S 3957 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I"I
ITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 3957
BUILDING PROJECT'IDENTIF'IC'ATION
ILIIINGADDRF.SS: SANITARY NU. APPLICATION SUBMITTAL DATE
11) W / Y �r~IF-
VNER'S NAME: PHONE: C( RACTORS N 1 C L IX LIC NO:
�Gcsk
NIC COM' OLM
CHITECDENGINEER: LIC NO: ADDRESS: LYTtI T ❑
CON'T'ACT: PHONE: y5? BUILDING PERMIT INFO
1 3) 1 /O" ❑ Consultant Fees Paid by Applicant(Initial) DO/ELECT PLUMB MECCH
to �7 �L�J
LICENSED CONTRACTORS DECLARATION Q'rY ELECTRIC PERMIT EEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WO with Scene.7000ts'Division Sof the Business and Pmfeai...Cule.andmyhormusis RESIDENTIAL:
FacO. in lull force and eye5s PERMIT ISSUANCE
�U(" licence Clas /rC�� N li p ❑SFDWL ❑KITCHEN REMODEL
6 U APPLIANCES-RESIDENTIAL [I ADDITION C1 PLUMBING RE-PIPE
G W Dam {((gyp Contrenrr�
F<y —�rF/ ,' ARCHITECT'SDECI.ARATIONCL( $Ta 1'ANGLS ❑MULTI-UNIT El STRUCTURAL
ZC-Z trade... my plans.Hall he u.ccJ us pantie records pigs Oar MO ]:[CATION
O Z� UP TO 2M AMPS ❑INTERIOR IMNEY REPAIR
F14F'm Limned Pmfcssional ONER 20t-IMAMPS IMPROVEMENT C]SWIMMING POOLS
C ¢ 1 hereby afford the T am BxempehomDECLARATION
h Comm tens License Law for the OVER 10MAMPS El BATH REMODEVREPAIR DEMOLITION
X3 As U follmving reason.(Section 703 IS.Business and Professions Corm,Any city or county SIGNS ELECTRICAL ❑OTHER
ul t�y which requires a permit to construct,alter,improve,demolish,or repair any structure
� prior m its issuance,also requires the applicant for such permit to rile it signed statement SPECIAL CIRCU IT/M ISC.
<�' that he is license) us
� pursuant lothe pf Dr,ition 31 eBusinessandP clow(Chapter9
A. th(commencing em it therefrom
91andm Division)tehveged Business pion,Any viGde)or 'TEMP.METER ON POLE?INST COMMERCIAL:
A.a e z That he is exempt therefrom and the basis fie the alleged exemption.Any violation of C1 NEW BLDG/ADDITION [I DEMOLITION
Section 70315 by any applicant for a permit sunjeas lM applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
t more Nan five hundred dollars(S5M).
IMPROVEMENT
=Q 0Lothe Owner k, the propeny.ormyemployees withwagesfas rlale(Sc .70,A.compensation, SWIMMING POOL ELECTRIC
WF.O will Professions,Code:
Thus cmreistnot s License
Law
of apply 909n.Business OT ER
�3m and Professions Cnde:The Contractors License Law does not apply it)an owner of (IIITLETS-SWITCfIES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employee+,provided that such iinproven¢nR ore ma intended or offered for NEW RESIDEN'IIN.HLE?CIR SQ FT.
tried.If,howeveq the Wildingar impmvournao add wmmone yearnlcnmplmion,the SSQ. '.GOR AREA $/SQ.FT.
mer-huilder will have the burden of proving that he did not build or improve for pur-
poseoL.mlc).
