S 3081 I APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDING-ELECTRICAL PE ITNO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3081
BUILDING PROJFILT IDENTIFICATION it
BUILDING ADDRESS: SANITARY NU. APPLICA'T'ION SUBMITTAL.DATI
OWNER'. NAME: P NE: CONTRA RS NAME: LIC NO: C / O
NIC CONBOLp
ARCIII F.LT/F.NGINHER: LIC NO: GA:ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT'INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ [(
LICENSED CONTRACTOR'S DECLARATION QT ELECTRIC PERMIT FEE
I hereby amen that I am licensed ander provisions of Chap cr9(commencing JOB DESCRIPTION
DWZ w'lh Section 7lggB ofDivision3ofthe ltusincss and lmmcssionsCtda,and nsy license is RESIDENTIAL:
1400 infull
Pli 1'T ISSUANCE
�lyF Liver tone nnJ ct ' „_�3T�S� ❑SFDWL ❑KITCHEN RE-P[EI.
VV Incense las. Lic.p�1 APl'LIA ES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
PZZ Due Contraarr
m6y
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAI,
PANELS MODIFICATION
I understand my plans Shull ed used as public records
OZ=,, UPT02W AM [I INTERIOR [I CHIMNEY REPAIR
M LiccmW Precast rnal 201-1000AMP5 IMPROVEMENT 0SWIMMING POOLS
CCC" �H OWNER-BUILDER DECLARATION
mat I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IOWAMPS sk ❑BATH REMODEIIRHPAIR ❑DEMOLITION
ippi55..06 V (allowing reason.(Section 7031.5,Business and Professions Cade:Any city me coumY SIGNS ELECTRICAL HER .n
tY 3 0.y which requires a permit m eonawcL alter,impmve,demolish,lir repair any xrmclure RCV �Q QLp�
�0I prlmrtoit,vamace,also requires theappMeant forsuchpereadtofileasignedstatement SPECIALCIRCUITIMISC.
that he is licensed punuunnt)the provisions of the Contractors License Law(Chapter 9
00 (commencing with Section 70W)or Division3 ofthe Business and Pnsfexsions Code)or -FEMP.METER OR POLE INS( COMMERCIAL:
d L c a that he is exempt therefrom and the basis for the alleged eaemptiun.Any violmiun of ❑NEW BLDG/AUDITION ❑UF.MOLITION
�m Senion](Dl Sby any npmlicmtfuru pemrit subjeme me nppliam macivil penalty of POWER DEVICES ❑TENAN'T ❑FOODSERVICE
>y out mom Nan five hundred dollars($5004. IMPROVEMENT
E 00I,us owner nfthe Pmpeny,lir myemployecswim wages as meirsole rnmpensnrinn, SWIMMING POOL ELECTRIC
will dothe work,maul thesuveme,isnot intended oroffered lbrsde ISce.7044.Business ❑OTHER
and Prnfessions Code The Contractors License Law does net apply to an owner of OUTLETS-SWITCHES-FIXTURES -^
his own who bu11J..or imped th thereon,and who dues such tinte ded or or ermugh Y/, T
his own employees,provided roar such inmrovanems are not intended or offered for NEW RESIDENTIAL ELECTR SQ
sale.IL hnweven the huilJin6 or impmvemem k-ld wiminomeyeor ofcmnplctiomthe E
.00R EA Q.FT.
