLARATION OVER IIgf AMPS ❑BATH REMODHILEEPAIR DEMOLITION
C al 1 hereby nffnn that I ate asimpf Rom line Contradlors License Law rot the
x O6 U following reason,(Section 703 1.5.Business and Proassions Cude:Any city or count, SIGNS ELECTRICAL ❑OTHER
W O H which requires a permit 10 construct,alter,improve,demolish,or repair any swnure n
F. murealso recruits,life applicant foror,h pant to fduasignulsoaemat SPECIAL CIRCUIT/MISC. �[ O
<s
that he is licensed pursuant to the provisions ofthe Contractors License Law(Chapter 9
W 0 (commening with Semon 70010)of Division 3 oftne Budifess and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
A. eT ohm he is exempt fnerefrom and too basis for fife allegwl conniption.Any,io4dum of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 703 IS by any applicant for a permitsuhjects the applicant to a civil penalty of POWER DEVICES
W�,n OTENANT ❑FOOD SERVICE
not more than five hundred dollars($500).CIMPROVEMENT O i]Lus nwmen,l he pn,peny.or any alpinyees with wages lis'Ihuirsolecon,pansednn, SWIMMING IH30L1?hIiCTIiIC
Apo. will do the work.and the stmnum is not intended oroUered for sale(Sec.]B44,Business
[]OTHER
W�� and Profession'Code The Commerce,Leonie Law does not apply m VI
an of OT.EI' IV
S-SWITCHES-FIX' R
0.3- pnmerty woo builds,,,improves lhomn,;rail who does .,If work diumal f or through
his own employees,provided that such improvements arc not intended or altered for NEW RESIDENTIAL Id-ECTR SQ
sale.IL hmsever,the bulldingor improvement is sold war.one year of connotation, he SQ.FT.FLOOR AREA $/SQ.ET.
wnerhullder will have Ibe buMon of Pre,ing had he did not hai Id or improve for pur-
pose ofLsale f
❑I,ns owner of Ne propeny.am exclusively contracting with lice„.d cnmrecm,s m TOTA
moo n he project(Sea 0044,Broncax and Pre!,ions Code'.)no Conmmmr's Lt.
cerise Law does not apply to an owner of property who builds or improves mercon,and QTY, PLUMBING PERMIT ' FEE
who contracts for such projects with a matmelor(s)licensed pursuant to the Contractors
License Lw. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&I'C for this reason
Owner Date ALTER-DRAIN&VENT-WATER THAT VALUATION
. WORK17R'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE d2_0I hereby affirm under Pennity of perjury one of the following declarations: //1/ �O”
❑I have and will maintain a Certificate of Consent o self-insure for Workers Comped- DRAINS-FLOOR,ROUP,AREA,COND.
S'fOR;E aPE UCTION
smion. r hick this
for by Sews,, 3900 of the Luton Code,for the performance of rife lu'I
1,�JPrk for which this permit is ark,. FIXTURES-PER TRAP
ave and will
tain
ttion
Q]00oldfuL M,r Coaenfinthepeur,Canc fthewnk for wfiich thi PeermB�s�ssucd, GAS-HA.SYSTEM-I INC.4 OUTLETS I�11�QR l]
timer: smion bsura c iris,a'Id�!or y{9u hchej9¢ GAS-EA.SVSTEM-OVER4(HA) V`a•`P/� 99
CERTIFICATE OF EXE ION FROM Wf1RKEA (}O�j
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR
This section need not be completed ifthe permit is for one hundred dollars($Its)) s y-t BUILDING DIVISION FEB.,
Thr les) GREASETRAP PI N iCK FEE
I certify that in The performance ofthe work forvach this permit is issued.I shall SEWER-SANITARY-STORM HA.2W FT.
not employ any porton in any manner so as to l mmem,vbjec,m the Workers'Compact- ENERGY FEE
ZZ smion Lows of California Date WATER HEATER WNENT FLECK
Applicant GRADING FEE
ti NDTICH TO APPLICANT:If,after making this Certificate of Exemption,you should WAT13R SYS'I'EMP TRIiAI'(NO a SOILS FEE become subject r)the Workers Compensatinn provixiom of the Labor Coda,you Ilius,
UJforthwith comply with such previsions or permit shall be deemed revoked, WATER SERVICE
7 0 PAID —!L_
z CONSTRUC'DON LENDING AGENCY NEW RESIDENTIAL PLMM SQ.PI'. D5N( Rmei t a
U 0 l hereby action that is a combination lending agency fonhe performance of P
IA ,--I the work for which this Permit is N,irvd(Sec 3099,Civ.C.)
C H Lender's Name TOTAL:
Leader',Address TOTAL:
I canify that 1 have rad this npPlicanier and nam ohm the above indemnified is t - - - ,. ,. I I BUILDING
Vl cormet.l ngreewcomply wifhml ehynnd county nNlnanas nntl store lows mlwingm QTY. MECHANICAL PERMIT' S tFEE
U Z building construction,and hereby authorim representatives ofthis city to enter operate SEISMI 'E
alxwe-memicemd property for inspection porpoises. `)'-
(We)agree to save,Indemnify and keep harmlmss the City of Cupertino agaimY PERMIT ISSUANCE �.5 T ) v� ELECTRIC MIN
Iiiladides.jidgmelns,emats and c,ivires which may in any way sccmeapgrot said City ALTER OR ADD TO MECH.
in mequence of the punting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TO IO,UfI)CFM) c
SOURCE REGULATIONS, ME A T
AIR HANDLING UNIT 10,000 CPM)
j.' CONSTRUCTION TAX
Si datum„font of Applicant/ Date EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
MATERIALS DISCLOSURE
Will the upPlicam Thr furore building oecupuat snrre,,rbandle hazardous material HEATING UNIT(TO 100,”B'TW 0
as demand by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Crile,Section 25532nd? HEATING UNIT(OVER 100.000 BTU)
❑Yes 7 N VEN'I'II.VDON CAN(SINGLE RESID) PAID lx
Date Reccipta 'ss -
Will the applicant or future building occupant use equipment or devices which
tit M1nBOBOILER-COMP(3HP OR Igl,(Ilp BTII)
card air wts connninunas deforest by the Hay Arca Air Qualify Managmnent T L'
D1nrC1Y
❑Yes []NoBOILER-COMP(OVER 100,000 BTU) I If
I have read the comment materials requiren dents under Chapter 6.95 of the Cali. AIR CONDITIONER O ISSUANCE DATE �I
(mmia Health&Safety Code,Sections 23505,25533 and 25534 I understand that if the NEW RESIDENTIAL MHCH. SQ.ET. /^ C -I�
fn msHdoth notamaCode,Sctions thmhla53 and
15541 mnurtand thccupam r !/ T
oil thgreq,.;mems wF¢h,,fust be Inez pilo,to usunnce of a Ce caW of Occupancy.
O�oi Thr tzW oall
pera ISSUEDBY:
OFFICE