S 3381 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL *BUII.DIPNG
NO. 3 3 8 1
BUILDING DIVISION APPLICATIONIPERMIT PLUMB ING-MWAIANICAL
BUILDING PROJECT IDENEOFICATION
BUILDING ADDRESS: CA'TION SUBMITFAL DATE
IIWNLR'S le: ) V NB: CON'fR 'S E: ICN _���
✓ CONTROL#
• ARCHITEC IE-NGINECR: LIC NO: ADD USS
:
COMPACT: PHONE RMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PIARIl MICU
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLAR TION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
"Z with Sectical700 )of Division 3oflhe liminessand Prib ions CW.,and my license is R - ID NTIA
LL1 W p n _ FERMI'T ISSUANC12
I- full force and effect. /7 ❑SFDWL ❑KITCHEN REMODEL
yUicense Class Lie.# FL O
Q U LAPPLIANCES-RESIDENTIAL. []ADDITION El PLUMBING BE PIPIT
F za LL1 Orae Carbuncle,
rn 0. -
[I MULTI-UNIT [I STRUCTURAL
ARC({ITECTS DECLARATION
PANELS MODIFICATIONz p t2 Z I understand my plans shall IS,used m public records
Oz—Q UPTO 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
24ts Limited Professional 201-100(IAMPS IMPROVEMENT E]SWIMMING POOLS
s1� OWNIiR-IIUILDER DECLARATION OVER 1000AMPS []BATH REMODEUREPAIR ❑DEMOLITION
Ex IX 6 1 hereby affirms that I am exempt From the Contractor's License law for the
0. affirms L U following reason.(Section 7031.5,Business and Profession,Code:Any city or county SIGNS ELECTRICAL OTI{ER _T --
a W 1-. which requires a permit to constrt,ones,improve,demolish or repair any structure C's r
Nzv
n uc
prior to its is applicant for such pertiva file aligned statement SPECIAL CIRCUITIMISC. -
y that he is licensed purawn,m the yrosomsof Nm Cmimetm,License Low(Chapter 9
(Commencing with Section 70001)of Division 3 office Business and processionalCode)or TEMP.METER OR POLE INST. OMMFR .fAl.:
6 K m y Ibaf he is tempt thertfrnm end the basis fm de,alleged esemption.Any violation of ❑NEW PLUG/ADDITION ❑DEMOLITION
Section 7031.5 by any sppllcam for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENAN'T ❑FOOD SERVICE
nm more than five hundred dollars($50% PROVEMENT
� [I,as ownerofthe property,or my employees with wages as their sale compensation. SWIMMING POOL ELECT RIC
Hwill do the work.and the structure is not intended oroftend for sale(Sm.]IW,Business OTHER
end Professions Coda.The Contractor's License Law docs nut apply In an ovact of OUTLETS-SWITCHES-FIXTURES
.. property who builds or imprnves thereon,and who docs such work himself or through
his own employees,provided Thu such intproven emu are not intended mr offered far NEW RESIDENTIAL ELECTR SQ EF.
sale.IL however,the building or improvement issold within one year of cnmoq plmithe SQ,iT I1,0OR AREA LSQ.FT.
