S 3829 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
F,=
Y OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
It
DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3829
BUILDING PROJECT IDENTIFICATION
LDINGADDRISS: SANITARY NO. APPLICATION SUBMITTAL DAT
4.2-1 L(KIMA r AVE � , q
ER'S tyAMEVAHil PHONE: CO.1'HACTOR'S NAM@ LIC NO:
•r/A WN NIC CONTROLa
;HRECT/�Iv'61 EER: LIC NO: ADDRESS: ❑ Y �O
CONTACT:r4 G PHONE: BUILDING PERMIT INFO
(yy►.1 II Irk n,a In ❑ Consultant Fees Paid by Applicant(initial) BLDG ELECT Pw2", Me�
LICENSED CONTRAMOR:S fDECLARATION QTY ELECTRIC PERMIT FEE �'
I hereby anion Nm l an Bcm.m under provisions of Chapter 9(commencing JOB DESCRIPTION
W0C) ith Section]IXXbor Division 3 of the Basions and Prones,io I,Cotm.and my liectow is RESIDENTIAL
WOO sur PEHMI'1'ISSUANCC
F u:• in full tura and cRttt. ❑S WI. ❑KI'T'CHEN REMODEL.
�UF License Class Lic.a
< U 4 APPLIANCES—RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
F 7jW Dole Convactnr
G ARCHITECT'S DECLARATION ❑MULTFUNIT ❑S9RUCTURAI.
F)p m PANELS MODIFICATION
y y Z 1 understand my plata shall he used as public recordsO Z G I UP T02W AMPS ❑INTERIOR [I CHIMNEY REPAIR
1-1 Lal Licensed l'fofc—amal 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
CL CLQ hereby ufnrm OWNER-BUILDER
exempt from the ontractor's license Law for the OVER Hall AMPS C3 BATH REMODEf/REPAIR ❑DEMOLITION
O C U followln (Section 91131.5,Entincs%and I'mfuvinnv Code.An t t (]OTHER
X g reason. y city or county SIGNS IH.IiCTHICAL
W W y which requires a permit to annruct,alum,improve,demolish,or repair any structure
< prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT'/MISC.
0o"J that he lx licenxedpursmnna the provixionsol the Contractor's License Law(Chapter'1
�no (commencing with section]Ig1U)of Division3of NC Business ani lkufeszions Crale)or TEMP METER OR POLL[NST. COMMCRCIAL:
a a cz that he is exempt therefrom and she breis for the alleged exemption.Any violation of dL4WW BLDGMDDITION ❑DEMOLITION
XON Section 7031.5hy^ny applicant for a Permit subjects the^pplicmuo it civil penalty of POWER DEVICES 01NT_ ❑FOOD SERVICE
not more than five hundred dollars 0501). 1 CMI'
~Sp ❑ Las owner of Ne pmpcny.or my employees wiN wages os thei..mlecampcnamme, SWIMMING POOL ELECT RIC
p. will du the work,and themordam isnot intended or offered for sale(Sec.7614,Business OTHER
W m and 1'nsfeasions Cade:'The Conunume,Lieenre Law dour not apply m an owner O1' OUTLETS—SWITCHES—EIXT RI? h
property who builds or improves thereon.and who docs such work himself Or though
his own employees,prm'ided that such improvements am not intended or offered for NEW RESIDEM'IAL ELECTR FT.
,are,If,bnwever,the hnilding or impmve^tem issold within One year ofccarructoo,the Sp.FT BOOR AREA S/SQ.FT.
