S 3921 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELE17FRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PF,RMIT PLUMBING-MECHANICAL S 3921
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Al.ft -r.11 )g7+b603
t.►i+� Loo C , _ q
OW NAME: _ �1 "" PHON CO tRA O NA is ) LI O9ri o,,
5}F-grzy ,.• '#�/ (� NIC (���/ CONTROL#
� A HIT[f, B GINEER: ••\\I •1—`IC NO: ate' wI^ Pa I W i, YY. ❑ 1
CONTACE n' Pl, I. J a�' 1 BUILDING PERMIT INFO..
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/i✓r� �wl��� 77
_ J I ❑ Consullanl Fecs Paid by App want(IDitlal) BLDG ELECT PLU❑h1B ME❑CH
s,! LICENSEDD C`OWRAC OR'S UECLARNHON !Jl_ QTY. ELECTRIC PERMIT FEE CrJ�
I hereby affirm that I am heencoM under pmviMom of chapter 9(commencing - JOB DESCRIPTION
BOO with Section 7000)of Division 3 oflam Business and Professions Cole,and my license is PERMI'1'ISSUANCB RESIDENTIAL:
FQFUZV in full bar.add eftel. Lie. ❑SFDWL ❑KITCHEN REMODEL.
NQDate
Co. APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
W
ARCHITECTS'l')IR AIION ❑MULTLUNIT []STRUCTURAL
Zp
it,
I understand my plans shall he used as public records PANUS MODIFICATION
07,E UlIT02MAMPS ❑INTERIOR [I CHIMNEY REPAIR
d�~.] licensed Professional 201-100JAMPS IMPROVEMENT E]SWIMMING POOLS
dsy 2, OWNER-B ciaptIiR D the CourRAItie OVER I0110AMPS ❑BATH REMODELMEPAIR [I DEMOLITION
6'tCYC Q 1 hereby mason.(irm chat 1 am exempt from the Cnnuns Co License Law Iia the
followinguire (Seaton]onstr Business and Professions Calc:Any city or county SIGNS ELECTRICAL ❑OTHER
¢1341" which requires o permit m constrvct,alar,improve,demolish,or repair any swcutrc
FSO be, its issuaam..),a requires the eppliramforsuch pc man in file a signed statement SPECIAL CIRCUIT/MISC.
, } that he is licensed commona.,M1eprofutar,ofine Comtmcmc's License Idw(Chaffer 9
W no (commencing with Secdom7000nof Division 3oflhe Romances and Professions Cede)or TEMP.METER OR POL
C' COMMERCIAL:
4 0 that he is exempt ihereGom and the basis for the alleged exemption.Any violation oOf ❑NEW BLDG/ADDITION ❑DEMOLITION
I
CydSection 70.91..5 byany applicant far a permit subjects the applicant to a civil penalty of POWER DEVICES
u1v1 OT[iNANT ❑FOODSERVICE
nm me than live hundred dollars MGM.MGM. IMPROVEMENT
F-
nor
=ODI,as owner of the property,or my employees wird wages as their sale compensation, SWIMMING POOL ELE R
F- will du the work,and the structure,is not imendedoroRercd for sale(Sec.7614,Business ❑OTHER y�
Ed 3 and Psnfcssioms Cole:The Centre limes License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXTURES /� f
property who hui Ids or improves thercnn,and who does such work himself fe through
his own em,lo,c..provided that such improvements ore mm imm�del of offered for NEW RESIDENTI .HLELTR SQ FT.
sole.If,however,the building to uaoanentis sold within enc year ofcompf ... the - SQ.FT.FLOOR AREA $/SQ.FT
ownetTailder will have the burden of proving that he did nm build or improve for P-1-
pose
oopose of sale.).
❑1,as owner of the Property,am exclusively contracting with licensed omarremrs to TOTAL: ''--''ll
construct the project(See.7644,Business and Professions Cole:)The Convectors Li - - 3 ^ /C
cense Law docs not Lilly to an owner of Property whit builds or improves thcmon,and QTY PLUMBIN IT FEE (�, I J
who wmrects for such projects with a convncrous)licensed pursuant to the Cnnwctor's
License Law. PHRMH ISSUANCE
❑ I on exempt under Sec. ,R&P C for this«mnn
Owner Date ALTER-DRAIN&VENT-WATT ) VALIlAT10N
WORKERm 'S COMPENSATION DECLARATION BACK ROW PROTECT.DEVICE O- 10ap O
IhercM1y affirunder psmalnyof Perjury one of the following declamtiuns: .O� V
I have and will maintain a Ceniftcute of Consenlmsel5lnaure for Worker's Connived. DRAINS-ILOOR,ROOEAREA,COND.
