S 3886 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL C OO
`"i ;"BUILDING:PROSECTIDENTIFICATION , J o 0
B D ILDING ADDRESS: - SANITARY NO. APPLICATIOP SURNYTTAL DATE
OWNER'SNAML PHONE: CONTRACTOR'S NAME: LIC NO: SIC CONTROL#
L-los.&J-14urnoo, 4M.-63-093
1• ^A ARCHITE GINGER: LIC NO: ADDRESS: (2A G'jqj ❑
l Il t
CONTACT: PHONE: -:j:j,EUILUINGFEERMIT INFO;
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTORS RAT TON Chap QTY i t ....
EEECTRIC PCRMIT{` - +
1 nGw,y xfrnm hot I a e p f Chapter 9(¢em,n¢ g , I ., s + r ,, r,(s, : JOB DESCRIPTION
Aaz with Section]a)o)er DartBusinessxim3enn¢ and r,re:;em cede nue my hoe xe is - ' ,
WF O O PERMIT ISSUANCE
W.. in Poll force and elect (, FDWL ❑KITCHEN REMODEL
aUZU License Ws Coal APPLIANCES-RESIDENTIAL. ❑ADDITION [I PLUMBING RE-PIPE
yG 1 Dam - Convector
ARCHITECT'S DECLARA [I MULTI-UNIT []STRUCTURALH N PANELS
X O onZ l unde,smnd any plans small be used nx puhlie re v MODIFICATION
CZ`4- UP TO 200 AMPS
M ❑INTERIOR El CHIMNEY REPAIR
; Licensed prom"i'som 201-IOCOAMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS ❑BATH REMODELBEPAIR ElDEMOLITION
q W
1 hereby affirm that I am exempt from the Contractor's License Law for the
x aW O F fallowing reao (Section 70315, 1sand nns Coda Ancity.,
ityocounty SIGNS ELECTRICAL ❑OTHEWy which reyure.a Permt l consumer,.1mq improve,demolixM1,oreprany swqure R
QFIfInPe J.17�'P('[ b, f
Q the,heik ceased If.alsn re a.the lheapplds ffer Corrosion's
law SPECIAL CIRCUUUMISC.
�;!l y"I Nat he it licensed pSection mlhe provisions ofmf mBusiness License Law(Chapter#
Q� (cat he is(commencing there Section and the
Division fn r of0o egad wss and Professions C¢d¢)or TEMP.METER OR POLE INST. COMMERCIAL:
pl o a that M1c is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
if Y. Section70315 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
W y []TENANT El FOOD SERVICE
F=Cnot more than five hundred dollars($SIXl).
❑ Lo the wor ,indfropeny,nr myemplended withwred fortheirsce.cnmpensiiess SWIMMING FOUL ELECTRIC OTHER IMPROVEMENT
E+ will dotheCode.
The cmreisnoti Licensorawdos of apply to an owner
OTHER
a and Professions Coda The Conlmemh End w Laws such
not apply s if owner of OUTLP.T9-SWITCHES-FIXTURES
ttt hpropertyis own who builds or improves thereon,i end wire doesrre n work himself or through
his own employeese provided r in such improvements am not intended or effa¢A for NEW RESIDENTIAL F.LF.CTR SQ PT
sole.l[hower it]have,the hanimpf poo,ml is.mld within oncildori improve
the SQ.PT.FLOOR AREA
eof srtlder will have the burden of proving Thal he did not build or improve for pur-
