S 3967 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/lat PLUMPING•MECHANICAL S 3967
BUILDING PROJECT IDENTIFICATION
BIJDING DQF55'. M ,r �� SANITARY NO. APPLICATION SUBMITTAL DATE
O G'S NAMLo:,^.y�(, % 1/1\ P p`E_ �" I TRACTOR'µ / - LIC NO:
`p t/O si^��,._LJ• 5,7731011NIC CONTROL M
ARCHITECT/ENGINEER: V LIC NO: AUD�31{, •� ri / � � - ❑
Ul 1F4`I (:.j �Y LI
CONTACT: PHONE I BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB
/ CIE
❑ ❑ LY ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,6'Z whit Section] )of Division 3 of the Businessawd Professions Code.an,m licensees
i-00 y PERMITISSUANCE RESIDENTIAL,
F is tell f.¢e ad Rec
Iy�F t ❑SFDWL El KITCHEN REMODEL
Q U U License Lic.p
HQd Dam Comracmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLAkKTEON [I MULTI-UNIT El STRUCTURAL
O Z end rand my plans s curd. PANELS
UP TO 200 AMPS MODIFICATION
AIR
[-4 F"ygi Li Professional [I INTERIOR ❑S IMMINGPNEY OL
CYX; OWNER-BUILDER DECLARATION 201-10(1(IAMPS IMPROVEMENT E)SWIMMING POOLS
C C Q I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER IW(IAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
X3 WU.FV- following reason.(Section]031.5,Business and Professions Cale:Any city or county SIGNS ELECTRICAL ❑OTHER
6 m which requires a permit m construct,
alter,improve,demolish or repair any structure
F�OQ pour to its issuance.also requires the applicant for such proton file a signal statement SPECIAL CIRCUH'/MISC.
E } that he is licensed promanno the provisions ofthe Contractors License Law(Chaptari)
aI�00 (commencingwith Sectionitiffoof Division 3 ofthe Businessand ProfessionsCalelor TEMP.METER OR POLE INS' COMMERCIAL:
6 a o C nor he is exempt tem efrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElDEMOLITION
I+• Section]031.5 by any applicant fora permit subjects the app emir m a civil penalty of POWER DEVICES
ul—rte C3 TENANT ❑FOODSERVICE
oat more Nan five hundred dollars y employees
mpl IMPROVEMENT
., ❑LoOw ark.We propcny,re myym imencesmuffered fwages ar
their, sea compensation, SWIMMING FOOL ELECTRIC
H will do lesions ands he Contisnotintended.raw does of a paJDW.Business []OTHER
{Q] m and Professions Code The Contractors License w Ivo s such
not apply w an owner of OUTLETS-SWITCHES-FIXTURES
progeny who builds or improves themon,and who nts a m n work himself ff through
his own employeese provided that such improvement arc not intended!or offered for NEW RPSIDEMIA!i ER SQ FT.
salen,builwevea the have
building improvement is sold within non wild or f completionJhe SQ.FL POOR AREA SISQ.FT,
ncr-builder will have the burden of proving that he did not M1ui1J or improve for pur-
poseofseleJ.
❑ h u owner of the property,am exclusively conwming with licemed commemrs to L:
conswct the project(Su.]094,Business and Professions CaJc:7'ITe CommcmLs Li�
use taw does not apply to an owner of property who builds or improves themon,and QTY. PLUMBING Pl MI FE
who comrxcts for such projects with a commences)licensed pursuanno the Contractors
License taw. PERMIT ISSUANCE '�f1
❑1 am exempt under Sec. ,B&PC for this reason 1 t 1t
[),,,aALTER-DRAIN&VIiNT-WATER IEA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FL
Owner OW PROTECT.DEVICE gg
I hereby affirm under penalty cfperjury one ofthe following declarations' D 19
❑I have and will maintain a Certificate of Consenno.self-insure for Worker's Camper- DRAINS-FLOOR,ROOF,AREA,COND. IES TY O STRULTION
svllon,wt provided for by Section 37M of the labor Code,far the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insunntec,as....meJ by Section
37W ofthe Labor Code.bar the performance of the work for which this pact is issued. GAS-IA.SRSTE.M-I INC.40UTLETS YOCC.GR APN
My Worker's Compensation Insurance carrier and Policy number ora
Carries Policy No.0 GAS-EA.SYSTEM OVER 4(EA)
CERTIPICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASHIINDUS'I'RL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thissectian at be completed if the pemmit is lar one hoothed doll..lS l W) GREASE or he',) PLANCHECK FEE
I certify tin eperformance ofthe work for which this permit is issue,,l shall SEWER-SANITARY-STORM F.A.2W)FT.
