S 3395 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. [fftITNO. 3395
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. `v
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMI ITAL DATE
DIP NAME: PHONE CONTRACTOR'S NAME:. LIC NO:
C-ett ` — Assn N/C CONTROL#
ARCHITECTIENGINEER: Fi LIC NP+ - ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
v w L d875 - of ❑ S. ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY ELECTRIC PERMIT FEE
I hereby affirm Thal 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
FDao with Section 700ffiofDivision 3 ofineBusiness and Professions Code.and my license i. RESIDENTIAL
O- in full force and effect. PERMIT ISSUANCE.
ul DSFDWL [I KITCHEN REMODEL
�UV License Class Lio.N APPLIANCES-RESIDENTIAL ❑ADDITION 11 PLUMBING RE-PIPE
yW farm Comm tae
>R ARCHI'TECT'S DECLARATION ElMULTI-UNIT El STRUCTURAL
ZO22Z l unm
dersndmy plan„ball be used.,publicrecords PANELS MODIFICATION
OZ-Z _ UPTO200AMPS [_1 INTERIOR [I CHIMNEY REPAIR
Licensed Paid..ioual 201-IOWAMPS IMPROVEMENT OSWIMMING POOLS
OWNER-BUILDER BUILDER DE CLARATION D BATH REMODEUREPAIR ODEMOLITION
.n,.1 1 hereby affect that 1 exempt from the Comment,',License Law for the OVER 1000 AMPS
iWWi55 O L U following reason(Section]1131 1.5,Business and Professions Code.Any airy lir county SIGNS ELECTRICAL _ El OTHER
u+'3 W which requires n permit re eomwm,aper,i applicant forsu demolish,urea vir ed structure _
�W0� ptl,,rtu,aits reodea ale,,requiree lhoviiisofor Cmuldrrmil License Law
statement SPECIAL CIRCUIT/#ISG
yy thatbe is liansW pumanntmme provision,of the Connnentr,License Law(Chapmr9
(commencing with Section 7030)of Division 3 of the Business and Professions Code)or TEM R METER OR POLE INST. COMMERCIAL:
6qi5 c c that he is exempt therefrom and the basis for the alleged exemption,Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
Wim Seclion7031S by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES OTENANT ❑FOOD SERVICE
F'S6not mom than five hundred dallies 6500).
E] 1,as owner of the proper,,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
FA wilIdothe wc,k,.nd Restructure is not intended,,,offered furred(See71034.Rosales, DOTHER
and Professions Cade:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
pro,cry,who be Ids or improves Iherme,and who does such work himself or through
his own employees,provided that such improvements arc not intended or offered for NEW RESIDENTIAL EIEC:R SQ FT.
sale.If,hoerveq the bmldlng orimpmvement I, old within ore year of completion,the SQ.M.FLOOR AREA $/SQ.FT.
er-ballder will NAE,burden aTurner t �nol build or hnpmve foe puo
you af,ulene
r he proper,,nm axduvvaly contr.mfng with licensed contractors Io TOTAL .17
O
no
ruct the project(See.7044,Business and Procedures Code:)The Contractor's Li-
m Law does not apply to an owner of pfopeny who builds or iinproves thereon,and QTY. PLUMBING PERMIT
who contracts for„ch project,with.moatmctaq,)licensed pursuant to the Conlmetods
License Law. PERMIT ISSUANCE
0 1 am exempt under See. .B&P C for hfs reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
cr Da¢
• WORKER'S COMPENSATION DECLARATION BACK F PROTECT DEVICE
I hereby affirm tinder penalty of perjury one of the following declarations: (
E]I have and will maintain o Cadeficma mf Consent to off asure for WorkerOOR,ROOFAREA,COND. p
Worker's Camper- DRAINS FLSTORIES TYPECONSTRUCTION
inner,as provided 6e by Section 3700 of the Labor Code,for the performance crude
work for which his permit is i,issued. FIXTUR Ve1IER TRAP
0 1 have and will maintain Workers Compensation Insurance,as required by Section
37M oflhe Labor Code,for performance ofthe work for which this permit is issued. GAS-E .S T .FT'S OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy Ni,: GAS- S STEM IVER (EA
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREAS L ftSTRIfIASTE R
BUILDING DIVISION FEES_
(This section need not be completed if Nepermil is fnrone hundred dollars($1 W) GREAS
or less.) PLANCHECK FEE
Icerliry lhal inane pedoransa ere the work far which his pernd is issued,)shelf SEWER-SANITARY-STORM EA2)10 PT.
nal employ any perwar funny manner so as to become,objeeuo me Workers'Cam .pcn- ENERGY PEE
O � sation Laws(if California.Date WATER HEATER WIVENTO.ECTR
Z 0 Applicant - - GRADING FEE .
tr Z) NOTICE TO APPLICANT If,after making this Cerificae of Exemption,you should WATER SYSTF,M,TRGTING
become subject m the Walkers Compereahon provinces ev he Labor Code,you must SOILS FEE
W forhwiN comply an such provisions or this permit s[,.If be devoted revoked. WATER SERVICE.
Q
pq, CONSTRUCTION LENDING AG NEW RESIDENTIAL PLMB. SQ.FT. PAID
✓ zi mance of Dale Rccei #
1 hereby affirm that there is a construction lending agency
gencyfor ane perfor
V�I'o the work for which this permit i,i„lied(Sm.3097,Civ.C.)
0 Lenders Name AI.:
V Lender',Address TOTAL:
r a 1 certify that 1 have read this application and state that the above information is BUILDING FEE
.Ni rn correct.1 agree to comply with all efty and county ominarce,mad state law,renting to QTY, MECHANICAL PERMIT FEE -
G z baildmgems0oetioa,end hereby authorise representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Caperton agaird LLECTRIC FEE
Iianilities,judgmenb.costsanl expenses which may in.ny only accrue againsl,aid City ALT ER OR ADD TO MECIL
consequencein of the granting of this permit. PLUMPING FIE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,003 CFM) MECHANICAL FEE
SOURCE REGULATIONS,
rlq _,Cty AIR HANDLING UNIT(OVER I0,003CFM) CONSTRUCTION TAX
ureof Aplunbr Coalman, Dale EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazallous material HEATING UNIT(70101,00 B'rU)
i,defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)! HEATING UNIT(OVER 100,000 BTU)
f-1 Yes Ll No PAID
VENTILATION FAN(SINGLERESID) Dote Receipt#
,0 Will the applicant or future building occupant use equipment or devices which BOILER-COMP(JHP OR 103,IX10 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Disnid?
E)Yes F1 No BOILER-COMP(OVER 100,(100 BTU)
I]case...d the hazardous asurni,requiremmus under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
Barry Health&Safety Code.Sections 25505,25533 and 25534.1 understand that d the NEW RESIDENTIAL MECII. SQ.FT, / ^�
building does not currently hN
ave a tenant, at it is my responsibility to notify the occupant
of the requirements which must be mol prior a issuance of a Certificate of Occupancy.
Owncror.uthoriecd.,car Date TOTAL: ISSUED BY: x �--�
'OFFICE',