1 Iwa1 of aforJ.
❑ 1,as owner of the property,am s and contracting with. mixed contractors l0 TOTAL:
construct Po project(S ]044 Business d Professions Cod )fir
'on era 1 r I
cerise Law does netpplyt fp prey who builds or improves thd QTy - �PI.UMBINO PERMIT,- :+ 'FEE ..$I
who oolract for.ashp..jainwahacontictina)I'eenaciprr. ant m the Contractor's - + •t t` -„
Licem.Law
. PERMIT ISSUANCE
C]I oto exempt under See. ,B&P C for ihia revxon
Owner Dam AL9'ER-DRAIN&VENT-WATER(FA) - VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penally of perjury,one of the following declamfiimw:
❑Those unJ will maintain aCGlifwte of ConsenDo self-in sur¢Ter Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
xmant av provided for by Section 3]00 of the Labor Code,for the perfe,mmse of rho
work for which this permit is issued. FIXTURBS-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
3900of the Labor Code,for performanceof(be work for which this permit is issued, GAS-EA.SYS"CBM-1 INC.4 OUTLETS OCC.GROUP APN
My Workc' m nvade�rlsmm� c IandPolic nye {e
Cardec of rlrw.ala ne policy No.Y yah.-][n5 OAS-HA.SYS'PHM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE� GREASIMISDUS'IBE WASTE INTERCEPTOR
(This section need not be completed if permit is for one hundred doper($100) $ .0 ItiGblVl$ION,FP.E9 d?W g .
er Io".) GREASE TRAP PLANCHECK FEE
I certify that in the performance ofthe work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Workers'Cartoon- ENERGY FEE
Z6 sation Laws of California.Dale WATER HEATER WNENUELECTR
Applicant GRADING FEE
.y y
NOTICE 10 APPLICANT:If,after making fic,Cmdfiraw or Exemption,you should WATER SYSTEMO REAFING
abacon,,suhjeet to TM1e Walk,, Compensation provisions of the Labe,Code,you must SOILS PEE
LI) forthwith comply with such provisions or this permit shall he deemed rooked. WATER SERVICE
CON ore is a cIONutionleGAGENCY NEW RESIDENTIAL PLMB, SQ.14. PAID
(.J 0 Thereby affirm that more is aeonstmetion lending agency For the performance of Dam Rocelpt#
W e-I 'he work for which this permit is issued(Sec.3097,Civ.C.)
C •`� Lenders Name TOTAL,'
COLI
Lmdm,,Addm,, 903AL O
6r I readily that I have read this pplicalmsend dmeffs,the b el s , , . . .,, , . . BUILDING FEE .,
I
m Coure11 g t ply an Tiny d ry ordinances and state 1 lv go, QTY. . I +MECHANICAL PERMIT ) gFEE'..i
V Z building construction,and hereby anthodm repre-,enlativewf this city to enter upon the -+ v5<. I SEISMIC PEE
iftrop mentioned property for inspection purposes. PERMIT ISSUANCE.
(We)agree 10 save,Indemnify and keep harmless TM1e City of Cupertino agxiust ELECTRIC FEE
Iiobilltics,judgment,,costa and expenses which may In any way accrue against said City ALTER OR ADD TO SUCH
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(f0 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
/9-iq_nn AIR HANDLING UNIT(OVER 10,00(1 CPM) CONSTRUCTION TAX
Signature of ApplicamUCmimc«rz -• ( Dole EXHAUST HOOD(W/DUCO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will lire applicant or future buildir,occupand,Imeor handle haeu,dorx material HEATING UNI9'(TO 100,000 BTU)
as defined by the Creatine Municipal Code.Chapter 9.12,and the Health and Safely
Code,Section 25532(x)I HEATING UNIT(OVER 100,000BTU)
❑Yes W(Nn VENTILATION FAN(SINGLE RF.SID) I
Date Rewtpt a
Will a a,contaminants a building occupant,A e.Anr Could,eat or Mmm,daes cm BOILER-COMP(3HP OR 100,000 BTU)
emit hawrdous mit contaminants as defined by the Be,Arca Air Quality Menngcmem
DUN 16 A -�
istrict? J
El I.G. s/..e BOILER-COMP(OVER 100,000 BTU)
1 have read the haeanloYar,materials acquirement,under Cha ler 6,95 of Cali- AIR CONDITIONER
p Q ISSUANCE DATE
forbuilds,Healgdoes no Safety Colo,Sections 25505.25533 and 25534.[understand amity
Thal dant NEW RESIDENTIAL MECH. SQ.Pm.
building does not currently haven latent,that it is myaresponsibility to notify the p,ame,occupant
of III¢requirements which must be are,prior l0 i.aunnce of II CettiBwle Of Ooeupency.
Owner,mmahoriaed.,an, Dam TOTAL: D
OFFICE