S 3954 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICA'FION/PERMIT PLUMBING.-MECHANICAL. S 3954
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICA'DON SUBMI FIAL DATE
�g �e �� r - d -gyp
OWNER'S NAML. \ O PHONE: CON'IRACTOR'S AMELIC NO'�
Y NIC CON TH
ROL
ARCHI'ECT/E NEER: LICNO: AD)R l ❑
CONTACT: PHONE: BUILDING PP,RMIT INFO
❑ Consul nl Fees Paid by Applicant(Initial) BLDGELECT PLUMB MECII
E?-G/ Er 1�r
LIC17NSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 b«eby mfirnt Ibm I am liecn.ed ander pmvishm,of Charter 9(enmmmmimg JOB DESCRIPTION
��Z Ih Scdion]IXI(B of Divi..i.n Infthe ltueine..uni]'mfessinns Csds.and my li,rise is RESIDENTIAL'
with
Sfortee 00(f of PERMIT ISSUANCE
aIy- annryn r ❑SFDWL ZYrITCHEN REMODEL
V V Liccn 1 1 Lic.M APPLIANCES-RESIOfiNTIAL []ADDITION ❑PLUMBING
URALRE-PIPE
�'�W Dute Convertor
7y A 1111'IiCI"S DF,ChAIi 1 PANELS ❑MULTh UNIT ❑STRUCTURAL.
~to Z I understand my p..,,hall he used as public......ds MODIFICATION
OZZNG UP TO 20(I AMPS El INTERIOR ❑CHIMNEY REPAIR
F�FDL Licensed Professional 201-1000AMPSf�I I..M�PROVEMENT SWIMMING POOLS
OWNER-NUILDER DECLARATION OVER I0fl0 AMPS &BATH REMODEIIREPAIR ❑DEMOLITION
C Q I herchy all! .hut I not exnnpl fnnn the Condaemrs Licanse Law for the
3 L O following rcn,mn.(Section]BJLS.Business vnd Pmtexsions Cldc:Any city nr county SIGNS ELECTRICAL �OTHER
I+f LL O y which rey pe 't to seminar. Its,improve,demolish.or bep y oucture
F- Q
prior to itsrequires the ppl t for suchpermitt Cite a signed.t summit SPECIALCIRCUIT/MISC.
fyy�, y-d
that he licensed pa the provisions ofth Contractors se La (Chapter 9
Irl..00
(commencing with Stelion But))al Divioun l t the . x
tl ' 11 :.
s f - sC elOor rPNIR METER OR POLE IN, ' COMMERCIAL'
lL 6 e C that h,is exempt therefrom and the basis for the alleged excatiption Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
xm Section 10i by any applicant for v permit subjects the applicant eta civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t mart than five hundred dollar,I5500L IMPROVEMENT
FZa O I as ownerof he pooh or my employees with wage,as their sole compcnsadoo. SWIMMING POOLEL[ R .
will) (hek dthe structurettintended Bred for sale(See,7044 Business [I OTHER
63SWm and Pn res nn. GdL. Th Contractor.,l:en: 1 does not apply In an owner of OUTLETS-SWITCHES-PIXY
property who build.,nr improves thereon,and who dors such work himself.,through
his men employee,,provided that such improvements art not intended or offered for NEW R651D6\TIAL ELECTR Q
,.1a.lf;hnwevec the building or improvement is sold within one year efcompletion.the SQ.FT.FLUOR AREA LSQ.FT.
owner-builder will have the burden of proving that he did not build or improve lar put-
Pa.
ur-
p u nl'sala).
