S 3116 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, rl! IT NoJJ11
N.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MF.CIh\NICAI. 3116 1 {.,
BUILDING PROJECT IDENTIFICATION 3
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
'9 r r //- 9- 76?
OWNER'S NAME: PHONE! "
ACfOR'SN LIC NO:
t , -^fO/ - Yew / - G NIC CONTROLN
CHITIZCTfEb1GINEE: LIC NU: / A RES ❑
�!
CONTACT: PHONE: BUILDING PERMIT INFO
�� D�/ [--1 Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUM MECH
,,,25-3- 0619
[ ❑ ❑ 15 ❑
LICENSEDCONTRACfOR'S DECLARATION QTY ELECTRICPERMIT FEE
I hereby atTm„hin 1 am licensed under previ.sion%of Chaper 9(commencing JOB DESCRIPTION
WOO with Section 7")OLDivision3 ofthe Business and Professions Code,and my license is RESIDENTIAL'
E,I-in full force and effect. PERMIT ISSUANCE APPLIANCES
CSPDWI. El KITCHEN REMODEL
I- W License Class Lic.M El ADDITION UMBING RE-PIPE
aoQ,a Ila¢ Comrxmr FMIAL
ARCHITECI-S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
E.Dm> PANELS
2.Z—a I understand my plans shall he umJ ns public records MODIFICATION
OZ— UP TO 2(NIAMIsS
F�F"W Licensed l4nfe..iunel - 201-Iqp AMPS ❑I PM ROVINTERIOR
F.MENT 0SWIMMINGNEY POOLS
Ia-J PAIR
OWNI!Rt exemp ERDECLARATION Contr.. OVER 1000AMPS ❑BATH REMODEIIREPAIR El DEMOLITION
0 hereby affirm that 1 um exempt from the Contacmr's License Law for the
x36F following renown.(Section 7031.5.Business and Professions Cede:Any city or county SIGNS ELECTRICAL COTHER
which requires a permit to couslmcL alter.improve,demolish,or repair any structure
qq y prior to it,its...va,.1,.mgmms sbeapplicam for .In pemuuu file timed stamnmot SPECIAL.CIRCUI'1'IMISC.
that he is licensed Forsworn in the pmvisiom of the Cnmfacooa License Law(Chapter 9
OW�.nQO (commencing with Sacti..7000)nf Divisina 7oOhe Basinessand Professions Cwle)or TEMP.METER OR POLE INST COMMERCIAL:
d c ns tbe,he is exempt therefrom and the basis furtive alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
4• Secum703 LS by any applicant fora mind subjects fle.fildrunt to it civil penaltyof POWER DEVICES
un ($508. 0 TENANT CFOOD SERVICE
nm marc shnn five hundred dollars($508.
=Z0 ❑l.as owner of the property,or my employees with wages as their sole compensation, SWIMMING PMOL ELECTRIC IMPROVEMENT
ill do the work,and m themmutaknot amended moffered far sale(Sec.7W4,Business C OTHER
3 ad Professions Code The Contractor's License Inco docs not apply m an owner of OUTLETS
-SWI TCHES-FIXTURES
operty who builds or improves thereon,and who does such work himself or through
his own employees,provided that such insprovemenr.s am not intended or offered for NEW RESIDENTIAL ELECTR SQ FE.
sale.IL however,the huiWing orimprovnncnt is sold within one year of con,pletimtthe SQ.FE FLOOR AREA $/SQ.FE.
tuner-huildcr will have the burden of proving that he did not build or improve for par.
pose of sale.).
