S 3372 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL Pli ITNO. /� /�
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECIIANIC L (32� '/L
BUILDING PROJECT WENT[FICA][ON N
ROILDING ODRES.S: SANITARY NO. APPLICATION SUBMI'flTE
'AL DA
�Q
238 130 2
OWNER'S NAME `LAl rat '. PHO E: O _ CONTRACTOR'S NAME: LIC NO:
NIC CONTROLp
/
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONIi: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG" ELECT PLUME M
❑ ❑
LICENSED CONnsed under
UECLANAT hap QTY. ELECTRICPITRMTF FEE I hereby affirm that 1 am licensed under porvisinn,of Chapter 9(commencing JOB DESCRIPTION
WOC with Stttian]gXl)of Divixion3 of the Business and Profnainnv GMe,soil my license is PERMIT ISSUANCE RESIDENTIAL
Fin full farce and eRect
QUV License Clea Lick ❑SFDWL ❑KITCHEN REMODEL.
vFi¢aL Dam Contactor APPLIANCES-RESIDENTIAL. []ADDITION ❑PLUMPING RE-PIPE
F.Dm ARCHITECT'S DECLARATION PANELS ❑MULTIUNIT []STRUCTURAL
,yCHZ I understand my plans shall be,used as public retards MOLLIFICATION
OZ,� UP702W AMPS
F.~ ❑INTERIOR ❑CHIMNEY REPAIR
W Licensed Pmfeasional 201-1g0AMPS IMPROVEMENT
Q E3 SWIMMING POOLS
=,x OWNER-BUILDER DECLARATION OVER IBBBAMPS �iiMREMODEDREPAIR El DEMOLITION
6 1 hbaffirm that I am exempt form the Comrecmr's License law for the
x6x�6hereby
U following mason.(Seetion 701.5.Business and professions Code:Any city or county SIGNS ELECTRIC AL ❑OTHER
FLL�W 3 LL y whicM1 requires issuance,also to a, ,wch alter.improve,h esu i file.repair any suucmm
¢ that heiuersedrHant to Cres Preapp0canfthefor wchpactoes License
Law(Chapter
SPECIAL CIRCUI f/MISC.
�} that heir licensed pursuant h)oflovioneof the Commness and
Prue Exons Code)or
� 4576 KTI)
� (commencing with Sectiren]000)ofDivision]of the Business ettJ Prolbssions Ceade)or TEMP.METER OR I'fyLE INST.
6 y o C that he is exempt themfrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITION C2 DEMOLITION
W^m Section 7031.5 by any applicant for a permit subjects the applicant a a civil penalty of POWER DEVICES ❑TENANT'
CCnot more than Fire hundred dollars($500). ❑FOOD SERVICE
�Q ❑ I.as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOL:ELECTRIC IMPROVEMENT
will Jo the wink,and the structure is not lnmnded on oHcred foredo(Ste 9044.Gas,mess ❑OTHER
no and Podessions Code:The Contractor's License Law des not apply m an owner of OUTLETS—SWITCHES—FIXTURES
�' .. progeny who builds or improves meram,and who doessnch work himself or through
his non employees,provided that such improvements um not intended or offered for NEW RESIDENTIAL.ELEcrR SQ I
ame.If however.the building or improvements laild whntnom yemol complawn,the SQ.IT.FLOOR AREA S/SQ.ET.
miner-builder will has the burden of proving thal herbal not buildor improve liar pur-
prse of sole.).
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
onxaod Ne project(Sec.70m,Business and Professions Cod,:)]be Cant user's Li.
nuLaw does not apply toanowner ofpropeny who builds or improves thermal.and QTY PLUMBING PERMIT FEE
who rommcls far such prejeca with a eentractothd License)pursuant m the Comurar's
License Law. PERMIT ISSUANCE
❑I am exempt under Sec. �l&P C fil this reason
Owner - L t ALTER—DRAIN&VEN I'—WATER(HA) )^ VALU>AI ON
S TI ECLAR I BACK FLOW VRUTECII DEVICE J A•//O
I hereby affirm under penalty of,,a,one of the Finnish,del moons: U v
❑ I Inecand will maintain aCertificateof Consent mself-inure for Worker,Corml DRAINS-FLOOR.ROOF.AREA,COND.