❑ I.as owner of the limpcny.am exclusively convecting with licensed commctom to L'
construct the project(Sec.](YLi,Business and Professions Calc)The Commmor's Li-
mLaw dasnot apply toanowner ofpropertywhobuilds orimproves lhereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contramr(s)licensed pumaanl to the C.ntrnebre
Liccnxc Law. PERMIT ISSUANCE �p
1 um exempt under Sec. .B&P C for this mason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKIiR'S COMPENSATION DECLARATION BACK Fl.OW I'R(y1F.CI'.DEVICE, I Q
1 from,notionunder penalty of perjury one or the fallowing declarations O
❑I have and will maintain a Comprise of Consrnl to self-insure lir Worker's Compcn- DRAINS-FLOOR,ROGER AREA,COND. STORIIIS '1'Y PE CONSTRUCTION
,Minn,as provided for by Sermon 3700 of he Labor Code for the performance of the A
wad far which this permit i,isues. FlXTURP_S-PF.RTRAV
1 have vad will nminmin Worker's Compensation Immure.,as,..aired by Sectio. ( v
3700ol the Labor Crxlc,far the erl non molar'
;:,kf.rwhichlhi,,brrhi,,cid. GAS-HA.SYB'CEM-I INCA OU'1'1.1;95 OCC.GROUT' ARK
My Worker Cm ca'n ec 'er rind Polie ny ym, br GAS-EA.SYSTEM-OVERaIEA) �, 3
Carrier. Policy Nn
VER IfICA EOFEXE. PTIONFR 1 O KER ' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATE NINSURANCE BUILDING DIVISION FEES
(Ihis section nerd not M completed if the permit is for one hundred dolluml Ina OREASF'TRAP
nr Ic,c) YLANCHECK FEE
I cenmfymat in the performance office work forwhich this permit iz issued.lsball SEWER-SANITARY-STORM EA.20y)FT.
m employ any person any mann y° to 1�P<nmewbjenttLtltc Wnrkeri Compcn- ENERGY FEE
O Z ..tion Laws of Culyoytiu.Die manner
j�lT� IN WATER HEATER WNENT/F:LECfR GRADING FEE
.z O Applic;,nt �L
NOTICE 1 O AP 1C is Ccnificam of Eaemptim.you should WATER SYS'D.M?REATING
F 7com
bee subpartto the Waders Comontsmod provisions.f the Ichor Code,you must SOLI S FEE
forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
'~ CONSTRUCT ION LENDING AGENCY NIiW RESIDENHALPLMB. SQ.PT. PAID
UC' I hereby action that is a commission lending agency for the perf.rnwnce of Um Receipt#
D. - the wad for which this permit is issued(Sm,309).Cie C,I TOTAL:
C) U Lended Name
Lender's Address AL
R] BUILDIN 'EE
0. emit,that I hove read I...Im,ladood mW some that the nb.vc IM'mrnmtiot n
RO conecv l agree to«nnply with all city and county ordinances and state lawsrclming u' QTY. MECHANICAL PERMIT FEE D
SEISM. IEE
U Z building construction,and hereby suNorix repmmntatives of this city to enter upon the
aMvemcmianed property for inspection paHrms. PERMIT ISSUANCE 1-�
(We)agree to save,indenaafy and keep h 1 Is
torks,ohe City of Cupe no ugvinst ELF RIC FEE
IiuM1 lioicx,judgmcnu,c anduxpc....which tiny in any way ucrrumtgai IsidJ CITY ALTER OR ADD TO MIiCfI.
PLU BINE FEE
nscyuence dt ,ming of oils permit.
APPLICANT "ANDS AND WILL COMPLY WITH . NON-POINT AIRHAND INGUNIT(I 1 CFM) —j MEC H NICALFEE
SOURCE RE S.
1
AIR HAND NIT YCR b) ICP CONST UCfION TAX
Signamr AppliceMConmartor Uma EXHAUST (Wrt)UCT) HOUSIN MITIGATION FEE
IIAZARDOUS MATERIALS DISCLOSURE
Will the applicant.or future building occupant store or handle haardous matcdal HEATING I T(TO B ) LJ
us dethe Cupcnino Municipal Calc,Chapmr 9.12,vnd the Healoh unJ Saf«y
Code..Section
n 25532(u)'! HEATING I rWT(OVEN I(IO.OW BTU)
❑Yes ❑No VENTILAT NIS INGLE RESIDE PAID
Darr Receipt
Will the applicant or future building acapant use equipment or devices which BOILER-COMP FHP OR I00AIX)BTU)
mit hazardous air contaminants as damned by the Be,Area Air Quality Management D
District] BOILBR-COMP(OVERRX)Ed,R,-U)
Yen ❑N.
1 have mad the harallous mvterials requlrtornv under «(.95 of the Cali- AIR CONDITIONER ISSUANCE,DATE
forma Health&P4 Cade.Smiinns 25505,255]1 and 255.4.1 undo and that if mo NEW RESIDENTIAL.MUCH, SQ.Fp
had, 1, n have atcnam,that it i.mym'amobilityw no - tne«cupant
of In squire n hi u , to
'v Ccmillcde of vpancy.
a thorieeJ agent Data TOTAL: ISSUED BY: �b /
OFFICE \