,.,,an.as provided for by Sdadon 3700 of the Labor GMs,for the performance of the STpRIES TYPE ONSTRUCTION
work for which this lscrntitisissued. FlX'1'URHS-PERTRAP
FlY l_ .,,e
I have and will maintain Worker's Compensation Insurance,as myuimJ by Section
3]00ofthe Labor Css%l TantePerformance of the work for which this permit is issued GAS-EA.SYSTEM-IINC.4OUTLETS OCC.GROUP / APN
My N'or tityr lnymunce cameroliy N.1 ynfl�lgrO-�J'�J7 O-Z
Carried Policy Nn JJ�01L GAS-EA.SYSTF-M.OVER 4 MA)
ERTII'ICATH OP EXEMPTION FROM WORKERS' Q (o
COMPENSA9'ION INSURANCE GREASUINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION PEES
('Phis section need not he completed ifthe permit ix for one hundred dollars 1$100) GREASE TRAP
or less.) PLANCHECK FEE / I O
me
I certify that inthe pertonnanceofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FIL O
not employ any person in any manner so as to becosubject m the Workers'Compen- ENE FEE
Qz sntion Lawsof Califomia.Date _ WAIHR HEATER W/VENT/IiLELTR
Z 2 Applicant G ItiE
h NOTICE TO APPLICANT:If,after making this Cenific:nc of Bsemprinn,you should WATER SYSTEMC BEATING
a !"� became o1n,,,rude Worker's Congwrtanion not'the Lobo,Cure,you must SOILS FEE
w t� tonhwlth comply with such pruvisiomor this permitshall be defined resulted. WATER SERVICE
Q
7 z CONSTRUCTION LENDING AGI2NCY NEW RESIDENTIAL-PLMB, SQ.ET. ID
U O 1 hambyam
ffirthauanga
here isco irsou nleodigency for the Performance of Date Receipt
{LF the work for which this pe.it is issacd(See 3057,Civ.C.)
C) V Lmd,es Name TOTAL:
;Q Lenders Address S
I certify char 1 have read this application and state that rhe above information is BUIL G FEE r
V) correct.f agree to comply with all city and county nuisances and state laws relating to QTY. ANIC I IT ,E
(.7 Z buildingcumuuction,and herehyamhonzempresmantivexofthiscity rocaterupnnthe SEISMIC3iVE LQ
above-mentioned property for inspection purposes. PERMIT 155 E
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
idhilities,judgmenrs,costs and expenses which may in any way accord against said City ALITR OR O in
meyua of she goading offlas Permit, PLUMBING FEE
en
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -Plot T AIR HANDL UNIT 10,000 CFM)
SOUR UTATI S. /7 //At MECHANICAL HE
��//�� wic')?q AIH HANDLE IT(OVER IO.000CFAt) CONSTRUCTION TAX
SigndmTn Convect/ uo FUaT1' EXHAUSTH }
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Wil l the appl icunr or future buildi ng occupant smrc or handle hazardous material H EA'l'INGUNIT(TO 100,000 BTU)
its defined by the Cuperldo Municipal Code.Chapter 912,and pro Health and Safety -
Code,Section 25532(a)? HEATING UNIT(OVER 100,000 BTI])
❑Yes E]No PAID
VENTILATION FAN(SINGLE NESID)• Dare Receipt#
emit rad rhe applicant ter furore Wilding Wilding occupant equipment or devices elect District?
us air commacommandantsmms as defined by the Bayy Area Air Management -COMP(3HP OR 100.00 BTU)
Quality Manngnn
r TOTAL:
Disrrret?
❑Yes E]No B011.lili-CUMP(OVGIi IIMI,IHMIBTIIJ
I have ren I the hazardous mammals rnyulmmenn under Chapter 6,95 of rhe Cali- AIR CONDD'IONER w ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 25534.I understand that if fire NEW RESIDENTIAL MF-CH. SQ.14.
buildingdoesnomypdatly hat I, it is my rtspmsRalinymnotify he«aupanr l/Y• U /
of thas�d�nei/Ju/hJic.�h It ten tin missuav:e nfu CeniMme o/whiy. (�
Own ol�iihots/P rill car r pad— TOTAL: ISSUED BY: / 0
OFFICE