S 3893 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDINCDIVISION APPLICATION)TERMIT PLUMBING-MECHANICAL. S 3893
BUILDING PROJECT IDENTIFICATION ;; (r
BUl DINGADDRBSS: SANITARY NO. APPLICATION SUBMITTAL DATE
D L i",/
OW F; 'S NAME: 0 •PHONE: a 51 /Q C IRAC70HS N�t. s,O� LIC NO:
(/Lf//- NIL`/ /9� 1/.�� HiI N/C CONTROLM
H / NGINE : - LIC NO: ADDRESS: L K U•1 ad4vt e
N ❑
ITACT. PHONE: 5 { ':'BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
oma ❑ ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY , ,E ELECTRIC PERMIT FEE V'
I hereby alrrm that 1 licensed under provisions of chapter 9¢amme s Cs i JOB DESCRIPTION
yy�II.Z wim Senior]note of D": 3 filer Buai e: dP f scions CA amy Bcc RESIDENTIAL'
FSB in full forceand eRcc, PERMIT ISSUANCE
1a1...VV License Cla Lie.M a DSFDWL ❑KITCHEN REMODEL
Vr6L Dale Conuoeror APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTIUNIT ❑STRUCTURAL
~r,=nZ I mottraand myplan AmII lwusedva public records PANGIS MODIMCAT0N
OZ-0 UP1'0200AMI'S DINTERIOR ❑CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
yy C Q 1 berehy amrat that I am exanpt Bonilla,Cmaracmr's Liceuse Law far the OVER 101AAMPS D BATH REMODEUREPAIR DEMOLITION
i9 3 H following reason.(Section 7131.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL D OTHLR
W p which requires a permit to consumer,almc improve.demolish,or repair any structure 1
Q26�
prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCU IT/MISC. G
WY (hat be in licensed mrsourn la the provisions of the C.mrecon,,Liamse Law(Chapter 9
W�pO (commencing with Section 7100)of Division 3 tefthe Business and Professions Cartel or TEMP.METER OR POLE INST. COMMERCIAL:
IS Xre C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW 6LDG/ADDITION ❑DEMOLITION
4• Section 7031.5 by myapplleam for. crmit,aoinn,dw opplicam lnauvil penaliyof POWER DEVICES
Y1-"H ZTENANT D FOOD SERVICE
not more then f ve hundred dollars y em). /CIMPROVEMENT
all D Lr,he as work,the property,or myemployeeswithwagesfar
sate(See
le compensation, SWIMMING POOL ELECTRIC
F will dancsomiis andthe he Cifeisnot,Lacm,c .tiered for sale,I, ,,(144,Business DGTRER
lay"m and arty who
Cade:The C.naaerors License Law stns not apply m an mvner of OUTLETS-SWITCH&S-FIXTURES
6 3 progeny who builds or improves thereon,and who docs such work himself orthroughf
his own employees,e provided that such meatimprovementswithin arc not intended or nffereJ for NEW kESIDfiNTIAL ELECFR SQ FT.
owarenFhowever r will hbe the Bding oren of pemenl isat hedon year ofWild
improve
letiogthc SQ.FT.FLOOR ARf?A E/SQ.Pf.
cmf,ildcr will have the Borden of proving that he did not build or improve for par
pose of salee
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: �s
.nsmum these.ma (Sec.]U44,Businessland I'rofessione Code:)'Ihe Conaecmr's Li- - I - . .I, ( -•�-{�
whoLawdcesr such plyman ithaofpmpeny whosedporant 1.the thereonend QTY,' '.PLUMB LNG PERMIT FEE
who amhacts for such projects with acomraclogs)lianaed pursuant 1.the Con[mema'.a t
Licence Law. PERMIT ISSUANCE
(]1 am exempt under Sec. ,13&P C far this..,an
ALT13R-DRAIN&VENT-WATER(EA)
Date VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRITIFC..DEVICE �!�
e Ihereby affirm under Penalty of perjury ane of the following declarations: p v
I have and will maintain a Certificate of Consent o self-insure Ra Workers Compeer- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
on,a provided for by Section 3713 of the labor Code,for the performance of the
13700of
rk for which this permit is issued. FIXTURES-PERTRAP mT
I have and will maintain Worker's Compensation Insurance,as required by Section Woo(.(� J
the LAwrCode,forthe performanceof thework fn„,Mich mispermit isiesud. GAS-FA.SYSTEM-1 INC.40OrLETS OCC.GROUP APN
W.rky _Ol nyyag(A DEMP '�dCNwYa�✓r ��7Z� GAS-EA.SYSTEM-OV13R 4 LEA) f�J� C'nIIIIb 1 Grier.FF GGLn _END(F r Oiir'�
CHRTIFICA'I'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASOINDUSTRL WASTE INTERCEPTOR a „
(This seati. r,rairol beurmpleted ifthe t is fortune hundred dollars IW) 1 jr, OUILDING 61y1SIONiFEES A
Derma GREASETRAP
or less.l PI ANCHECK PEE
I tenify that in Ne performance ofhe work for which Nie permit is issued,I shall SEWHR-SANITARY-STORM IIA.200 FT.