owner builder will have the hurler of proving that he did not build or improve for par-
pose m'sneJ. !'s
❑ TOTAL:
I,as owner of the property,am exclusivelY Contracting with licensed contractors toven
msmam the projem(Sec.o an Business ung ny who
i Imo Ctsdc:)Tho Cnmracmr's and
wlawdnesn pFail owner of progeny whebsedsorjmpro the Contractors QTY, PLUMBING PERMIT FEE
who umwmsf s pmjcc (Nae nructor(a)IicensW pnrsnunun Ne Cnmmmnrs
License law, u PERMIT ISSUANCE
Alan ,in C,!cC .B&PCfarthisreamn
ALTER-DRAIN&VENT'-WATER(ITA) VALUATION
Da¢
OR :R'S C M SATION UIiC1.ARATION HACK(LOW PRU3ECT.DEVICE
0 ElI hereby uffina under pe nab perjury one of the following declarnams:
lhuve unA will mnimmn aCenifcam ofConsenum elf-insert fur Workers Comber- DRAINS-FLOOR,RUDE AREA,GOND, STORIES TYPECONSTRUCFION
smiun,as provided for by Section 3700 of the labor Code,for the perfo scone of the
work for which this permit is issued FIXTURES-ITER THAT
❑I have end will maintain Wnrkcrs Compensation Insurance,as required by Section
J]W of the labor Core,for the perlamsantt of the work for which this pemnit is issued. ' GAS-fA.SYSTEM
INC.4 OUT LETS `f OCC.GROUT' APN
My Worker,Compensation Insurance carrier and Policy number am:
Carder Policy Nw: GAS-F.A.SYSTEM OVER 4(FA)
CERTIPICAI'1?01'EXEMPTION FROM WORKERS' GRIiASF/INDUS'1'RL WAS FF.INTIiRCEIT(l
COMPENSATION INSURANCE BUILDING DIVISION FEES
('This section need na be enmpluWif Nepmmmil is forme hundrNdnllars(Slap GRLiAS,J^' P
m lel'.) PLANCIIECK FEE
I certify that in Ne Performance of the work for which this permit is issued,I shall SEWER SA TAR 'TOR iA.200 FT.
not employ any person in any manner sec as to become subjecun the Wnrkcrs'Compen- ENERGY FILE
Q Z safion Laws of Coil'ornin Data WATER!DATER 1Y1,V.HtfVFtECrY i9as GRADING FEE
O Applicant
NOTICEq'OAPPLICANq':If,after making this Cenifcas of lixcmplion.yon shaulJ WATERS FEMn RF:ATING
SOILS FEE
OFfi , become subject to the Worker's Compensation provisions of the Labor Code,you must
Lkl fnthwith comply with such provisions or this permit sbull bmdecmedrevokd WATERS n ICE
Q
0, CONSTRUCTION LEN DING AGENCY NEW RESWpgl PAID tel- Rccciptp
Vz I hCmbyalRrm I'll reisawnmmclion lending agency for the performance of C✓`
LL the work far which this Permit is issued(See3097.Civ.C-)
ULenders Name TOTAL:
DJ lander,Address _X(JAL:
WI Certify that 1 have mad this application and state that the above information is BUILDING 13
,iii correct l agree to Comply with all City and county ordinances and sale laws relmingro QTY. MECHANICAL PERMIT FEE SEISMIC FF.
V Z building comsfinetiun.and hereby aathoriu representatives of this city to enter upon'he F-t above-mentioned property far inspection purposes. PERMIT ISSUANCE. ELF:CTRI FUE
(Wil agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,'4_�U,
costsandes'll s which mayor any way active against said City ALTER OR ADDTD MECH. PLUMHI IEE
g tinguf roil.APPL1(d . ANDS DWILLCOMPLY WITH ALL NON-POINTAIR IIANDLING UNIT LTO 1D,fNp CFM) MRCHANI LFeE
OU ES. AIR HANDLING UNI1'(OVER I AX)CFM)Si m ono n Dam EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FI7F
A/ARUDUS ATERIALS DISCLOSURE
Want ter tet wilding occupant store or handle hamNous material I RLsOING UNIT H 0 I W.000 B'1'U)
waAeRneJpenina M isobar Cala Chupmr 9J2,and the HcaIN unJ Safety HEATING UNIT(OVER IW.(10)BTU)
Code,Section 25532(al]
Fl Yes E]No VENTILxrION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or boom buddmg Complain use equipment or device,which BOILER-COST(3HP ORI ill BTU) //'�
unit hazardau,air mnwmin ials as defined by the Ray Area Air Quality Manugerem s�L: rV
District] BOILER-COMP(OVER Hands)
❑Yes 0N
1 have read the hamrdnus materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATN�yJ�
mrain Health&Safety Code,Sections 25505,25533 and 25534.I mlersfand Nw fine, NEW RESIDENTIAL MEC({. SQ.FE /2 Z_.Z— ( •��
building does not Currently have a rental,that it is my responsibility to notify the frcupanl
of the wForm encs which most M ref be,In isswmac mf a Ccerdficate o1O cupancy.
Owner or authorised ager Date TOTAL: ISSUED By.
OFFICE