cation,in pnvided for by Section 3700 of the Inbar Code,for the rydmmance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. 11 IXTURES-PER TRAP
C]1 have and will maintain Worker,Cm,crsxtidtt mailmen.as banned by Section
370X1 ofthe labor Coda mature perfornanccofthe work for which lbispemait is issued GAS-EA.SYSTEM-]INC.4 OUTLITTS
My Worker's Compensation Insurance carrier and Policy number arc: OCC.GROUT' APN
Canis: Policy N,,: GAS-EA.SYSTEM{)VER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION TNSURANC17 GRHASUINDUSTRL WAS 11:IN'I'FIdCEPIOR
(Thissectlnn need nal becompleted lf the permhie hrtanc hundred Jnllurx($100) BUILDING DIVISION FEES
GREASETRAP
it,le".) PLANCHECK EGG
I candy that in the pernamance of the work liar which this p rnnit is issued,Ishall SEWER-SANITARY-SI ORM EA.21X117.
not employ any person in any manner so as to become subject to the Worker.,Comps- ENERGY FEE
O Z section Laws of Califamia.Dec WATER HEATER WNE,NT/ELECI'R
z Q Applicant GRADING FEE
.N. NOTICE TO APPLICANT:If,after making this Cloollot,of Exemption,you should WATER SYSTEM/TREATING
a , become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
frrans th complywithsuch provisions or this permit shall M Jecmed revoked. WATER SERVICE
0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,IT PAID
L) 0 l hereby alarm that there iso construction lendingageney for me performanceof Dam Rariptp
work for which this perrm is issued(Sec.307.Civ.C.)
Q Vam Lanai Name TOTAL:
Lender's Address IOTA
GI codify that F have real Rai,application and state that the above information is IBUILDING FEE
W coat.l agree to comply with all city and county remittances and state laws relatingm QTY. MECHANICAL PERMIT— ^^"~' FEE
UZ buildingconswction,and hereby auuaot;ze repmscnmtives nfthiscity ea corer upon the - SEISMIC FAkN
uMrvementioned property for inspection purpose'. I )
(We)agree to save,indemnify and keep harmless the City of Cr,mlino against PERMIT ISSUANCE (�'� �,:--'S� VLECTRIC
liahilifrs,judgrmi s.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECR 1I
•j' i 6 _ 1 MBINZ
mscyuentt of the graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON�POINT AIR HANDLING UNIT(I o'cou q1"). r HANISOURCE REGULATIONSAIR HANDLING UNIT(OVER,IB,BIXI CFM) C TRUAX
FignamrcofApplicant/Conummr Dme EXHAUST HOOD(W/DUCT) _ —r. HOUSINGION FEE
HAZARDOUS MATERIALS DISCLOSURE _
Will the applicant or future building occupant store or handle Wourbus material HEATING UNIT(TO I010(1I B'IU1
av defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
Code,Section 25532(x)? HEATING UNIT(OVER 110,000 BTU)
❑Yes ❑No PAID
VENTILATION FAN(SINGLE RESID)Wool air
Receipt4
Will the applicant ar contaminantsfuture building occupant use Area
Air Quality
or devices which BOILER—COMPOHPOR110.0X0 BTU)
¢miWoolair contaminantsinanas defined by the Bay Acca Air QualManagement
Opera? BOILER-COME(OVER 100.000 B'TU)
❑Yes El No
I have read the hvadaus materials requirements ands Chapter 6,95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
fnmia Health&Safety Code,gect 25505,Z533 oil 25534,I anJemath Thal if doe NEW RESIDENTIAL MECIf. SO.I.T.
building Jces not currently M1av amnant,that it is ngeardaibi"ariol calem the mention Z G✓
LA
the swhich mus p eafa C,rtilicutc of(Xcapmcy.
Owner r authorized,gem Date TOTAL: ISSUED BY:
OFFICE