S 3849 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 3849
BUILDING PROJECT IDENTIFICATION
BUILDING�R�.� 70(rh Soh /.WV SANITARY N(l. APPLICATION SUBMITTAL DAfI
OWNER'S NAME PHONE: _ CONTRACTOR'S NAMI'.; LIC NO'. _-7
- NIC ///]]]CONTROL#
CHITECTIENGINEEIt'. LIC NO: r ADDRF,SS'.k 13v �F r LL/`J ❑ 4J Y3_3
CONTACT, CQAuj PERM
NE: BUILDING IT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLUMB MF,CH
zz S--2 �. ❑a- �
LICENSED CONI RAM OR:S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby armed mut I am hearted under provi em of Chapter 9(aotmmencing JOB DESCRIPTION
MWaZ with Section 9E(10)ofDr,i..„n3 of he Buameoread Profeesiotis Code,nnd my licensee RESIDENTIAL,
OO PERMIT ISSUANCE
=� L enle Class
effect. WL El KITCHEN REMODEL
a_$u License Liu# APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
h d w Date Contractor
ARCHITEC`I S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
p en Z I understand ransy plashall he used as public......d, PANELS
D.
ZMODIFICATION
OZ•-�
UP TO 200 AMPS ❑INTERIOR---_ HFMNEY'R'PAIR
F1tW Licensed Pndmsional 201-i000AMPS IMP@OVEME�S'tTtAv WIMA i 'OOLS
�'4 OWNER-BUILDER DECLARATION OVP,R I(NXIAMPS ❑pqT REM99EVREPAIR ❑ EMO( Rl I
C C Q 1 hereby affirm Lha 1 am exempt from the Contractor's License Law for the
1 P.U
following reason.(Section 911315,Business and Professions Coda Any city or county SIGNS ELECTRICAL ❑YY HHR
3 la+ which requires a Permit to co-tam,alrnq improve,demolish,a,topic,any
,,C< prinrtn its inuanw.at,,,rcyuie,the opplicem finmch permit m file asgncd,mmment SPECIAL CIRCUIT/MIS !1 atr L
�gmyJ that he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9
4l (commencing with Section 70)(00)of Division 3ofthc Business and Profession Code) 'TEMP,METER OR PO NST R
d g Qo C CIAL
that be Is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITIO
Section 90315 by any applicant fora permit wbjects the applicant mi civil penalty of POWER DEVICES 15 TENANT ❑FOOD SERV( E
na mme than five hundred dollars(55010.
H Z Y IMPkOVF.MF,NT
< ❑Lotowner
k,the property,nrmyempleyms with word foralei(Sec.ntmpensminn, SWIMMING POOLELECTRIC
WFC
will do the work,and the Thestructure
Cont is to s n ooh Law dor,o,apply 2(M4,Business' ❑OTHER
3 aro property
who
Code.The ce,m rco Unmoor w Law dues not apply Himself an owner of OUTLETS-SWITCHES-PI%TURES
11.
pmlmrty whooyees,or sided th th..Isi and who docs such work drfo nr through
his own employees,provided mut such impmvemm�¢arc not imenAcd or offered foe NEW RESIDENTIAL ELECTR SQ f4.
sale.If,however,the building or improvenmm is told within one yearol'completien.the Q SQ.PT.FLOOR AREA $/SQ.Cr.
