S 3997 AIPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINTO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 3997
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS; SANITARY NO. APPLICATION SUBMITTAL DATE
.AmF-6 I' O. CONTR R'S NAME: LIC NO I to • 2 2-Q
11111011111111, 408 ro S)l -A.-, N/C CONTROL#
GERADDRESSARCJCOJ—2&0O
CONTACT: PHONE: BUILDING PERMIT INFO
/� ❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT PLUMB - MECH
LICENSE NT t1R'S DECLARATION QTY. ELECTRIC PERMIT FEE 1:1 El
Ao
1 hereby affirm That I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTAIMN
WO,
Z with Section 7070)th4Divicine 3ofthe Huninessand Professions Code,and my liceme is RESIDENTIAL'
l . full force anJ m , PERMIT ISSUANCE. ❑SEOWL [IKITCHEN REMODEL
�UU locate Clas., Lit.p
y<a Dale Gmt u m APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RF.PIPE
ARCHITECTS DECLARAT C1MULTI-UNIT []STRUCTURAL
Z O•T'Z ,1 1 undersmntl my plans shall be used as public records MODIFICATION
W (a
PANELS
OZ V�D�P-T' WS'F �/� /)�qq UP TO 2W AMPS
F F' Licensed Profe,moml �IM1PROVE El CHIMNEY REPAIR
201-IIXIOAMPS IMPROVEMEEl NT POOLS
Es1EU
OWNER-BUILDER DECLARATION C)
C C Q I herby uffrnt that 1 am exempt from the Contractors License Law for the ({VER I0g)AMPS ❑BATH REMODEIJREPAIR DEMOLITION
Kow U following ma.mn.(Section]031.5,Burnett.,and Pron,im,Code;Any city or county SIGNS ELECTRICAL D OTHER
toy which requires a permit to construct,alter,improve,demolish,or repair any shommre
%ton prior nails issuance,also requires the applicant fof such Permit fie a signed statement SPECIAL CIRCUMMISC.
rThai he is licensed ammmmlhe provisions of The Coulmmors liceme l,.w(Chapter 9
Iy tYCon (commencing with Scnion]oWlofDiviman3ofthe Busincsc and Pmfcstions Code)or TEMP.METER OR POLE INST.
E.E.a that he i,exempt therefrom and The basis for The alleged exemption.Any violation of C1 NEW BLDG/AUDITION C1 DEMOLITION
�My Section 9031.5 by any a,dicmt for.pvival iljubthe s'dieam w a civil mmollyof POWER DEVICES TENANT ❑FOODSERVICE
not mom than five hundred dollars S5010).
=C ❑1,us owner of the property.or my employees with wages'Their ole tompe'emion. SWIMMING POOL ELF.11
p.. TU IMPROVEMENT
will do The work.and thectrueture is not intended moffcom for sale(See.9044,Business _ q ❑OTHER
a3 aad Preffeagms Code:The Carmcmr',License Law does nor apply m an owner of OUTLETS-SWITC{ S- (� OQ
property who builds or improves thereon,end who doework s such k himself armrough
his own canplmyem,provided that such improvements ore not interceder offered for NEW RESIDENTIAL ELECTS SQ E-n
sal,If,however,the building ar improvement is sold within oneyear ofcnmpletion,the SQ.FT FLOOR AREA S/SQ_EF
ownersbuilder will have the burden of proving Thm be did..,build or improve for par-
�wle.L or
owner of the property, B sine exclusively contracting with licensed Commerce,
n, )TAC'
arcs the project(Sec.]D44,Business and Prthfesmant Codes)The Commcmrs Li.
must,Law docs ern apply'an owner of property who builds or improves Thereon.and QTY. PLUMBING PERMIT FEE
who comae,forcueh projects with a eonrmccr(s)licensed pursuant To)the Conwemr's
Liceme Law. PERMIT ISSUANCFi
Jam axe ties. ,B&P C Eur Thisreasrn
ALTER-DRAIN&VENT'-WATER IEA)
Own it
Jun D #_a /1% 00 VALUATION
ORK: C PENS N DECLARATION�C I-- BACK FLOW PROTF:CI'.DEVICE
I hereby aR rte under penalty of perjfffy oneof the ful lowing declaration
I have and rill maintain a Cenificatc of Consent o self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONT.