r-Builder will have the Burden of proving,hut he did not Build lir improve for par- I
poseafsdaJ. Y 1 0 1999
M 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
conswct the project(Sec.7044.Business and Professions Calc:)the Contrucmru Li. ,
sea law does not apply to an owner of properly who Builds or improves thenen,and QTY. PLUMBING PERMIT .E .J
C5commas forsuch projrets with a commons)licensed pursmen or he Contaaers
License law. s PERMIT ISSUANCE
❑I am exempt under Sec. .B&P C for mis reason
TER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dart
WORKER'S COMPENSATION DECLARATION BA FLOW PROTECF.DEVICE
I hereby affam under penalty of perjury one of the filming ming declarations: er
• ❑ I have and will maintain a Cerifieure ofConi in self-insure for Workers camper- DRAINS Fl.00R,RODE,AREA.COND. STORIES MIE CONSTRU(1IOI
Nation,us provided far by Section 3700 of the labor Cale,Ibr the perfoomerec or the
work for which this permit is issued, FIXTURES- ER TRAP
❑I have and will maintain WorkeL.Compensation Insumnee,as required by Section
3700.f the Lahv Code,for the Performance of the work for which this permit is issued. GAS-EA.SYS 'M-f INC.4 OUTLETS OCCGROUP APN
My rs tom nl�t1% ns raneecarrierand PnI ynumhic
Cartie�} Policy NlaTfjS+��7'L(.IiZ��S-� GAS-IiA.SYSTE )VER4 HDO
C:RTIPICATF.[F EXEMPTION FROM WORKERS' GREASIVINDUSTRL STE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This sectionneed not he completed ifthe permit is forme hundred dollars IS 100) GREASETRAP
or less) PLANCHI!CK PF.E
I certify that in the perfonnanceofthe work for which this permit is issued,l shall SEWER-SAM TARY-STOR IiA.200 FT.
not employ any perom in any manner so arm become subject lir the Workers'Common ENERGY FEE
0 Z Otion Laws of Califamia.Dam WATER HEATER WNMNFI LE GRADING FEE
cai
Z 0 Applicant
r.t fq NOTICE TO APPLICANT.If,after making this cenifcam of Exemption,you should WATER SYSTEMnRF.ATING
b' Was.subject no he Workers Compensation Provisinrn of me Labor Code.you must SOILS FEE.
Wfanhwith comply with such provisions lir mise Pemsir shall be deemed revoked. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'LMB. SQ. T. MAID Date Receipt N
V 0 I hereby affirm that iso construaim tendingausncy for mu"fnumanceof
IL r the work for which this permit is issued(Sec.3097.Ci,C.) TOTAL:
Lenders Name
Uj Leralers Address TOTAL: BUILDING FEE
eF"�s 1 cenify that 1 have read this application and sate that the shave information is
jj correct l as.to comply with all city and rounty.extreme,and sato laws relating to QTY MECHANICAL PERMIT
V Z buildinEemostmemen,and hereby authurim representatives of thiseity roentersprm the SEISMIC FEE
ti .hove vacationed properly for inspection mmaws. PERMIT ISSUANCE
( )agree to save,indemnify and keep harmless the city of Cupertino against ELECTRIC ME
Iird iliues,juJgments,craw,mad expenses which may in any way aecmeagainst said City ALTER ORADDTO MECH. PLUMBING FEC
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CF14) MECHANICAL MF. war L
SOOOISMCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signaiu oft ApTGnUCommamr Data EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
IIA9ARDOUS MATERIALS DISCLOSURE
Will the applicant or fmure building'wcupam store or hurdle hovNous mnerialH EATING UNIT TO FOM)RTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? 1 HEATING UNIT(OVER 100010 BTU)
Year - VCNf11.A'TION FAN(SINGLE RISIU) PAID Date Recciptp
Will the applicant or future Wilding occupant ase equipment or devices which BOILER-COMP(Still OR IW.000 BTU)
email hazardous air contaminates s as defined by me Bay Area Air Quality Management TOTAL; LL n
Duriel'! / BOILER-COMP(OVER[00,000 BTU)
C Yes gN
I have readthe Bmmdoas amounts reyaremenaunder Chapterh95afine C.H. AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Code,Sections 25505,25533 and 2D 4.I undersand that if the NEW RESIDENTIAL MECH. SQ.FT.
ouilAing Jnes nm curtamlyhaveaanam.mat it is my rcspmsibilitym notify the
art a rets which most be met poor a isxuame or a Ceniticmc of Occur,a.y..c
As DQ Lr a p,
wnerorallumiad agent ruse
TOTAL r SSUED BY.
O �a
OFFICE