S 3812 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE,CI'RICAL PERMIT NO.
BUILDING DIVISION AIaPLICATIONt'PERMIT PLUMBING-MECHANICAL S 3 812
BUILDING PROJECTIDENTIFICATION
BUILDINGADDRESS oo SANITARY NO. APPLICATION SUBMITTAL DATE
/t.- r- 7 .-�.
OWN- :SNAME: PHONE: / CONTRACTORS NAME: LIC NO: L
Q N/C CONTROL
`• ARCIHTECI'/ENGINEER: LIC NO: AI R,..: ❑
//
CONTACT: /I(1/s Al� PHONE: a BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEECCH/
LICENSED CONTRACTOR'S DECLARATION QTY 14LECTRIC PERMIT FEE
I hereby anirm mm I am Leered ander pro,iwmna of chapter 9(commoners JOB DESCRIPTION
�zZ with Section 7000),d Divfsinn 3nfrbe Business and PmfeWmis Code.:md my license is
O O PERMIT ISSUANCE RESIDENTIAL:
od I� Li
mli cC and
QF.UV LicctucC ._ r � .LOLic.« ❑SFDWL [I KITCHEN REMODEL
N<1 Date Comrunm e G APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARCHITFCTS DECLAR TION [].MULTI-UNIT [ISTRUCTURAL.
z p o,Z [understand my plans shall to used as public maonf, PANELSMODIFICATION
O Z..O UPT020()/IMPS C1 INTERIOR [_1 CHIMNEY REPAIR
Q,;-;,,; Licensed ProBssion°I 201-1000AMPS IMPROVEMENT (]SWIMMING POOLS
y,5$i': OWNER-BUILDERserepDECe Contractors
OVER i0u)AMPS ❑BATH REMODEIIREPAIR El DEMOLITION
1 LL:6 1 hcrtbY affirm mal 1 am octopi Toon me Commctor's Liccn,c Law for the
3�U following reason.(Section 71131.5.Business and Professions Code:Any cup or cvmnly SIGNS 171.1; r RICA]. ❑OTHER
y which requires a permit to couNruct,alma improve,roundish,or repairany q ocheO
FLL�et
prior to its ismance.also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUITIMISC.
feyThat he is licensed putsaam to the provisions of the Contractor's License Law(Chapter 9
ta+1a000 (emoneneingwith Second 70(Xo of Division Sof me Bminna and Pmfircomns Code)or TEMP MI?T ER OR HULL I NST. CQMMERCIAL
L G e z that he is exempt therefrom and the basis Lor the allcectl excmpfwn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W�H Senion]OJLS by any applicant fora permit xuhjecu me upphcannn anvil ponahy of OW EV IC FS []TENANT ❑FOOD SERVICE
not more man five hundred dollars(5500). IMPROVEMENT
7E< Ol,as owner of the morped..onny employees with wages as their sole mmpers.nm. SWIMMING POOL ELECTRIC
E- will M the wod.nnd the atruaum h not intended or offered huaale(See.9tK4.ewciness ❑OTHER
Icy'-m and Profession.Code: the Conlracmr's License Law don not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3 property who builds or iini Ihemon,and who does such work himself or through
his employees.Provided that such improvements art not intended or offered for NEW RESIDENTIAL ELF,CTR SQ FT.
sale.If.howevice the building or inrproverecnt issold within line ywrofnrmpletinn,the .Icr II. N REA a Irr.
et-builder will have the burden of parva ng That he did nut build or Ilopmve for put- 'k
c
Oe 1,as owner of he properly,am eaNmively narrowing with licensed aomracton to OT LI D
consumer me pmjeet(Sec.7044.Business..it Pmfadnns Code:)The Contractor's Li- JUN
.a 1 ���
c se Law docs nolnpply it)an owner of property who builds or improves thereon.rind F,E JUN QTY. PLUMBI IT F
who .nwcn for.nd,prrjecte with a comraam(c)licenced pursuant o the Contractor'a
Lmeme haw' PERMIT ISSUANCE
I am eacmpl under See .B&P C fronts moron )/
ATTER-DRAINT F, E TION
Owner Date
WORKER'S COMPENSATION DECLARATION RACK PLOW PROTECT'.DEVIt
1 lumby affirm under Penally of Perjury one of n,following deelwations:
• ❑ I have and will maintain a Ccniticam of Consent to self-insure,for Workcr'e Campton DRAINS-FLOOR.ROOF.AREA,CON STORIES '1'YI CONSTRUCTION
smion,as provided fur by Section 3700 of the Lobar Cod,fur Ibe pcfmnnnnce of the
stick Ito'which this lerndt a Ixyuod. FIXTURES-PER TRAP
dUcl have and will maintain Workers Compensation Insurance,as required by Section
l of the labor Cods,for me performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
OCC.GROUP APN
My Wird "Moon Inver carzicr and Policy boo
Car �(��� AYir x4 / IPolicy 10NNO�OR✓-____�r��q0 GAS-EA.SYSTEM-OVIiR4(FA)
CH 'TIPICATIi Oi 13X 'rl(TI FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FFLS
(This section need not be completedlithe Permit is forme hundred do11ars(SI010) GREASES RAP
lir less.) PLANCHIiCK hili
cvnify thin in the pr finen,col'the wnrklorwb'mh this penmi ,is-rd'Wrall SItWER-SANITARY-STORMEA.20OFT.