Poner builder will have the burden of proving that he did not build ornmpmve for par- / L e J ���a 1/ Ak” p
as owner of me property,am exclusively contracting with licensed contractors to /t t N�L+�r Z�KS Dy
,nstruct the project(Sec.7044,Business and Professions Code)The Cortmemrs Li-
eLaw does not apply toonowner ofpfopc0ywho bnild.v or Imposes thereon,and QTY. PLUMBING PERMIT FEE
Li-
cense
c ntmcts forsndt projects with a contractors)Iiccmed par aunt m the Cnmmcon', y{�
License Law. s PERMIT ISSUANCE. 4 �•- A /' l I+
❑ lam exempt./�S'r/•+ .B&P C for thisreason T(o71"•
ALTER-DRAIN&VENT-WAT A) VALUATION
Owner
Data
WORKL . SATION DECLARATION BACK FLOW 1'ROTELT.DEVICE11ff �` !1
I herthy mfirn An der pcoubyof pepury mm ofebe following declarations. y V lJ
D lhave and wlllmaintuio nCcrtiOwlenfGmecnuoxll-Insure fur Worker's Confer- DRAINS-FLOOR,ROOF,ARBA,COND, STORIES TYPE CONSTRUCTION
sitim,es provided for by Section 3700,d the Labor Cade,for the performance of the /
work for which this permit is issued FIXTURES-PER'TRAP -7— /�N
❑ 1 have and will abetment Worker's Compensation hortative,as required by Section V
391)0oftheI.mmrCode,fonhe perfourearmof1he work for which this permit is issued. GAS-FA.SYS'FEM-I INCA OUTLETS OCC GROUP APN
My Worker's Compensation Inmrancc carrier and Policy nmnber ,arc: /�
Carries Policy No GAS-EA.SYUSrEM-OVP,R4(EA) G� 3
CLRTIFICA'1'E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASF/INDSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
('Ink section need not hccompleted if the permit is far one hundred dollars($100)
ales,) GREASE'fRAP PLANCHEC FEE C)S O
(certify stmt in the perinrmance of the work for which this permit is itsued.I shall SEWER-SANITARY-STORM EA.200 I1'. p
no,employ any parson in any mannered asm bccomembjeelto he Workers'Compen- ENER E 3 r Q Q
Z nation Wws of California.Data WATER BEA'T'ER WNENT/ELECTR
z 0 Applicant GRAM
.-t 4 NOTICE TO APPLICANT:If,after nuking this Certificate of Exemption, no sbord WATER SYS]EMaREATING
abemnesubjeet mthe Workers Compensmion pto,kionof the Labor Cods.younum BO E
forthwith comply with such proviabm ur this vorrod,hal be deemal revoked. WATER SERVICE
Q
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLACE. SQ.IT PA Date Receipt#
1 hereby akimo that them is a construction lending agency for the performance of
theworkred which this permit is lxmed(sou 3(19],Co.CJ _2L 2_0
Lender's Name ( s�IB!-i
Lender's Address T
certify that 1 have read this application and.stale that the above Information is BUILDING FEE 3
correct l agree to comply with all city and county ordinances and state laws refuting to QTY. MECHANICAL PERMIT FEE .L 3 O
V Z bnclmog mnsrtction.and hereby authorize representatives ofthischy m enter upon the SEISMIC FF. .
aM1nvc-nmmiotad properly fur mspecfam Pm,..s. PERMIT ISSUANCE.
(We)agree to ve,indnmlfy and keep huronfe,the City ofCupenine agaiissI ELECTRI F
sac
l Criflics,judgmcn¢.wstsand cxpeneswhich may mtiny wayuccoeagaimtsaid City ALI'EK OR ADD TO MEC({,
PLII EE
in n
tot{Acott , of this Pcnnit. 16 1
APPLICANT UNDERNDERSTANTAP(DSAN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'((T'O IB.Oq)CPM)
SOURCE REGULATION A CsAL PF,F,
AIR HANDLING UNIT(OVER IBd%O CFM) CONS UCTION TAX / b
nmmaf AppllcanV.nura Date EXHAUST I IOOD(W/DUCT) HO ING MITIGATION FEE r�
IIAZXk22USERIALS DISCLOSURE
Will the applicant orfotic IF dmgoccu,rd Nopeorbeadle ba,romarnmaoial HEATING ON]'F(TO❑01,(X0 BTU)
ax defined by the Cupertino Mommipul Code,Chapter 9.12,and be Health and Safcty
Code Section 25532(a)9 HEATING UNI'['(OVER 130,000 BTU)
E]Yes EJ No VENTILATION FAN(SINGLE RF.SID) PAID
Will then applicant or building t use equipment or device,which Data Receipt#
1 pp goccupan Area
BOILER-COMP(3HP OR Iog00(1 B'ru)
noir hazurAom air comwninams as AeOned by We Buy Aren Air Quality Management TA
D evict I
❑Ycx FJ No BOILER-COMP(OVER 100,000 B'TO) #
AIR CONDITIONER
Ili*theha�fdoasat 'Isrw ts I Claps 6.95 fthCali- '' ISSUANCEEDATE
foron 11 '25505255?? d255341 J .t JlktiNe NBW RCSIDEN'TIAhMECH. $Q.FF �bald gd tthatt y _p bItyt ifym pant oflhe qOwne,or lam T Ak ISSUED BY. L
OFFICE