S 3091 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECI'RIC
At, PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3091
BUILDING PROJECT IDEN'T'IFICATION'
BUILDING ADDRESS: SANITARY NO. APPLICAT/TION SUBMI'MAL DATI
L / -5—
ON NF 'S NA F SPIIONE: C HA OH;S NAh1 E: /J LIC NO:
• Y NIC COM'ARCHITECOEANG/IN.ER: LIC NO ADDRESS: o� ❑
N .
CONTr/j�CI 'HONE: MMM BUILDING PERMIT'INFO
tj& 07'5 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' PLt-U�MB MECH
De v ! ❑ ❑ Iltl ❑
LICENSED CONTRACTOR'S DECLAHA ON QTy ELECTRIC PERMIT FEE
1 hereby arprrm mm 1 am Deemed ander pravixiamu of 'oaten Ramuraenci"g JOB DESCRIPTION
��Z with Sxtipn7lxxl)ol'Division Jot the Badness and Pr Ihsxio .Code nd my Geon is RESIDEN'f1AL
I,WC in full forte and of I'E0.MIT ISSUANCIi
,WC License Lic.I ❑SPDWI. ❑KI'1"CHEN REMODEL
rFag Uma— ^ — COmacrn APPLIANCES-RESIDENTIAL ❑ADDITION []PLUMBING RI:PIPH
ARCHITECrSDECLAR T N ❑MULTI-UNIT ❑STRUCTURAL.
O Z h Z I understand my plans shall be u.cd as puM1lic usamds PANELS MODIFICATION
ht qUP TO 21X1 AMPS El INTERIOR El CHIMNEY REPAIR
Fes..Tal Lla,ntal 11 rensional 201-I000AMP5
yalYE-',j OWNER-BUILDER DECLARATION IMPROVEMENT 0SWIMMING POOLS
y IY W Q 1 hereby affirmthat I am exempt from the Contractors License Low for the OVER 1000AMPS ❑BATH REMODEUREPAIR [I DEMOLITION
x d U following teas...(Sectio.9031.5.Business end Professions Cole:Any city or nsmdY ❑OFHER
'3 LL F SIGNS EhIIC'fRIGh
F.LL U ya which requires a perm.to construct,aper,improve,demolish, fi repair any aimmere
E
m.J lin lei-r. once,al q 'rt.th ppl tf hpannu tl a.mg ed xmmmcm SPECIAL CIRCUIT'/MISC. l.Y
qn�. thmheI.I .edpnrst It 11 p 'sun' OM1 Coronation',oL Law1CL:pI,,9 _
W C00 (commencing atilaSection 7000) Mnis 3 ofthe Business dl f..mm CWe)or 'TEMP ME I'ER OR POLE INSI'. COMMERCIAL
3.%a y that he is exempt therefrom and the basis for the alleged exemption.Any violation of [INEW BLDG/ADDITION [ID17NIOLUION
Ito Section 7(31..5 by any applicmn for a Permit subjects the applicant it)a civil penalty of POWER DEVICES F,yp, nut more than five hundred dullu, SStxq. ❑T'13NAN'I' ❑FOODSERVICE
=Q Las owner of Ne property,or my employees with WI as their side compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
en
will do the work,and the structure is not intended proffered for.sale(Sec.704..Business DOTTER
L 6C and Professions GNc:The Cornmeal's Lice Ira,does not apply m ua owner of OUTLE9 S-SWITCI II?S-FIXTURES
Furriery who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nes intended or uttered fur NEW RES]DENTIAL ELECI'R SQ TT.
Into.If,how,the building nr impbweourros wild vibiatieyrl,ot orticm ,the SQ.FL MOOR AREA S/SQ FI'
nerlwilder will have the burden of proving that he did nm build or improve for put
pose mfolle.f
T.as owner of the property,am exclusively contracting with licensed contractors to TOTAL: /
nnsuam til project Sec.71144,13th nes,and Proussions Call She Convector's Li-
cclsw Law does not apply to an owner of propilly who builds or improves million.and QTY PLUMBING PERMIT' FEE 2
who contracts mrsuch prose,with a ambecoalx)licensed Pursuant n the Contactors `� a
Limnsc how. PERMI IISSUANCE S D /
❑Tem encmpr under Sec. .B&P C for this mason
Owner Date ALTER-DRAIN&VENT-WATER(HA) A ION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROI ECT.DEVICE
1 hemby aRna under penalty of perjury one of me following declarations:
❑ I have and will maintain a Certificate of Consem to salginsum for Worker's Compete DRAINS-FLOOR.HOOF,AREA,COND.
