S 3971 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3971
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/02n3 (i�(so)Okwdl e
OVER S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
�P 3_ L C) NIC CONTROL M
'RPRCHITECTOGINEER: LIC NO: ADDRESS: ❑
CONTACT. / / Is 0 F:: BUILDING PERMIT INFO
oe;, (5/ �cnn:e Roue 0 ME 3_1a"46 El Consultant Fees paid by Applicant(Initial) BLDG - ELECT PLUMB MECH
U 0b -741`1 -`0,r15 ❑ ❑ ❑
LICENSFDCON'rRACTf3R'S DECLARATION Qq•y ELECTRIC PERMIT FEE
1 hereby afRrm Bm 1 em licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 700B of Division 3 of me Business and Professions Code,and my license is
WOOfall PERMIT ISSUANCE RESIDENTIAL:
�U[- in Classfromeed effect. ❑SFDWL [I KITCHEN REMODEL
Q U U License Class Lin.p
Date Contractor APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION - ❑MULTI-UNIT []STRUCTURAL
Z p Z 1 understood my plain shell be used as public records ANBLS MODIFICATION
OZ•.0 UPTO200AMPS [I INTERIOR ❑CHIMNEY REPAIR
C=~� Licensed Professional 201-100DAMPS IMPROVEMENT SWIMMING POOLS
C ••1 OWNER-BUILDER m.tUILDER DECLARATION OVER IWOAMPS ❑BATH REMODEUREPAIR ODEMOLITION
6 T hereby affect that 115 exempt from The Conttumors License Law for the
L?�S OD.0 whichfrilloveingreaes a permit in consumer,
alter andmp Professions Ca le:Any city or county SIGNS ELGCfRICAI. ❑OTHER
sa a 1�F which requires a permit m cnnswct,alter,improve,demolish,or repair my swcturcA/W 1W2
prior toits issuance,also requires mPermit e applicant for such Permio file o signed statement i SPECIAL CIRCUITIMISC. r
that he is licensed pursuentto the provisions ofine Contractors License Law(Chapter 9
5�p (commett<ing wire Sation7X10)of Division 3ofthe Buvinessand Professions Cob,)or TEMP.METER OR POLE INST. COMMERCIAL:
d q M C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDDWN ❑DEMOLITION
Section 703115 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
^ZF-tnot more than five hundred dollars(SSW). IMPROVEMENT
Sa 1,as owner of the property,or my employees with wages as their aole compensation, SWIMMING POOL ELECTRIC
willdethework,anitheaaumumisno intendeduroRered torsade(See.2b14,Bminraa .OTHER
W3.
3m and Professions Code:The Contractors Licen.¢law does not apply m an owner of OUTLETS-S W ITCHES-FIXTURES
property,who builds or improves thereon,and who does such work himself of mmugh
his own employees,provided that such improvements are nm intended.,offered for NEW RESIDENTIAL ELECTR SQ IT
sale.If,however,the building or improvement is sold within one year ofcompletion,the — VSQ.FT.
owner builder will have the burden of proving that he did not build or improve for put.
pose of sale.).
1,as owner of the rt am exclusive) g with TOTAL: nn I D
Sec. y, yconwctin th OcTheeCcontractors i- F�
cents La me project(Sec.o an Business and Professions Code:)The Contractors Li-
whocoawdarorsuchplytoaswithaofpropcnywho censeddursimptoves duration.'heCommeond QTY. PLUMRINGPERMIT E JUL •I Q 1999
who L.ta for such pmjecrswith aconummor(s)licensed pursuant Be Conwmors ,I 1 A:
License exempt
PERMIT ISSUANCE 111
❑I am exempt under Sec. .B&P C for this reason
ODam ALTER-DRAIN&VEST-WATER ) VALUATION
9EU14 (I 4=A rlW -R'SCOMPENSATIONDECLARATION 'J
BACK FLOW PROTECT.DEVIC
herchy ath o'er penuhy of perjury enc of the following Jeclarmions:
T have and wi 11 mammate v Certificate of Commit.xelf-insure far Worker's Co.,.- DRAINS-FLOOR,ROOF,AREA,COND. 104STORIES TYPECONSTRUCTION
sation,as provided for by Section 37M of the labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP _
❑I have and will maintain Workers Compensation Insurance,as required by Section fff
37M of the labor Cod,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLGTS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier: Policy No.: GAS-IIA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE INDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed Bass permit is for one hundred dollars(SIWf GRGSETRAP
' or less) PLANCHECK FEE
I cenifythamdo perfmmanceofthe work for which this Nautilus issued,Ishall SEWER-SANITARY-STORM EA.2W Fr.
not employ any person many m..mor q kgyg subject to the Workers'Cortaro- ENERGY FEE
ZZ sation Lows q[C if. u.D+� Ja� "wl WATER HEATER WNENT/ELECTR
O Applicant T�1 ut GRADING FEE
y NOTICE r APPLIC IL offer making Bis Certificate of Exemption,you should WATER SYSTEM SOUS FEF.
a > become subject to the kers Compensation provisions of the Labor Code,you must
foMwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
UZ CUCT1ONLENDING AGENCY NEW RESIDENTIAL PCMB. SQ.FT. PAID Date Receiptx
V O Thereby option that
then there isaconswctinn lending agency for the Performance of
the work for which this permit is issued(Sec.30G.Cie CJ
(L F" Lender's Name TOTAL:
Lender's Address TOTAL:
1 certify that i have read this application and state mat the have information Is BUILDING FEE
(A correct.I agree to comply with all city and county ordinances and state laws relining to QTY. -MECHANICAL PERMIT FEE
U z building consudan.and hereby aummire representatives ofihis city to enter upon the SEISMIC FEE
uc
above-encmioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless me City of Cupertino against ELECTRIC FEE
liabilities.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence ofthe granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IROW CFM) MECHANICAL FEE
SOURCE REGULATIONS
AIR HANDLING UNIT(OVER IO, CFM) CONSTRUCTION TAX
Signature of ppl' Contractor at 10j"O EXHAUST FLOOD(W/DUC
AZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building occupant store or handle lismadms material HEATING UNIT(TO 1011,100 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yes �o VENTILATION FAN(SINGLE RFSID) PAIDlft -
Will thea applicant on future building cu am use equipment or devices which Date Receipt M
pp gow p' Area
BOILER-GDMP(JHP Ok IM,OW BTU)
mit haenrdous air wntvminums as defined by the Bay Attu Air Quality Management(
TOTAL:
nsmet?
❑Yes B--illy^// BOILER-COME(OVER 101"FITU)
1 have read the hazardous materials mq moments under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Heahh&Safety Cim,Sections 25505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.ET
building dors not currently have a tenant,that it is my responsibility to notify the occupant
of the Aril
cots which the mm prions Lasuance ora Cenifcmc of Qcupv cy.
Owner or uufhodz Iff Da TOTAL ISSUED BY.
OFFICE