C 1,as owner of the property,am exclusively contracting with licensed contactors m TOTAL:
nnsham the project(Sec.7044.Business and Protcssions Code:)The Cunuadnr's U.
cense Law does not apply to an owner of pmpeny who builds or improves thaean,and QTY. PLUMBING PERMIT FEE
whn contracts for such projects with a cmaactm(s)licensed puauantto the Contractor's
License Law. PERMIT ISSUANCE Q
C I am exempt under Sm. ,B&P C for chis revsnn
Owner Hate ALTER-DRAIN&VENT-WATER(E) VALUATION
WOBITER'S COMPENSATION DECLARATION BACK PLOW PROrECE.DEVICE
• I hereby a0ims under penalty of penury one ofthe following declarations:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Camper- DRAINS-FLOOR,ROOF ARFA,CONE. STORIES TYPE.CONSTRUCTION
,,,,an,as provided for by Section 3700 of the Lalau C de,for the p,dornance of]toQ
k for which Nis permit in issued. FIXTURES-PER TRAP
1�and will maintain Worket's Compensation Insurance,as required by Section
37M of the labor Code,for the performance of the work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Work Can ,sat' In d Policy nu s
Currier 'antl�' rlc Policy Na: 0� GAS-EA.SYSTIiM-OVIiR 41FA)
CF.RMFICA'IEOFEX PfION FROM ORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FENS
(This scoria need not ha completed ifile permit is forme onamind dollars l$John GREASE TRAP
or lezx.) PLANCHECK IEE
I ccnify that in the performance afore work for which this Fermis is issued,Ishall SEWER-SANITARY-STORM EA.200 Ff
not employ any person in any manner so m to becmne wAiect to she Workers'Compen- ENERGY FEE0 ,Z 'nolo.laws of Calilorria.Data WATER HEATER W/VHIFFELECTR
O Applicant GRADING FEE
y NOTICE TO APPLICAN'L:IL,afar making this Cenificme of Exemption,you should WATIER SYSTEM,TREATING
hremin subject in she Worker's Compensation provisions of the Labor Code,ynu nano SOBS FEE
W r� fanhwiN comply with such Provisions or this permit shall be,deemed revoked. WATER SERVICE (�
Q
CONS
tthereRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ,FE. PAID
LJO I hereby ahhithermit 1 isaed(Seconstruction lending agency for the performanre of Date ReceiptM
W L) the work for which his permit is issued(Sec.307.---Civ.C.)
O U Lendels Name�Addm,, � O TOTAL:
Isnde'I Addfess T
1 1 ccnify that 1 have his app c d state IU she ab narration is BUILDING EI!E
7Vi carted.l agree m comply �js.�Icity. county ordiwncesvnd ata I relmingm QTY. MECHANICAL PERMIT FEE
C.) Z building concoction,and 'V�, thorim representatives mfthis city s rupm the SEISMIC ME
above-mentimnedpropeny rrsmrerLppVggs sp 1.19aQo
(We)a gree m save, "n�st�}s��LL T,lMWrrttD 6��Jf t no against PERMIT ISSUANCE. ELECTRIC FEE
liabilities.judgra ts,costs lexpanes which may in anyway aceme tsaid City ALTER OR ADD TO MECIL
asequence of the gran i ofshis permit. PLUMBING ME
APPLICANT UNDERST NDS AND L C Y W I H ALL N( -POINT AIR HANDLING UNIT(10 lo.(NN)CEM)
SOURCE REGLU MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signa F' ontor'm Dam "EXHAUST HOM)(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamor future huiWing occupantsmre or handle hxanimsmumrid HEATING UNIT(TO W,fNltI BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(0), HEATING UNIT(OVER 100.00y)RM)
❑Yes F1 No
VENTILATION PAN(SINGLE RESID) PAID
Will Thea applicant or Tamm building encu ns me e 1 nr devices which Date Receipt N
rr 8 e Ana
BOILER-COMP(3HPOR 100,00)BTU)
-� emit hazardous air mnWminums as define)by the Bay Arca Air Quality Management TO
Uis act!
FJ Yes No BOILER-COMP(OVCR 100,M)BTU)
' I have read the humobvis materials nquiremods under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
Laic Health&Safety Code,Sermon 25505,25533 and 25574.1 understand that if the NEW RESIDENT IAL MIECIL SQ.FL
buildingdoes rot cimeady have.teesm,that it is my responsibility m notify the mt cupmT �U
.fine requirements which muss be met Earn to issuance of a Ceni&are of Occupenry. _
i Owner of mommixed agent Dam TOTAL: ISSUEDBY:
OFFICE