suuor,as provided for by Section 37M of the Labor Cole,for the performance of the STORIES TYPE.CONSTRUCTION
work for which this Dennis it ismaf. FIXTURF_S-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
370hf the Labor Code.for The performance of The work for which This permit is isvaul, GAS-EA.SYSTEM.]INC.4 OUTLETS OCC.GROUP APN
My Work,,',Cnmperoation Insurance coria and Policy number are:
Comer: Policy No, GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COM PENSANON INS URANCE GREASF%INDUSTRL WASTE INTERCEPTOR
(This sermon need nm W completed if the pcmtit is(throne hundred dollars(SI W) BUILDING DIVISION FEES
or los,) GREASETRAP PLANCHE:HEEoy anythaninthe anymnmofrhe work for which this l¢mtiti v ed, SEwER-
uc'ploy any pecan#in any munnc..onsm bee c hic't eWrersSANITARY-S'[ORM liA.2001'1'.,Zration Ivws nl C4� Dare ENERGY FA licum .Ret WATER IfFAI F.R w/VENT/ELECIRZ O �YJ�� GRADINGP Ln NOTICE.h APPLICANT:IL nUer'akin Cisionsa f,h LaInc,io d yon snnld WATER St'STEM?RF.ATING
hnvme subect y the Workers Coons or this previsions thfthe Lahr Code,you mustSOILSfunhx nth cmply with Hoch povicions onhls permitshall be deemedrevoked. JV
WATER SERVICE
Z) Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMEL SQ.FT. PAIUpEherebyalfinn that There is.coremmume lendingagency for the perfneraraceof 17 -1-
not
(LF' he work for which this pundit is i...ed(See 31F)7,Ci,C.)
Lender's Name
U TOTAL:
Isndcr'I Address TOTAL
F 4 1 certify that 1 have read this uPPlicmiu.and slide that the above iafon mums is B 11, IN;PER
co) corner.I agree m comply with all city and county im inatio-and ,an law.,relating to QTY, MECHANICAL PERMIT FEE
U Z building construction.and hereby cathartic representatives ofthlscirym cnmrupnn the SEISMIC FEE /
above-mentioned property far ito,whinn purpocex. PERMIT
ISSUAN'CIi
(We)agree ea save,indemnify and keep hamlets the City of Chairman against BLE CITE O
IiahiWicajudgmenn,ro,LwnJexpenses which def,many way acerve againv wid City ALTER OR ADU T(1 MECII.
comcyueneu of rhe gond#,of this Dente PLUMBING EE
APPLICANT UNDERSTANDS AND WILL COMP I LUN AIR HANDLING UNIT(TO ED(pO CF,N)
SOURCE EGULATIO MECHANICAL �E
AIR HANDLING UNIT(OVER I r(W CFM) CONSTRUCTION TAX
Sig urofApplican onto or Date EXHAUST HOOD(W/DUCT)
I IAZARDOUSMATERIALS ,OSURE HOUSING MITIGATION FEi
Wllthe applieumor fumre huildingomupmn Tore or handle hamrdous marooned HEATING UNIT(TO I W-(I00 BTU)
as dclined by the Cupertino Municipal Code,Chapter 9.12,and The Health and Sarety
Code,Sc tin.25 25532h)? HEATING UNIT(OVER E W,OfI(1 BTU)
❑Yes <�I No
e /_ VENTILATION FAN(SINOLL'RESIU) PAID _
t Will the applicant it future building occupant sea ea Air Qu or devices which Dam Receipt#
mitict, us wrcnmaminuno ns defined by the Day Area Air Quality Management BOILER-COMP(3HP OR IW,BOp BTU)
Diztrim? AL:
EJ Yes BOILER-COMP(OVF.H I010,0008TU)
I have teal the bavallous marerinls requiremcros under CM1aptarG95 of the Cali AIR CONDITIONER
forma Health&Safety Cade.Solicitor,25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FC ���SSUANCF,PATE
hndling does not womanly have a tenant,that it is my resp,nsibility to notify The occupant 2
o the requim'ennich moa M noes primo iswanc a e Ccnifi care of ponoy.
6 u
Owmr or aaththm< Dam TOTAL: ISSUED BY:
OFFICE