not employ any person in any manner so as to become subjem to the Workers Compeer- ENERGY FEE 7y r/o
Oz cation Lnws.f California.Date _ WATER BEAT FR W/VEhyFM,ECI'R
Z Applicant GRADING FEE
rNi NOTICE TO APPLICANT:If,after making this Certifieme.f Exemption,you should WATER SYSTEMOREATING
abecame aubjem to the Worker's Compcnsation provlslona of the Labor Cale,you most SOILS FEE
fLl forthwith comply with such provisions(it this permit shall he deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FL PAID
tip I fares affirm tMer there isawn(Seelianlendis,agency for performance of Date RecelplN -
F' me work for which this permit is issued(Sec.31YJ],Civ.C.)
0 U
Lenders Name TOTAL:
Lender Aally t TOTAL:
(r” In 1 really that 1 comply
tl allapplicationa and nate that the above Iws iclam n is t ,t- BUILDING FEE ,
rp correct.I agree m comply 1ch, city notheri ne,aciounty ordinancesike, f and store laws,upon
g m QTY MP.CHANICAL PERMIT ,FEE a
V haildogcotionedonantlhrinspcchtnercpresemet vasofthascny toemer upon the t SEISMIC FEE
aMrvomemmncdproperly Iia inspection keep s. PERMIT ISSUANCE
(We)agree m cost,indemnify and keep harness the City or Cupertino against ELECTRIC FEE
Iiabilitiesjudg of the
and expenus which may in any way acerae against said City
in cmincyuenw of lM1e lin Tabic � ALTER OR ADD TO MECH. PLUMPING FEE
gran D Dumb.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-MINT AIR HANDLING UNIT(TO 10,0110 CFM)
SOURCE REGULATIONS. MECHANICAL ITE
AIR HANDLING UNI'I(OVER 10,000 CFM) CONS FRUCTION TAX
Signature of ApplicarrCommctor Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applic,m err home thelbogoccupanl sane mrhandle haeeN.us material HEATING UNIT(TO MOM BTU)
as defined by the Cupertino Municipal Cale,Chapter 9.12,and the Health and Safely
Code,Section 25532(ayf HEATING UNIT(OVER 100,000 BTU)
❑YesIq VENTILATION FAN RESID) PAID �f
l" Date Receipt N
Will me applicantor building occupant use equipment or devices which BOILER DHP OR 100,IXq BTU)
incl?
hneN
uous air ennmminaoBnls a ore detinet -
by the Bay Area Air Quality Management TOTAL. /, Q
el?
❑Yes BOILER-COMP(OVER 100,000 BTU)
�No _
I have readme hamrdmo mamdmsrerequirements Cha AIR CONDITIONER ISSUANCE DATED
quircmen Chapter .I me Cnli-
fomia H.I,h&Safery Care,Sections 25505.25533 and 25534.1 undcmanJ mat if me NEW RESIDENTIAL MECH. SQ.FT.
building m,, of at dy havea¢nant,[bm it is myresponsibility to notify t coccupant
of me rnyurr ems �M1muab net Pnnrm cola Cur llicmeo
.�/ OrM' e �4°� n yT
Owner oreth me agent Dam TOTAL: ISSUED B /�� rTN7O/1.(-a}"�-
OFFICE