S 3801 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PER PLUMBING-MECHANICAL. S 3801
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
i1 ,t ,&iz0 of 4 _S' -?- 9 f
OWNER'S NAME: � PHON CONTRA R'S NAME: LIC NO:
NIC /CONTROL#
,• Ak ITF. li GINEER: ^^ LIC N A ESS: ❑
l�Z'
^; CONTACT. PHONE: - BUILDING PERMIT INFO
{„.��� �(�1..'1 �� � ❑ Consultant Fees Paid by Applicant(Initial) BLD ELEO PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm that 1 am accused ander provisions of chapter 9(Commencing JOB DESCRIPTION
OZZ win Sem me7u)(10)or Division dorm,Brouresand Processions Code,mdmy,fieen.o, - L,
'ly.. PERMIT ISSUANCE
in full force and effect. SFDWL Ll KITCHEN REMODEL
UV Lams,Clave Conti APPLIANCES-RESIDENTIAL L1 ADDITION [I PLUMBING RE-PIPE
m ¢ Date Contractor
C� ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z Q a,Z 1 understand my plans shall be used as public records PANELS MODIFICATION
O Z4n UP T02W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
1'+.�Ed Licensed Professional 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I000 AMPS FI BATH REMODEIIREPAIR (]DEMOLITION
I hereby affirm that I am exempt from the Contractor's License Law name
3 W F following reason.(Section 1031.5.Business and Rofessions Code:Any city nr ttmmy SIGNS ELECTRICAL EI OTHER
y which reyuires a permit to wnvtruc0 alter,nnprove,demolish,or repair evy nrewre
0< prior to its issnared,also requires the applicant for such permit to file asigmed statement SPECIAL CIRCUIDMISC.
F. y door he is licensed parsoont totheprovouss,oTthe Comnacrors License Law(Choprer9 00
^QC)a (commenciogwah Second7000)of Division 3ofthe Business and Proriedian Code)or TEMP.METER OR POLE INST.
P k m LL that he Is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
W^y section 70315 by any applicant fora permit subjects the applicant toacivil penalty of POWER DEVICES ANT ❑FOOD SERVICE
not more than five hundred dollars($500).
F Z Y IMPROVEMENT +
SQ' ❑I,as owner at the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC
ay0 will do the work,and the structure is not intended or offered for sale(See. Business El OTHER II �A .
dYv$ and Professions Code,I'he Contractors License Law does not apply to un owner of OUTLETS-SWITCHES-FIXTURES
prpedy who builds m Improves thereon,and who doer wad work himself onbrni
his awn employees,provided that such improvements are not intended or offered fur NEW RESIDENTIAL ELECfR SQ FT
sola if,haweveq rte building odmprovemmtis sold within oneyrr a fcompletiov,the SQ.FT.FLOOR AREA $/SQ.Ff.
wner-bulldcr will have the burden of proving(hut he did not build or Improve for par- 2 d 1` 4,K"an F� A
prose orsale.). ^ O� L'v(Ey r e-,l r�R-I" 91y.
I,• TO
❑ 1,Orsini the property,,a.B exclusivelynd umnacting with licensed eommetors to L �1 ,{ yry �+
nnilma the es not (Seco an Business and property
who
Code:i The Cdr sated,Li-
c eLnwdoesnotapply moan owner ocpmeaft woo buildsos ant to the Contra,ova QTY. PLUMBING PERMIT FEE
who contracts such p jea,coirucommctor(e)liwneed pursmmtone Cantracmr's - c�+Lbi LI+
Licensor Law. PERMIT ISSUANCE 44-z
❑ I am enemy(mdu.Sec. �..B&P C fonhiv masonS�
Ow 1 M 11 i n,., -2 ALT[R-DRAIN&VENT-WATER(EA) // AZ q 00& pT10N
N age ORKE COMPS�I ��Y1 N DECLARATION BACK FLOW PROTECT.DEVICE /� �7 V
I hmaby offirm under penalty of ]my Dae fine following declamations: ' BM7 .7�7� ✓✓
❑I have and will maintain a Certificate of Consent to self-insure for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,CONE, v{W/
sativn,as provided for by Section 3700 of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
° --�1 work for which has permil is issued. FIXTURESPERTRAP 'v/
1 ❑ 1 have and will maintain Worker's Compensation insumoce,as required by Section
3]00of(he Labor Code,for the performance ofthe workforwhich this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTL GROUP APN�p
My Worker's Compensation Insurance carrier and Policy number are
Caries - Policy N.: I GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTER OR J
BUILDING DIVISION FEES
(Thio section need votbc completed tithe permit is[Drove hundred dollar($I W) GREASETRAP or less.) PLANCHEC FE6 6#
]certify that in the performance ofthe work for which this permit is issued,I shall SEWER-SANITARY-STORM EA. th.
nn(employ any person in any manner vv sore to heatme Nbject to mho Warkars'Comped-
Z ,Z sedan Laws of California.Dam WATER HEATER W/VENDELECTR
2 Applicant ` GRADING FEE
ti NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM,TREATING SOILS FEE
Iti became subject to the Worker',Compensation provisions of the Lobar Code,you mus(
a, forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
a' Q CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAIti
w7 ,Z I hereby affirm that there is a concoction lending agency for the performance of �^'' to Rueipt#
V the work for which this permit is isaned(See.309],Civ.C.) 3 0 J 3
Lenders Name TOTAL:
VLender's Address TOTAL:
'� I curry that 1 have read this application and state that the above information is BUILDING ME
iFi h ommec(.1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE 2 !^O
(.) Z building umstru tion,andhereby authorize tepreseomtivee nf,bi,,i,y to enter upantho SEISMIC PEE .J
` above-mentioned property for inspection purposes. PERMIT ISSUANCEELECTRIC FEE 2--3 ��
(We)agree m cave,indemnify and keep Insurance,the City of Cupertino against
liabilities,judgments,costs undexpenses which may in any way accrue agaionsaid City ALTER OR ADD TO MECH. PLUMBING FEE
in cox,faence of the gormint,of this permit, c S
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR IIANDLING UNIT(TO 10.000 CFM) MECHANICALFEF.
7 its,
SOURCE REGGTION �
AIR HANDLING ON[*[(OVER 10.0010CFM) CONSTRUCTION TAX
lo,dramicsisTA,licanuOmfilidentur g, Date EXHAUST HOOD(W/(IUCD HOUSING MITIGATION FEE
HAZARDOUS MAT LS DISCLOSURE
Will the applicant or future building aaupamincre or handle hazardous material HEATING UNIT(TO 1010,000 BTU)
as defined by the CrOmpro Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTU)
0Yes E]No VENTILATION PAN(SINGLE REMD) PAID ago, -
Reurii
Will rte at,cmm tubun
iet fure tinre hi
g occupant aequipment ordevices wch
mi(
eharurdouc air omaminanis as defined by the Pay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
District]
El Yea El No BOILER-COMP(OVER 100,000 BTU) s
f�
I have mad the hazardous materials requirements under Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DAT��ETff11
forin health&Safety Code,Sections 25505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT .-I z - ITT C�
building does tcmrentlytru a(em:mh(mn it is my responsibility to notify the otcupam ` r
of the require a is which mu -metprinr to issuance of a Cen are of Osco ney, O r
rtrial agistat TOTAL: ISSUED BY. T®
OFFICE