S 3175 'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELEC IHCAL PT: IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MPICHANICAL 3175
BUILDING PROJECT IIIEN'1'IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION STIRMITTAL DAFE
Qi
0 N 'S NAME, PHONE: CONTRACIOR'S NAME: LIC NO.
l/-. _ NIC CONTROL#
ARCHU'BCOHNGINHER: LIC NO ADDRESS: ❑
MW CONTACT: PHONE: BUILDING PERMIT INFO
,D5.3 Co /'.,y-. �faSAAC%—�Mq¢j ❑ Consultant Fees Paid by Applicant(Initial) R.ruo ELECT PLU�M/1� MUCH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm mat f am Inceaed ander proviomi of Chapter 9 commenting JOB DESCRIPTION
OCZ with Section 700X1)of Division 3wftht Businmsand Professions Cale,and mL'
y license i. RESIDENTIAL
WOO PERMIT ISSUANCE -
F�O infallforceand ct. Z ❑SFDWL ❑KITCHEN REMODEL
WU~ ClL¢ense ass Lie #
6 U AI'PLIANCtS-RFSIDENDAL [I ADDITION ❑PIAMBING RE-PIPE
iZz w Date Camracurz
all ❑MULTI-UNIT ❑STRUCTURAL
(,Zy A HOECI-S DECLARATION PANELS
Z p v2 7J. I undemmrd my plans shall be used as puhlic records UI"Isl 2(X1 AMPS MODIFICATION
OZ-0 ❑CHIMNEY REPAIR
f 14t:W Licensed Professional 201-10011AMPS IMPROVEMENT (]SWIMMING POOLS
�,2-; OWNER-BUILDER DECLARATIONOVER I00XIAMI'S [_1 BATH REMODmAEPAIR ❑DEMOLITION
04 m m
6 I hereby affiral 1 am exempt train the Contractor's License Law for the
gypqx(,0 W following revspn.(Section 703 1.5,Brinamss and Pranessinm Craft:Any Oly or county SIGNS ELECTRICAL ❑OTHER xk
W 3 LL y which rei permit m construct,cher,improve,demolish,or repair any trammoe _ �(
an tom is...nee.also requires theopplicant for such permit ill file a signed ewmment SPECIAL Cl RCUITIM ISC. L o
that he is licensed pursuant us the provisions of The Contract's License Law(Chapter 9
_0C (commencing with Section 700)ofDivi.ion3 of tire Business and Profesiona Crdt)or TEMR ME'IER OR POLE INST. COMMERCIAL,
a�cy that he is exempt therefrom and the bads for be alleged exemption.Any violation of [3 NEW BLDG/ADDITION [IDEMOLITION 1n Section 9031.5 by any applicant far.pernitxubri applicumm a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
or
not mom than Fine hundred dollars($500). IMPROVEMFNT
SSG ❑Las ownerullhe propery.or my employees with wagerstes theirsolcmmpersation, SWIMMING POOL ELECT RIC
will do The work,and The svucwm is not intended proffered far sole(Sec.711W,Business ❑OTII[R
63$ and Professions Code:The Connector's License Law does not apply m out owner of OUTLER-SWITCHES-F1XT'URES
propery who builds or implants clarions,and who does such work himself or through
his own employees,provided Nat such improvements aro not intended or offered for NEW RFSIDENFIAL ELECTR SQ IT.
mile.if.hawcveethe building or improvement is sold withlnone year of completion,he SQJT ILZ_ LSQ.FT.