not employ any peon any m neer co as m becomemhj,m to the Wmkcrd Compen- ENERGYFEE
O Z sation laws of Caldcuria.Dates NATER HEATER WNENVELECTR
Z O Applicant GRADING FEE
= NOT ICH 10 APPLICANT':It.Idler makingthio Ccnilicum of Excmpuon,You should WR'I'ER SYS'I'EMRREAI'[NO
> bcconm xabject to the Worker's Campcncmion provision.of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or his pennilthall he deemed¢,eked. WATER SERVICE
6.
z CONSTNEW RF.SIUIiNi'IAL PLMIi. SQ.IT.
RUCTION LENDING AGENCY PAID
'U z
I Mier,utlirtn In,,,tlammct
mre is aaalnn lending agency fonhc lcrl'nnnanacof ale NccciplM
p 0e work for which this permit is issued(Sec.3097.Civ.C.)
O U Lender's Nam, TOTAL:
r w lander'.,Address TOTAL:
1 sonify that I have mad llik application and ntam Out the above informmion is BUILDING FEE'
IA'A correct.i agree to comply with all city and county ordinances and sum laws mladng m QTY. MECHANICAL PERMIT FEE
U ,Z building convection,and hereby authorize representatives of this city to enter upon the SEISMIC PEE
abon,racr toned printery for iov,soo opurrynes. PERMIT ISSUANCE. r V^
(Wee)agree hr save,indemnify and keep harmless the City of Cupertino against 3 J ELECTRIC FEE
liabdida,iudgmm�ln,costo and cxpcnsnwhich may In any waytccmcuguinat said City ACTERORADDTOMECH. PLUMBING FEE
in c o..cqucnce of n,grunting of this pcnnil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS.
el AIR HANDLING UNIT((OVER 10,000 CFM) MECHANICAL FEE
CONsTRUCT1O.N TAX
Si nutmcof Aa/Pp/l o/VCMsn c�rry/ -Dim" — EXHAUST HOOD(W/DUCT)
HAl RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FFE
Will the applicant or future Funding occupwl store lir handlehur.Miss ntmeriil BEATING UNIT(TO IIX1.000 BTU)
ac delined by the Cnpenino Municipal Code Chupmr 9.12,and the 11-111r..it Snlely
Code,Section 2553201' HEATING UNIT(OVER 100.000 BTU)
E3 ye, 11 No VGTILATION FANS INGLE RESIDI PAID _-
Date Receipt N
Wrdonvthe appt'llorcant or Colum building by the nt use Bay
Air Quality
Manaenenis which IIOILF,R-COMP(3HP OR IIV'W0 BTU)
Dist ictznrJuuc air cunwminunix an JulinW by the Hay Araa Air Quality Manugcnann TIAL:.
I ni:via!
E]Yes E3 No BOILER-COMP(OVER I00,000 BTU)
I lmve mad the haterdonatnmeriaN teoulaDnens under Chapter M)5 of the Call l- AIR COND I OVER
1 p ISSUANCE DATE
forma I does&Sul'cre Coda e a tens 25505,25533 and 2.5534.I 0 notamnd Lha ifhe NEW RESIDE pll MF:CIL SQ.FT H 9 Q
building drcc ton currently haveamtunl mm it is my rtaponsihilitytonmify me occupant ` C
o "m - Is ich meat k met prinna isxaance nfu Cenificam of[kcupancy.
Owti rnuthorize:lagent Date I TOT ISSUED BY: 40
OFFICE