S 3885 APP'LICANTTO 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 3885
' t' BUILDING PRQIECTIDENTIFICATION .�
BUILDINGADDRFSS: SANITARY NO. APPLIQATI SUB TTAL DATE
L /C/ /6 �i �1
OWNER'S NAME: PHONE:I CONTRACTOR'S NAME: LIC NO:
L _ L NIC CONTROL Y
•A RCHITECI'/ENGINEIi LIC O: I ADDRESS: CA 95945 ❑
C loss
CONTACB PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
B MECH
El F-1p ❑
LICENSED CONT'RACTOR'S DECLARKriON QTY ELECTRIC PERMIT FT:E
1 hereby affirm that[.as licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
w4'Z with Section 70(a))of Division 3 of the Business and Professions Code,and my license is RFSID NTIA
Ia10 0 PERMIT ISSUANCE -�-E—I
F� in full forte and eH q. C�� . �$FDWL ❑KITCHEN REMODEL
QUU
Li CI I,ic.N APPLIANCES-RESIDENTIAL
F.zW oath Cnmmc� 1 � AA�' ❑ADDITION ❑PLUMBING REPIPE
F.Dm ARCHITECPS UECLAR��y,'PLtt - aver PANELS ❑MULTI-UNIT [I STRUCTURAL
024y Z 1 understand my plans shall he used es public riMU, MODIFICATION
-0 UPT02MAMP5
F,�'n t:W Licensed Professional ❑INTERIOR ❑CHIMNEY REPAIR
201-1080 AMPS IMPROVEMENT (]SWIMMING POOLS
SM, Oat I A. Unna fo DEthe Com ON
arm OVER BX10 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
C W Q I hereby affirm on 1 am eBusin Irons the fessions C s License Lou for the
3 4 F which
rearm.Section ri 1.5.Business and Professions Code Any city or county SIGNS ELECTRICAL El OTHER
4 which friction,con a permit re construe,aper,improve,h farmuh, fi mpair any structure 3p� p (��';*p[' ep P("
� 'h,1, e...lece,also reyuithe thcapplmofthe sucContra..... RlcasLaw(statement SPECIAL CIRCUIT/MISC.
that he is licensed pursuannu the previsions el the Cnmrvnnr'x License Law(Chapter9
Qnto (commencing wins Sectinu7(UO)al Di vision Sof the Business and Professions Code)A, TEMP.METER OR POLE INST. COMMERCIAL:
4 4 othat he is exempt therelnnn:rod the hall,for the alleged attention.,Any violation of ❑NF,W BLDG/AUDITION ❑DEMOLITION
W.mrN Section 7031.5 by any Applicant for.permandocns theupplicunun a civil penvltyof POWER DEVICES ❑TENANT ❑FOOD SERVICE
�^6 not more than rive hundred dollars(550). IMPROVEMENT
0 Las nwnetof the property.or illy employees with wugesmtheir rale compensation, SWIMMING POOL ELECTRIC
will do the work,and thexmtcalre is not intended oroffered for sale(Sec.9044,Business []OTHER
g,3 and Portesvions Code: lite Convenor's License Law does not apply m an most of OUTLETS-SWITCHES-FIXTURES
property who mid,o,ilmpnrvm thereon,and who docs such work hona,elf or through
his own nnpinyecs,provided that such impmvelments or not intendetl or oftercd for NEW RESIDENTIAL ELECTR SQ
sale.If,however,the building in inmrovemed is sold within one yemidlmmpleton,me SQ.IT.FLOOR AREA S/SQ.IT.
owner-builder will have the burden of proving that he did nm build or improve for par Az
-
fnhse of sale).