anebuilder will have the burden of proving that he did not build or improve for put-
plsale .). TOTAL: /
❑ 1.as owner of The property.am exclusively cont rional wish licensed"monalom m
construct the project(See 7144,Business and Professions CodeB no Gsntraerors Li-
arrive Law
i-c uWw dons not apply to an owner of property,who builds or improves Themon,unit QTY, PLUMBING PERMIT FEE J ��
who contracts scratch project-,with a con nmer(s)Intoned pursuant o the Cnatracmr's
Liceme Lnw. P1iRMI'I ISSUANCE
❑ l am axtmpt under Sec. ,B&1'C for thismason
ALTER-DRAIN&VENT-WATER(IiA) VALUATION
Ownef Dale
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
El ale tt
I have and will maintains Cenifico1 Consent tnself-insure far Worker's Cooper- DRAINS-FLOOR,ROOT',AH�'�rA.Gf) ,. 4 STORIES T PF,CONSTRUCTIO1,
satin,as provided for by Section 37M of the Lathan Cade,for the performance of the 1
work for which this faults is issued Il%TUN' - :H'fR7 t
FI 1 have and will maintain Workers Comps nallm Insurance,as respired by Section '1
371n ofshe Labo Cde.fertile performance ofthe wad forwhichfai,parmil is issued. GAS- STE INC.40UTLITS OCC GROUT' MIN
My Workers Compensation Insumnce turnaround Policy nutter arc: 1(I
Comer: Policy Na: GAS- . S TEM- H li 17
Child ipICAT1i OF EXEMPTION FROM WORKERS' GREASE UST ASTE INTERCH"OR
COMPHNSAI[ON INSURANCE BUILDING DIVISION IEFS -_-_
(This section need not becomphrimEthe permit is forone hundred dollars(51(91 GREASE 1 P
or loss.) PLANCHECK EfiE
I verify that in the performance ofine work fur which this penes is issued l shall SEWP.R ItY-
not employ any person in any manner so as to become subject to the Workers'Compcn- ENERGY
zZ nation Laws of California.Dane WATER Hit RW/VENTIELECTR GRADE GFEE
12 Applicant
N NOTICE TO APPLICANT if,after making this Cerifcate of Exemption.you should WATER SYST'EbETREATING JPA
F become subject to The Workers Compensation provisions of the Labor Code,you most
Wforthwith comply with such provisions pubis amour shalt be deemed evoked. WATER SERVICE
Q
n' CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL YLMB. $Q.Fi Date Receipt#
I hereby alRrm thatthe.iso cpnsaction lendin,idamay for The perlmmanceof
the work fpr which this permit is issued(Seo.3197,Civ.C.)O L) Lenders NameTOTAL:DJ Lenders Address>a 0. I cenify that I have readthis applicaionand state mat the above information Is FEE
Flt wrens.l agree to comply wish all city and county ordinances and state laws relating in QTY, MECHANICAL PERMIT FEE SEISM FEE
Ubuilding cpnsuuctios,and hereby andante represenmtives of Thixcity to enter upon The
move menlioned property for impemion Pmfnssts. PERMIT ISSUANCE ELECTRI 'EE
(We)agree tu save,indemnify and keep hornless the City of Cupertino against
Iiibilinies,judgments,costs and expenses whi,hm,y army way accee.gamnsaid City ALTVRORADD'IOMECH, PLUMBING FEE 3 O
in consequence,of thegranting of this permit.
APPLICAN"r UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITTO 10,01(ICFbU MECHANICAL I
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.04 CFM) CONS FRU(1fION TAX
Signature of Appliven✓Comecmr D:de EXHAUSTI LOOP OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building acceptors store or handle fractionalalHEATING UNIT(TO Idd,gas BIG)
as definW by mu Cupertino Municipal Cale,Chapter 9.12,end TM Health and Safety HEADING UNIT(OVER I(p.(XXI H'1'U)
Code,Section 25532(.)!
E)Yea, ❑No PAID -
VENTILATION FAN(SINGLE RESID) Dam Receipt if
Will the applicant or future building occupant use equipment or devices which BOILER OHP OR 1(10,00111 BTU)
emit haeNnux air r,o mmicrats as defined by me any Area Ail Quality Management TOTAL.
,�Disuinp BOILER-COMP(OVER 100,000 BTU)
LT
❑Np
ad the latmoous ma¢rlalsregoiremen¢under Cirl 495of'he Cali- AIRCONDITIONER ISSUANCE DATE
Safety Call,Sections 25505,25533 and 155)4.L understand aha if the NEW RESIDENTLAL MECE. SQ.IT.ot currently have a tenant dos it is my respenslhilitym nonly mourimpan
ents which must be met prior to isumnce of a Certificate of Occupancy.rixed agent Dae 'TOTAL: ISSUER BY: Vim"
OFFICE