er-builder will have the burden of proving that he did not burld ar improve for pun
awn 7
pose of owner
AFFEE
1 � `
1,as owner of the property,am exclusively contracting with contracontractorslicensed contractors tar o
nut the project(Sec.9(Wq Business and 1'ndessiort Con,I I'he Connector's Li
cerise Law does not apply m H
an owner of property who builds or impraxes drooped.and QTY. PLUMBING PERMIT'
who sonnets baronet projects with a contracmr(s)licensed pursuant to the Contractor's
License law. PERMIT ISSUANCE
I um exempt under Sec. .B R P C for this tenon
Dam ALTER-DRAIN k VENT-NATER(LA) VALUATION
WORKCR'S COMPENSATION DECLARATION RACK FLOW I'ROHSC'I'.DEVICE Z Q O O
1 hereby aMo.under penalty of perjury One Of the following declarations:
LJ l have and will maintai a a Ceti ofCon.mnt to oelf-insum for Workeex Compere- DRAINS—FLOOR,ROOK AREA.COND.0 STORIES TYPE CONSTRUCTION
smion,tax Provided her by Section 3700of the I,nhur Code,for the ,for...anec of the
work I'or which this femur is issued. FUTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
37Otlot'tire Luh or Codr.for the p,ifnnnarecof the ork lin which this pemdt k osned. GAS—IiA.SYSTEM-I INC.4 OUTLETS OCC.GROUPPal
My Workers Compensation Insure ee,artier and Policy number,arc: ^ C�
Carrie: Policy No.: GAS—EA.SYSTEM-OVER4(EA) I
CERTIFICATE OF 'VEXLMP1 ION MOM WORKERS' CRIiASIJINDU51'RL WASTE INTERCEPTOR ,V
COMPENSATION INSURANCE BUILDING DIVISION FEES
GEr,opctionnced notbcmmpeteddNcperej isfomnchumbeaddollurs($1110) GREASETRAP
or less) PLANCHECK FLP O
Loy any that in the ficalknuallec stohakfm whish thio(Lienitis ersCed.lshall SEWIIH—SANITARY—S'TUItM IiA.21N1In'. LLD
^
not employ any(anon in any manner w as m become subject to Om Workers Compcn. I?NLRCY ' � 'V
Z scion Laws of California.Data WATER HEATIiR W/VENT/ELECTR
ZQ Applicant GRAD R!+ E
= NOTICE TO APPLICANT.If,alicr making his Ccnificam of Exemption.you should WATER SYSTEM,REA'1'ING
became mbjact m the Waders Compensation provisions of the I:rMr Cud,you masts iE
form thcomply with.wch provisions or this permit shall be deemed revakeJ. WATER SERVICE
aQ
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL ITEM). SQ,FT. PAID
Uo hereby affirm that isarondmctian lending agency lonh<performance Done Nccciptp
the work for which This permit Is issued(Sec.309],Cie C)
lL F Lender's Name TA T v
U Lenders Addmas TOTAL'
y J BUILDING FEE
y I amity that 1 have read this application and.vtac that the uhove motormmn is
F N correct.1 agree u.comply with all clty and county ordinances and seam mwx hedeamg ort Q'rY. MECHANICAL PERMIT FEE
U Z building construction,and hereby amhorrre representatives of this city m enter upon the SEISMIC PEE
abtwcmentloned pmp try for inspeetion Prop Ao,x. PERMIT ISSUANCE
(We)rgno m sma inden^Ity and keep hanoless the City Or Cupertino against ELECTRIC FEE
Im1nitin.ju1gnonts,coasavd colarms whicbmay intrny wayaarucagain.t said City ALTER OR ADD'FO MECH.
PLUMBING FEE
in consequence Of the Planning of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO 10,00(i MECHANICALFEE
SOURCE REGULATIONS.
AIR HANDLING UND(OVER I0d100 CIM) CONSTRUCTION TAX
Sinecure or AlilichmCmdretur Date EXHAUST GOOD OVIDUC ) HOUSING MITIGATION FEE.
HA7,RDOUS MATERIALS DISCLOSURE
Will the applicant or future building reception store or handle bmnNOus mmerin HEATING UNIT(TO 100.000 BTU)
ac defr¢d by the Cape,in,Municipal Gtde,Chapter 9,12,roil the Health and Safety
Code,Section 25532ND DEALING ONII'(OVER 100 000 BTU)
(Yes Fl No VENTILATION FAN(SINGLE RESIT]) PAID Date Receipts
Will the apPlmenr nr from hnilding occupmt use equipment or devices which BOILER—COMP(3H1'OR 100,000 BTU)
t hazardous air contaminant as defined by the Buy Arca Air Quality Management TOTAL_
Ui dicR BOILER—COME(OVER❑0,000 BTU)
❑Yes EJ No 3--L
I have read the hanuNous mammals requirements under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
hrmiu Ilcahh h Sufcay Cndc,Sections 25505,25533:nd 25534.1 undcoumd and'he NEW RFSIDIiNr1AL MUCH. SQ.Fr.
horning docs nor cunenuy have a mount.that it is my mspomibilay it,nadfy the occupant
of the revuirements which must be not prior to issuance of a Certificate of Ceruwncy.
Owner fir conformal agent Dale TOTAL:I I ISSUED BY:
OFFICE