E] 1,as owner of me prnpeny,not exclusively canvacting with licensed contractors at TOTAL,
cumwat the prolan(Sec.7044,Ruvincas and Professions Code)The Convmmrs Li-
u Law dues net apply .air owner of ptopeny who builds or improves thereon,and QTY. PLUMBING PERMIT t 1 FEE
who contracts for such projects with a conttuctots)licensed punonnt to the Commerce,
License Low. PERMIT ISSUANCE
❑ I vm exempt order Sm .B&P C fill thoneason
Owner Ume ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby affirm under penalty of perjury one of the following dMatudi s: S�
❑I have and will maintain v Cenificme of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Code,for the prdormance of the
work far which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Contpensetion Insurance,as required by Section
37M of the Labor Code,for the performance of the work for whichmis permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Works' rope canon Gh 'rend Policy n ��ree
Caries Policy No.: (O� ,115 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OIa EXEMPT ION[ROM WORKERS'
COMPENSATION INSURANCE. GREASFANDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FLIS
(This section need not he completed ifthe permit is fnrnne hundred dollars(SITU) CREASE TRAP
or less.) PLANCHECK FEE
I certify that in the performanceo011 wnh far which miandmit is issued,[,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any Person in any manner so as to become subject to the Workers'Comp
en- ENERGY FEE
Z ,z cation Laws of California.Date WATER HEATER W/VENT/ELECTR
Applicant GRADING FEE
a-1 ^ NOTICE TO APPLICANT:If,after making this Ccniricme of ExcmOhnn,you should WATER SYSTEMIIREATING
a , become subject to the Worker's Compensation provisions of the[.abo Code,you must SOILS FEE t
L1a fonhwim comply with such pmvisinnnor this pemin,holl he deemed Avowed. WATER SERVICE
Q
CONST is aconNLENDINOAGFNCY NEW RESIDENTIAL PCMB. SQ.Fri. PAID
UQ Ihetehy affirm that mere is ncmnstmetinn lending Agency for the Performance of Dam ReceiptN
FAl••1 the work for which this la mit is issued(Sec.3097,Civ.C.)
Lender's Name TOTAL:
WLenders Address TOTAL: �'
1 in ify the I have read this vpplicudnn and some that I above information 1s BUILDING FEE
E+ Tail coven.l Agree Bt complywitudl city unit county ohdhhances and sate lows relating it) QTY. MECHANICAL PERM IT' '.y('. FEE
U nuudlnyeomwel'mn,and Norhy uulhnrire mprceentnivcv of this city to enter uptm the •• SEISMIC PEE
anavc-(Wit a ed ,,sloe Rn i inion,nn l see,limitless
PERMIT ISSUANCE -
(Wo)ngma m ease,indemnify and keep hannlcvc the Colof Cupertino against ELECTRIC PP,F:
Imbitines,jutigmemts,costs and ea""ta which may many wiry necrue uguinct said City
ALTER OR ADD TO MF,CH.
asequence mine Grunting ofthis permit. i'hUMI{ING PEE ..5
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI,NON.POINP AIR HANDLING UNIT(1010,0IU(FM)
SOURCE RREEGULATIONS. MECHANICAL FEE
71 Ae-r K/•� La.�Lf.99 NRIIANULING UNIT(OVER IO,IXIO CFM)
CONSTRUCTION TAX
Signature of Appllearuclilr.¢mr Date EXHAUST HOOD(WIDUCe) HOUSING MITIGATION FFP.
HAZARDOUS MATHRiAI S DISCLOSURE
Willthe Applicant or fume buildingoccupamsmreer handle turmoil martinet HEATING UNIT(TO 100.000 BTU)
as defined by the CApenims M.Aicipsl Code,Chapter 9.12,and the Health and Safmy
Code,Section 25532(a)? HEATING UNIT(OVER 1 ill BTU) pp7
❑RsNo VENTILATION FAN(SINGLE RFSID) UI
. U m R ipt
Will the plicanlo,future building..poor use equipment or devices which BOILER IW.WO BTU)
emit hazallous air contaminants As Defined by me(ivy Area Air Quality Management T
DistricC' BOILER-COMP(OVER 10[1000 BTU)
❑Yes eNo
1 have read the hvmrdws mamrink p AIR CONDITIONER
requirements under Cha ter 595 of Ne Celi- ISSUANCE DATE
forte Heath&Safety Code.Sections 25505.8533 and 25534.I understand that if the NEW RESIDENTIAL MECH, SQ.ET.
buildingdhwsnmcurently revenue nant..hot it is my responsibility eh nhnify the occupant y C
of the requirements which must od met prior m issuanceof a Ceri ficam of Occupancy.
Owner or authorized agent Dote TOTAL: ISSUED flY:
OFFICE