S 3136 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PEg`p1IT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. V 3136
BUILDING PROJECT IDENTIFICATION
BUILDING AIIIIRESS: \ - SANITARY NO. APPLICATION SUBMITTAL DATE
14'1"1 F U-,QA Picl-c-e-. -(?f
OWNER' NAME: PHONEYitilm
CO LAC OR'S NAME: �w s �I�C Nj� NIC CO ROL#
ARCHITEC'UINOIN88 : LIC NO: ADDRESS: lTJ (3 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
One- 4 �F� ��O��b'tq-28 13 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELEG r PLUMB MECH
❑ .. ❑ ❑ i
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE -
E)2 I hereby affirm that 1 am licensed under provisions or chapter 9(commencing JOB DESCRIPTION
with Section]000)of Dlvision3 of the Business and Professions Code,and my licensees NTIAL:
F O with Section
and PERMIT ISSUANCE
W i" T11 � FD ITL ❑KITCHEN REMODEL
U Liceme Cl ss Lie.tr
yQ� Dam 1 Commdor APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
ARCHITECCS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
F o,Z I understand sit plans PANF.I.S
y D y y p o s s mil he used as public records MODIFICATION
OZ.+ - UP T0200AMP5
F ihW Licensed Professional r ❑IMROVERIOR ❑SWIMMINGP OL
201-IgM1AMPS IMPROVEMENT �SWIMMINO POOLS
OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH REMODEL/REPAIR D DEMOLITION
CL sv Q 1 hereby affirm that I am exempt from the Contractor's License Law for the
ipyk� L U following reason.(Section]03 L5,Business and Pmfeseiens Cade:Any city mrnunty SIGNS ELECTRICAL El OTHER
Bl�+at 1"' which requires a Permit to construct,alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant forsuch permit to rile a signed statement SPECIAL CIRCUI'UMISC. L
y that he is licensed pursuant,,the provisions of the Convaetor4 License Law(Chapter 9
00 (commencing with Section 7")of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMM
t1 c yr that he is exempt IhercGam and Ibe basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
mW Sell ion]U315 by any appliunlfor a permit subjects the applicanranacast penalty of POWER DEVICES
not more than Live hundred dollars($5Utp. ❑TENANT FOOD SERVICE
7�>' - IMPROVEMENT
xQ ❑l,as owner of IM1c progeny,or my employees wim wages as lheirsolecompenention, SWIMMING POOL ELCCI'RIC
'� O will do thework,and theswewreienm intended oroffeaJ roc sole(Sec.]f14f,Business T R
3 and Professions Code:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who docs such work himself or through
his own employees,providst that such improvements are not intended offered for NEW RESIDENTI S
,site If,howeveathe bad lding or improvement is sold within one year or completion,0e - Q 17. FyO AREA $/SQ.FT
""'builder will have the burden of Leaving that he did not build or improve for put- f(f,(//
pose more.),
❑I,as owner of the property,am exclusively contracting with licensed crntzactots to O
construct the project(See.704T Business and Professions Cale)The Connector's Li-
emtce Law does not apply to an owner of property who builds or improves thereon,end QTY. P N P. M T FEE
who contracts for such projects with it comractons)licensed pursuant n the Contraemfs
License Law. PERMSSUANCE
❑I am exempt under See. ,B&P C fanho reason
Owner Data ALTER UN as VEN VALUATION
WORKER'S COMPENSATION DECLARATION BACK F, fIPECT DEVICE 4.' -3-2-50
Iheme,afrm ander penally af,crj.,one aline following drdamtlons:
11_.T�t1��� antl will mainluina Certificate of Concent l,,self-insure fur Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONE). STORIES TYPE CONSTRUCTION
eetiolt'ss provided for by Seddon 37M oldie Luber Code.for the performance of the
walk far which this permit is issued FIXTURES-PER TRAP -
❑ 1 have and will madmen Workers Campenst wit Insurance,as requdced by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLE'Is 'OCC.GROUP APE
My Woflv,'iIt=so Insurance came,sad Policy pp '9 _C
Car rier:CC Ik•t•�-.o Policy No.:� xr}bl�� `� GAS-EA.SYSTEM-OVER4(EA)
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. BUILDING DIVISION HEGS
(Tak,,ection need not boldmpleted ifthe permed,parent,hundred dollars($IOU) GREASETRAP
or less.) PLANCHECK PEE
I rrmymat in the afformanceofthe work forwhichth��ett��yyttmitisissued lsh�ll SEWER-SANITARY-STORM EA,2011 Fr.
not employ any person In any manner so as m o bee nt 1 I d Workers'Copen
m - ENERGY PEP.
z cation Laws of California.Date WA'rI R HEATER WIVENT/ELECTR
0 Applicant ` GRADING FEE
y NOTICE TO APPLICANT:If. making this Certificate of Exemption,you should WATER SYSTEM/TREATING
F^ become eub'Ieet m the Werke Couram modern provisions of the Labor Code,you must SOILS FEE
finhwith comply with such previsions or this permit shall be deemed revoked, WATER SERVICE
Q
Z CONSTRUCTION LENDING AGEN NEW RESIDENTIAL PLACE. SQ.PL PAID Da Receipt#
U 0 I hereby affirm that there is a construction lcndi eocy for the perfarmmnceaf
the work for which this permit is issued(Sec.309 rv.C)
0 Lender's Name TOTAL'
V Lenders Address TOTAL:
D.I I verify that 1 have and Ih' plication anJ smut drat Ino above informainn is BUILDING
IlLaIN
raid correct l agree to comply wfth city ace county otdinancea and state laws mlating to QTY. MECHANICAL PERMIT FEE
U Z building construction. rd byamhorizercpresedmtivesofihiecitytoemeruponthe SEISMIC FE
abovo-memiened grope far inspection purlwses.
(We)agree to Bove,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC PEE
habilities,judgmenls,costs and expenses which may in any way accrue against said City ALTER ORADD TO MECO PLUMBING PLUMBING
in ,,sequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) MECHANICAL 'E
SOURCE REGULATIONS.
AIR HANDLING UNI IF(OVER I0,000 CFM) CONSTRUCTION X
Signature of ApplicanUCotnrecmr Date EXHAUST HOOD(W/DUCT) I IOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant(it future building eceupautstore or handle hazerdous materialONEWRESIDENTIALMECH.
NI'r(TO 100,000 BTU) � .
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)] NIT(OVER 100,000 BTU) ,
Yesn
ION PAN(SINGLE RESID) PAID Onto Receipt
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined h the Ba Area Air Qualit ManagementOMP(LHP OR EX),000 ETU)
Y Y Y S TOTAL
District] COMP ID),000BTU)
❑Yes T n
I have mad the hazardous
materials requirements under Chapter 6.95 of the Cali- ITIONER ISSUANCE DATE n
lomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand mat tribeDENTIAL MECH. SQ.FC
building dons notcuaenfiy nen[enant.Lha it i,my responsibility to orally the occupant ` �� �'• WWW
e requirements whd udhrdr Prior to issnowe ofa Ceninemefine Fancy.
a �t k
Owner or am ized agent D e TOT ISSUED BY:
OFFICE Ilk