not employ an rs in any oviners..1 at boon..subject,the Workers'Contpem ENERGY FEE
O Z section Laws at mmiu.Date WA1'17R HEATER W/VENT/EI.ECTR
Z Applicant GRADING FEE
(� NOTICE O APPLICAMR If,after making this Cenilicam of Ess mptinn,you should WATER SYSTENIGn BATING
I� hecome subject m the Worker's Contpensation prow aeons of the Lubar Cale,you must SOILS HE
W forthwith comply with such promslum or this permit shall an Jaunted revoker. WATER SERVICE
Q
] fir CONSTRUCT ION LENDING AGENCY NEW RESIDENTIAL PLM. SQ.ET. PAID
U O Ihereby affirm that them is a amstmetion lending agency for the performance of Date ec tY
V. the wort for whietimis permit is issued(See 3097,Co.C.)
C U Lenders Name TOTAL:
OJ Lenders Address T
Ca 1 certify that I have read thi.sapplication and nate that the above information Is BUILDING Ffffik
Fy correct. agreemcomply with all city and county ordinance.and num Iowa relining nt QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authorive representativev of this city to enter upon the SEISMIC
above-nmwmned,mEmfty for inspec' aptrposes. PERMIT ISSUANCE?
(We)agree to save,indent -y rd keep hamsless the City of Cupertino against ELECTRIC FEEZ
liabilities,judgments,costsand pen s which may in anyway acerae againstsuid City ALTER ORAOD TO MIKE.
inconsequence ofthe inteUDS
permt. PLUMBING FEE
APPLICANT UNDERSD WILL COMPLY WITH ALL NON-MEW AIR HANDLING UNIT(TO 10,0!X1 CFM)
MECHANICA FEE
SOURCE REGULATION -^`^`
ua'sav `\ AIR HANDLING UNIT(OVER 10,"CFM) CONSTRUCTI N TAX
Signature ol'Applican 'ontracam Date EXHAUST HOOD IW/DUCT) HOUSING MTD TION FEE
HAZARDOUS MATERIALS DISCLOSURE:
Will the applicant or future Wilding occuprnt store or handle hamedous material HEATING UNIT(TO 100.(1(10 BTU7
as defined by the Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code,Section 25532(x)] HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Date Receipt p
W d the applicant or was a building occupant use equipment of devices which BOILER-COMP 13HP OR 100.000 BTU)
emit haeurdnus air cwmaminanta as refired by the Boy Arta Air Quality Management
D'stria?
❑Yes ❑No BOILER-COMP(OVER 100,001 BTU) /
AIR CONDITIONER e
Lha the hvallous materials requirements umMcr Chapter 6.95 of the Cali ISSUANCE
/p'ATE/�
Tome.H th , fa Cale,Sections MI ES,25533 and 25534.1 undersand that if Ne NEW RESIDENTIAL MECH. SQ.ET / 1 l/ Y
buildi m icurrentlyNveatenant,thetitismymspanalbilitytonmify Jmmcupant
of th ui as which must be met Prior m issuance ofd Ce ofo, y. 111VVV r
L
(twimallFfIffrommal agent Date TOTAL: ISSUED BY:
OFFICE