S 3913 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING-ELECTRICAL PERMUTING.
6DILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICALS 3913
BUILDING PROJECT IDENTIFICATION it
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7-%4
OWNER'S NAME: PHONE: CONTRACTOR'S AME: LICNO:
Z NIC CONTREi
I'll lag d
AR CHITECTIENGINEE : LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE Vg- E:11:11 haffi
ereby rm chat 1 am licensed under provisions oo
f Chapter 9(commencing JOB DESCRIPTION
,a-,QZ with Sectian]000)ofoivismin 3ofthe Bustncs,e and l'mfesxions Cade,and mylicerlse is RESIDENTIAL'
W c in full force and effect PERMIT ISSUANCE
o; F T1F979g= ❑SFDWL ❑KITCHENREMODEL
_UI LicenseCass Lich ( gppLIANCFS-RESIDENTIAL ❑ADDITION ❑PLUMBIKITCHEN REMODEL
Dam Commcmr
F-Ovf ARCHITECTS DECLARATION s I --" — PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O Z 1 understand my plans shall bassist os public records MODIFICATION
OZ- Q UP T02W AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
aMid Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
11'' , OWNER-BUILDER m DECLARATION N OVER 1000 AMPS BATH REMODELBEPAIR [I DEMOLITION
6 1 hereby.(Sete(Section nt 1 1. exempt from the Contras Co License Law fm the
W whowinguiresaermi7031.5.Business and Re,demolish,
Code:Any city or county SIGNS ELECTRICAL "�H
ER
W W which requires a permit to constmd,alcor,improve,demolish,or repair any structure '
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUITIMISC.
W�" that hens licensed patsuaumi
naile, ore s.fiha Comracaus License Law(Chapter 9
.Eia0 (commencing with Section]000)nf Divisian3of Me Business and Professions Cale)or TEMP.MEfER OR FOLEI T. COMMERCIAL:
611 v oC Unt he is exempt therefrom and the basis far the alleged exemption.Any sodium.of ❑NEW BLDG/ADDITION [I DEMOLITION
�y
Section 7031.5 by any applicant for o permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
t more than five hundred dollars(4580). IMPROVEMENT
6 �1,a owner of Ne propeny.or my employees with wages as their sale compensation, SWIMMING LELECTRIC ❑OT
O will dothe work,and the saucmre is not intended or opened for sale(Sm.]044.Business
W and Professions Code:The Contractor's License law does not apply to an owner of OUTL -S W ITCHES-FIXTURES
propcny who builds or improves thereon,and who does such work himself m through
his own employers,provided that such improvements am not intended or oaered for N RESIDENTIAL ELECTR SQ FT.
sale If,however,the building m improvement is sold within one year of completion,the .FLOOR AREA
owner-builder will M1ave the burden of proving that he did nat build of improve far pont- JUN O 1 !
pose of sale.). 19
❑L as owner of the prole ny,am exclusively comacting with licensed comsacan.m TOTAL: t'
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with o contmaor(s)licensed pursuant to the Contractor's By
License Lou. PERMIT ISSUANCE
❑ lam exempt ander Sec. .B&P C for this reason
Owner Date ALTER-GRAIN&VENT-WATER(EA) /\ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 046c)1 hereby affirm under penalty of perjury one of the following declarations: V
❑I have and will maintain a Certificate ofConsenun self-insure for Workers Camper- DRAINS-FI.00R.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3900 of the Labor Code,for the performance of the /
work for which this permit is issued. / FIXTURES-PER TRAP .3
I have and will maintain Workers Compensimen Insurance,as required by Section
37W of the labor Code,for the performance of the word for which this permit is issued. GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP _ APNO
My Workers Compensation Insurance carrier and Policy number art: !///�
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(FA) ��
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FE"
(This section need not h completed ifthe ptimit is(coon hundreldollarx(8100) GREASETRAP
nr less 7 PLANCHECK FEE
I certify that in the pertomunce nfthe work d'Or which this permit is issucd.l shall SEWER-SANITARY-STORM EA.200 FT.
nm e y any person in n towner ser a nt bmome e -ut to the Workeri Compen- ENERGY FEE
0Q on taw"arc tJ+ WATER HEATER WNENT/ELECTR
¢ant GRADING FEE
!n NOTICE TOA , �
I A Y I fakiog this Cenlfrcnt
e of Exemption,you should WATER SYSTENIUREATING
a ^ became subject to Ne Waders Compensation pmvisions of the Labor Crde,yuu most SOILS FEE
IV 1ti fanhwith comply withsuch provisions or this pennvshall be deemed invoked. WATER SERVICE
d A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL pLMB. SQ.FT. PAID
U O to Receipt N
1hereby ich thi that then issued construction agency for the performance of
{L � the work fur which this permit is issued(Sec.J09],Co.CJ
l.endets Nam< � TOTAL
der -
W Len 's Address TOTAL
y 1 cenify that I have read this upplicaion and state that the above information is BUILDING FEE
tr to correct.I.gree to comply with all city end county radinanms and state laws relating m QTY, MECHANICAL PERMIT FEE
UZ Wiliingconswction,and hemby authorize repmsentativesofthis ciptoenterupon be SEISMIC FEE
abate-mentioned property for inspection purpose.
(We)agree to save,indemnify and keep harmCupertino against
the City of Cupeagainst PERMIT ISSUANCE ELECTRIC FEE
Iiahilities,judgments,..is anal eaten..which may in any way accrue against said City ALTER ORADD TO MECH.
in consequence of Ne gemming of this permit PLUMBING FFE
413,
APPLICANT UNDERSTA S AND WILL COMPLY WITH ALL NON-POINT AIRHANDLING UNIT(TO bL"CFM) MECHANICAL FEE
SOURCE REGULATI /�_ayf n
-•-` 4 ze / / AIR HANDLING UNIT(OVER ba"C9,11
CONSTRUCTION TAX
Sinmur of APP iemJCammnm Dine EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle haserdaus material HEATING UNIT(TO IW,f00 )
s defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
oda Setion 25532(2)+ HEATING UNIT(OVER ped BTU)
❑Yes 0N VENTILATION FA (SINGLE RESID) PAI
Will the applicant or future building occupant use equipment or devices which are Receipt If
emit huallous air conmminwB as Defined by the Bay Amn Air Quality Management BOILER-C P DHP OR I W,(D3 BTU)
TOTAL:
District? BOILER/OMP(OVER 100,01(a)BTU)
❑Yes ❑No
I have read Ne Initiation.materialsre,immcros under Chapter 6.95 of the Cal i- AI ONDITIONER DANCED E
fomm Health&Safery Cade.Sections 2550.5.25533 and 25534.1 understand that if the OGW RESIDENTIAL MECH. SQ.FT.
buildingJttsnu -ndy my rtsponsibility m nmifythe occupanttl
of the most he et priono isuance of a Cenificme of Oceupamoy.
Owner iharizedaem g Date TOTAL: ISSUED BY:
OFFICE —