S 3940 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MEcxANICAL S 3940
BUILDING PROJECT IDENTIFICATION
BUONG
DRESS: T " /'1- /Z ySANITARY NO. APPLICATI'O�NSUBMIy/TTJ/A,L DATE
'R'S NAME: P E: CONTRAC R' Ap1E. a IC OO�
_ S N/C CO
NTROL#
lAt
C ITE / INEER: LIC N ApDRE55'. ❑
CONTACT: x./ yHONE r�L BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG LLE PLUMB MOH
LICENSED CONTRAftGRTDECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm dint 1 am e an
licensder Pm earnew of chapter 9(commencing JOB DESCRIPTION
QaZwith Section]000)o(Dlvlslnn 3 ofthe Business and Professions Code,and my license is RESIDENTLYL:
WOO i PERMIT ISSUANCE
F W n full force and(Rea. ❑SFDWI. El KITCHEN REMODEL
aVV License Class m
W uc APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
/),n'FDam Commcmr ARCHITECTS DECLARATION ❑MULTI-UNIT CSTRUCfORAL
Z p�2 N 1 undesaand my plain shall be used as public retards PANELS MODIFICATION
0Z_0 UP TO 200 AMPS C INTERIOR C CHIMNEY REPAIR
r4I"W Licensed Professional 201-IMOAMPS IMPROVEMENT CSWIMMING POOLS
;5W �Mj OWNER-BUILDER DECLARATION OVER IOUTAMPS ❑BAT"REMODEL/REPAIR DEMOLITION
p, GGGG'"'Q I hereby alTrm that 1 am exempt from the Contractor's License Law for the
3 0.wu W F+ following reason.(Section]0^L5,Business and Professions p.W Any city or county SIGNS ELECTRICAL ❑OTHER
y which regoires a permit m consumer alma Impmv demons\',or repair any ewemro
X06..1 primtoinaa...ace,elsvreyuma Na epplicam for I signedsmtement SPECIAL CIRCUIT/MISC.
y that he is licensed pursuant thepmetslansofthe License Law(chapter 9
W Qp (commencing with Section 000)of Division Sof and Professions Coaa)or TEMP.METER OR POLE INST. COMMERCIAL'
that he is exempt Iheref and a basis f thea exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section]031.5 by any;.
ny a licam for a panni Is he applicant to a civil penalty of POWER DEVICES []TENANT C FOOD SERVICE
Z>+ not more than five hun ed dollars($ ) IMPROVEMENT
6 ❑Lace owner of lhep party,or eye play w, wages es lheirsole campenmion, SWIMMING POOL ELECTRIC
05.0 will do the work,and t estme re
of mndc orn0ered forsale(Sec.]044,Business COTHER
W"m and Profession Coal The Co amor'a 'cense Law dnc not apply m un owner of OUTLETS-SWITCHES-FIXTURES
property who builds or s thereon,and who does such work himself or through '
his own employees,provid hat such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.If,however,the building o improvement is sold within one year of completion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the bu it of proving that he did not build or improve for pur-
pose of adc'.
aswer of the property,am exclusively contracting with licensed comments to TOTAL:
ru
constct the project(Sec.7044,Business and Professions CWe:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who crorects forsuch Pryects with a conn or(s)Iicensed pursuam to the Contractor's
License Law. PERMIT ISSUANCE
❑ I am axe I under Sec. .B&P far this reason
Owner Date ALTER-DRAIN&VEM-WATER��,. - : / VA DATION q�
WORKF: E SA ION DECLARATION BACK FLOW PROTECT DEVIGIi .a`� �^+I"1 - `Ii / Cal• I hereby affirm and enalty of perjury one of the following declaration I ((( V!/
❑ Ihav'e and will maintain aComficam of Consent to elf-insure for Worker's Compen- DRAINS-FLOOR,ROOFfREq:GDND. g FS TYPE CONSTRUCTION
cation,as provide far by Section 3900 of the Labor Code,for the performance of the I.I
work for whichdia permit is issued. FIXTURES-PER TRAP } _,j
❑I have and will maintain Worker's Compensation Insurance,as required by Section L/
37IXl ofthc Labor Code,for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC. UTLETS OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number am:
Carries Policy No.: GAS-EA.SYSTEM-OVER zlEA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE NDUSTRL WASTE 4BUILDINQ qVISION FEES
('Dais section need not becumplerendthe permit is foranehundaaldollnrs($IW) GREASETRAP HI
or less.) PLANCHECK FEE
I certify that in the performance of the weak for which this Permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject to the Warlums Compen- ENERGY FEE
C) Z scion Laws of Cnlificu,4 Data WATER HEATER WNENTMLECTR GRADING FEE
Applicant -
TA NOTICE TO APPLICANT:If,atter making this Cerdlem,of Exemption,you should WATER SYSTENIGREATING
^' become subject o the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
G forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
7ID Q
rz CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID De Receipt#
L) QThereby affirm that there isaconswetion lending agency for the performance of
the work for which this permit is issued(Sec.3097,Civ.CJ
LT•I U Lender's Name TOTAL:
O V Lender's Address TOTAL
as BUILDING FE
I certify that 1 have read Nis application and sem that the above in
ws Mating is
Tap condingcoagree mcomply
and with yimaciternd coummutine,al and aye .are attractive
QTY MECHANICAL PERMIT FEE
V ,� abovengcotioned construction,and hereby nuttion purporesemmivex alibis city mentor upon the SEISMIC FEE
above-mentioned agree
to ertysave for demnifyi an keep ha PERMIT ISSUANCE
(Wa7 agree m eve,indemnify and keep harmless the City of Cupertino against ELECTRIC P6
liubilitiesjudb Ice.costs and expenses which may in any way accmeagainst said City ALTER OR ADD TO MECH.
inconsequent Ihegramingoflhis eamad. PLUMBING FEE
APPLICAN NDERSTANDS AN 1 Wll .C JMPLY WITH ALL NON-POINT AIR HANDLING UNIT(T010.000CFM)
SOURCER ,ILADONS. MECHANICAL FEE
_ AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatorof p an Cont ' Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZA US MATE IALS DISCLOSURE
Will the applicant or or re building occupant store or handle hazardous material HEATING UNIT(TO 10),000 ITT U)
as dented by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)^ /�/ HEATING UNIT(OVER 100,00)BTU)
❑Yes W-1 VENTILATION FAN(SINGLE RESID) PAID
. Will the applicant of future hmidited occupequipment or devices which Date Receipt#
emit hazardous air contaminants its by Ne Bantayuse Ar -COMP CHP OR 100,000 BTU)
ea Air Quality Management BOILER TOTAL'.
District? BOILER-COMP(OVER 1110,(100 BTU) 7 7e
❑Yes No O
I have read the hazardous materials re,immems under Chapter 6.95 aids,Cali- AIR CONDITIONER ISSUANCE DATE
fomia Heal Safety Code,Section . 5,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building of currently have!Vha aha it is my responsibility to notify the occupant
ofthe meats which moll bee tpri m"mmuccof.Cangmef),
Ow r gem , DateTOTAL: ISSUED BY:
OFFICE