xmmr,as provided lar by Section 3700 of me Labo it.for the IxrIII muuma of the S'I'(IRIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compemation Insurance,as required by Section
3700 of he[,hill Cock,for the perfonnuncc of the work for which chis permit is issued. GAS-EA.SYSTEM-1 TNCAOUI'LEI'S
My Workkkv-.Cropr uon�_r�creamer nnJy No.:r�r� UCC,GROUT' AI'N
Caaiec Lri' (eLL+ (fit EX Policy FROM
f/ Z7417 GAS-EA.SYSTF.hbOVEN4(EAI
CENI'TFTC6rE OF E%IiMPTION FROM WORKERS'
COMPENSRFION INSURANCE GRF.ASIDINDUS'I'RL WAST,:INTERCEPTOR
COMO awdon need not be completed Bae permit is(Intent,huileddollarslSIN)) — BUILDING DIVISION FEES
last.) GREA. AP - - - -
Icertif mut in me - PLANCHECK I2E
y perllrrturne ul'tbewacorne,objee,spermi'Is msxucA.l shall SIiWE -ti NI'fA LSTN IA. X PIl
not employ tiny person in any manner eo ae to haeme subject to the WnrkerF Compete O LNIiIiGY FEE
Z sation Law,of Cdifnmia.Dam
O Applicant WATE :ATE WAENDELECFR GRADING FEE
NOTICE'I'OAPPLICANT.It,after making arms CmiGcam of Exemption,you should WATE YSTE TI
a , hecome subject 1.the Worker's Compensation provisions of the Labor Cale,you must SOILS FEL'
fJ.l
forthwith comply with tach provisions or this liable,shall he deemed revoked WATE SERVICE
� z CONSTRUCTION LENDING AGENCY
U0 T hereby affirm that then is a comvuction lending agency for performance of NEW E 'NTIAI.YLMB. SQPAID
.Irl'. D Receipt
V. Pthe walk rnr which'his permit is Issued(Sec.3097,Civ.C.)
Lenders Name
WLenders Address T TOTAL:
0. I lenity arm 1 have read this t liemion aad...robot the above information.. BUILDING F IF
tZ) ebmrect,l agree to comply with all city and county aMnances and state laws aiming.) QTY MECHANICALPERMIT FEE
�.) Z building construction,and hereby amhoris,representatives ofmis city to enter upon the SEISMIC FEE
above-mentioned property for inspection pmpnus' PERMIT ISSUANCE(Wm)
ugat save,indnnnUy and keep hnnnless the City of Cuparunn against ELECTRIC PEI?
Iiabilitiet,judgment,costs and expenses which may in any way seems against said City ALTER OR ADD 11)MECIT
In consequence ofthe granting of this permit. PLUMBING FEF,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Apt HANDLING UNIT(10 Flood CPM)
SOURCE REGULATIONS. MECHANICAL FEE
ATR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCHONTAX
Signature of Apppcarm Cmint Wr Due EXHAUST IIOOD(W/WCL) HOUSING MITIGATION PCI:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hatmduus material ABATING UNIT T 0100.000[11 U)
us detinnl by the Cupertino Manicipnl Gale,Clader 9.12.:md arc Health and Safety
Code,Section 295321x)? I(RATING UNI f(OVER IN).NX)BTU)
❑Yes tj<
VENTILATIONFAN(SINGLERESID) PAID tea^
• Will mea`I^umt or Iumre buddin,coca pmt user tar devicex which - Dam Receipt �(/ ll
IP b I aAirQn BOILER-COMPLIWOR IWAWRTU)
noir hazvJous m nmminm'rs as defined by the Bay Arca Air Quality Management
Dix..... / MOILER-COMP(OVER I OENDD B"HD A
I erred the amNms els requirement under Chapter 6.95 of me Cali- AIR CONDITIONER
ISSUANCE DATE
Poria Hc: m&Sulci Cale,S at 25505,25533 and 25534.1 understand that if the ryl?W RIZSIUIiN"rl AL MECIL SQ.Irl'. �
huildti,it .c poly tly have a t mot that ire is Illy resgmsibilay at notify areoecupam ! U< �!F/X
of the ireme s ich mum all prior to formula,of. ilicatIr u nay.
Owns o 'hot ' uta TOTAL: ISSUHD BY:
OFFICE