S 3189 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL - PE IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3189
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ZZ101 1,1110y
OW ER NAME' PI{ANC: CONTRACTOR'S NAME. LIC NO: NIC CO ROLN
c�opg
C-417 DAcoaf LS79iiS c P9
l� ARCHITECT/ENGINEER: LIC NO ADD ESS: 1:1IN& 0Lr0 ,G07SNonL SS
CONTACT: PHONE: BUILDING PERMIT INFO
2s 7 / �+ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ 0� ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT ' FEE
1 bunchy nflirm that 1 am licensed under provisions of Chapter 9(wmmencing J
CW 0'L with Section 90W)of Division 3 nithe Business and Pro@ssions Code.and mylicenssis OB DESCRIPTION
RESIDP.NTIJO
F. O in full force and effect. PERMIT ISSUANCE
GVrj License Class Lica ❑SFDWL ❑KITCHEN REMODEL.
v Zee, ).it Cantnmor APPLIANCES-RESIDENTIAL '[]ADDITION El PLUMBING RE-PIPE
¢ ARCHITECT'S DECLARATION -rr 'Ll MULTI-UNIT El STRUCTURAL
1d
Z O q rmerstand my I lans,hall he used as blit om it, PANELS 7, Pu CHIMNEY
REPAIR O Z.-0 UP T02W AMPS El INTERIOR ❑CHIMNEY REPAIR
gg�W Licensed Prol'essinnal - 201-1000AMPS IMPROVEMENT SWIMMING POOLS
.",.'.II OWNER-BUILDER DECLARATION El
06 hereby eby affirm that 1 am exempt from the Commerce,License Law Entire OVER IOW AMPS L1 BATH REh V PAIR ElD LIT N
iW O y V following reason.(Section 0031.5,Business and Professions Cnde:Any city or county SIGNS ELECTRICAL ❑OTHER
F.W w y which requires a permit m comtmet,.Iter,improve,dmnolisb,nr repair any awemen
CNOj prior to its issuance,at,.mamas lhevpplicnml for such permino filensigmd staroment SPECIAL CIRCUI'P/MISC. -
W�Y rhvt M1c is licensed p.rsuammlhe provision,of the Conlmclors Gmnae Luw(Chaprer9
00 (c4g.withh tion9W0)ofDivision3of theBusinessand Professions Gde)rr TEMP.METER Ok POLE INST. COMMERCIAL:hrefrom and the ha.ithe allegedexemption.Any v, mi'aofNEW BLDG/ADDITION ❑DEMOLITION
eany applleuOhn,pcorose"cesthevpp"fou'undenehyofPOWER DEVICES ❑TENANT ❑FOODSERVICE
n ,undre,""I $,do) IMPROVEMENT
t ry,nywithwagesar"'irsolecampa ,anSWIMMING POOL ELECTRIC if wind lh"matureisornamentedoredforsale(SacmadBasinsOTHER
Lode:I'he Contractor's License Law does not apply m an savor of OUTLETS-SWITCHES-FIXTURES
properly who builds nr improves thereon,and who does such work himself or through
his own mople,ces,provided that such Improvements am not intended or offered for NEW RESIDENTIAL ELECTR SQ PT.
sale.IY,however the building nrimpmvement is soli within one year of completionthe SQ.FT.FLOOR AREA
uvmar-hrildvr will have(]to burden of proving that he did not build or improve for pun
pom of salcJ.
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to I TOTAL:
eoulto m the project(Sec.9044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owmarof po,wrl�,,Hhcs
i-seLawdoesnotapplytoanownerofproert�,who builds or improves thereon,and QTY, PLUMBING PERMIT FEE '•
whocommasfor,uch ojecuwithacm, uRTr(O licemedpursuunlatma Cmdraanre
License Law. � PERMIT ISSUANCE 3
❑I am exam der Sec ._ ,H ffi P C for this mason
O Dale AIA ER-DRAIN S.VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penally of perhry one of the mile.ing Jeclvralions:
❑ I have and will maintain a Cenihcateol'Conxenuo sclf-insure lar Wnrker'n Compen- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES
TVPF.CONSTRUCTION
smion,as provided for by Section 37W of the Labor Code,for performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Cmmpeasation Insurance,as required by Section
3/00 oflhe Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS
APN
My Worker x Compemmion Insurance carrier and Policy number are OCC.GROUP
Carrier: Policy No GAS-EA.SY$TE14FDVrR4_
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIIND . .R WAS / EPTO BUILDING DIVISION PIiES
(This section need not be completed tithe permit is fortune hundred dollars OlHd GREASETRA
rr le".) ell PLANCHECK VE
I certify that in the performance of the work for which this permit is issued.1,all
in un
amemploy anypccson mbetude.wbeet lathe Wmaers'Com F:WF.R-SAN V- EA.2W FT Q
y manner so as j par- EN[RGYP
12 Applicnws of C.lifaroin.Dom
O WATER HEATE NENT/ELF,CTR
7 O NOTICE GRAD[
G rjl NOTICE TO APPLICANT:If,after making this Cenifcale of Exemption,you shouldWATER SYS'TE RBS TING SOILS E
abecome subject m fle Worker's Camperemme pmvi u s of the Labor Code,you must _
W forthwith comply with such provisions onhis pemulehall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDEN'1'[AL LTM. SQ.PT. PAID am Receipt If
V Q Ihereby affirm that there is a construction lending agency for the performance of
W Prho work for which this permit is e.ned(See 3097,Civ,C.)
O Lenders NameTOTAL:
r V Lenders Address )TOTALL.
I rarity shot 1 have mad this application and slog shot tire,hd c information is BUILDINeE
50 correct,l agree to comply with all city and county ordinances and stale laws minting to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
down-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City(if Cupertino against ELECTRIC FEE
Iiabililies.judgments,costs and expenses which may in any way.arae against said City ALTER OR ADD TO MUCH. PLUMBING FEE, D
in omegmm,u of the gmnt g of Nis pennil.
APPLICANT UNDE NDS AND WILL CO H ALL.NON-POINT AIR HANDLING UNITUO 10.000CFM) MECHANICAL FEE
SOURCE REGUL NS,
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
rileala o ppa'anUCrnlmelm Dale . EXHAUST HOOD(W/DUCT)
x HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE -
Willtheuppliemainfmurebuildingrecopamsminumhandlehazardousmaterial HEATING UNIT(TO 100,000 BTU) -
a,defined by the Cuperim.Municipal Cele Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? BEATING UNIT(OVER 1 W,OW BTU)
❑Yes No
_ VENTILATION PAN(SINGLE RESID) PAID
Dale Receipt#
Will the applicant infurore building by the Bl use equipment or devices which BOILER-COMP(3HP OR 1(11,0011 BTU)
emit hazardous air contaminants as defined by the day Arca Air Quality Management
Uistricl?
YSTTO
❑Yes No
BOILER-COMP(OVER I foods)foods)BTU)
❑
I have read the hmam!.us annelids requirements under Chapter,6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
n
fomite Health is Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RPSIUEN'1'IAL MECH. SQ.Pf. / '7 2s `
building does not currently have.tenant,that it is my responsibility to nolify the necupnit . V !/
of the roquirementn which muss to mm priono insunna rf a Cenifieme of Oeeupvocy. .y�� �
Owncr m inkfamized agem Date TOTAL: ISSUED BY:
OFFICE