1.as my net of the pmpsny,ten exclusively contracting with liveried c rmme ms to TOTAL:
consumer the project(Sea.]Dpi,Business and professions Code:)The Conuaaols Li-
crook Law does mmapplyit)ana%net of property who bends or improves thereon.and QTY. PLUMBING PERMIT FEE
who commas Is.,wch projects with a moruaobs)licensed pursuant to the Contractors
Liccn,c law. PERMIT ISSUANCE
0 1 nm exempt under tics. .B&PC for this rcaern
�
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER COMPENSATION DECLARATION PACK FLOW PROTECT DEVICE Z O
1 hereby alarm unlet penalty operjury one of me following Worker's
Ihavc and will for
maintain7N)ofComanfoselfrCod i,for the Worker's Compen- DRAINS-Fl,OOR,RODEAREA.COND. gTQRI. JJYPE CONSTRUCTION
sdion,as provided fpr fy Section 3"I(NI Of the Luhnz Code,for the parfnrmmnm of the
work forwhich this maintain
tiis issued, FlX'TURES-Ph,TRAP
i] 1 have and will inainuin Worker's Cpmpcnsnlinn Insurance,tu mynlrcA by Section
3]Moflhe Lapses Code,for lheperfonwnce ofthe work forwn'do thea per a lis issued. GAS-EA.SYSTEM ANCA OUTLETS OCC.GROUP � TJPN,
My Worker's Compenmtion lyynoccaorrim Pnlicynumb are: GAS-EA.SYSTEM OVERn(FA)
Carries T rw.+o I—U NIS Policy No I�'
CERTIITCATE OF ENPDON FROM WORKERS 3 y GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thisccenonneed.ol M1e completedHine permit is harem hundred dollars(SIM) GREASE TRAP
or lk,,) PIANCHECK FEE
I cenily that no the ferfanmmner oftfe work]or which this permit is issued,I shall SEWER-SANI'T'ARY-S'H)RM EA.200 PI'.
not employ any prison in any mmnncr so as to hcnnne subjmuo the Works,,Compen- ENERGY FHE
Z ration laws of IiG mi U WATER HEATER W/VENT/ELECTR
Applicant J�f� �.0 c � GRADING FEE
'Z y NOTICE.T(S APPI ICAN :If.aAl king this Ceri firm of F.xcmption.you should WATER SYSTEM/TREATING
a , become subject to the Workers Compensation previsions of the Labor Code.you sun SOUS FEF.
{TI forthwith comply with such provision,or this permit mall be deemed rooked. WATER SERVICE.
U0CONSTRUCTION LENDING AGENCY NEW RESIOF.MI'IAh1'LMN. SV.I°f PAID Daly ReceiptN
U O I hereby is hno I pe dery is s Cld(Ser,30 lending7.CsmgvmcY rte the perfmmnnce of
Le work for which this permit is issued films.3(19].Civ.C)
� Lender's Name TOTAL:
UW Landers Address TOTAL: BUILDING FEE
1 teddy that 1 have read this application and state that the above information is
Ffa/l correct.)agree rot comply with all city and county ordinances and.state laws relating to QTY. MECHANICAL PERMIT FEE O
C.) ,Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
ah—c menfoned property for inspection purposes. PERMIT ISSUANCE
(We)ugrm m rove,indemnify onJ keep harndcas the City of C"I inn against ELECTRIC FEE
Iiablliiccjudgments,costs and expenses which Huy in any way sceme against said City ALDER OR ADD'TO MRC,.
in consequence of the gmnling of this penult. PLUMBING FEC
APPLICANT UNDERSTANDS AND VIII PLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO Ig0WCFM) MECHANICAL HE
SOURCEREGULATION
AIR HANDLING UNIT(OVER I0.000 CFM) CONSTRUCTION TAX
Signature of Apphwnt/Co Tuan, f Dille EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant rr future nmlJing occupant pore or handle bwardnas material I II;A'I'ING UNIT CTO bitfu MI BTU)
as dcfinW by the Cuprninr Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'1 HEATING UNIT(OVER IMMO BTU)
Yes
Ell.,11 VENTILATION PAN(SINGLE RESID) PAID Date Receipt#
Will the applicant or future Wilding occupant use equipment or devices which
coil hazardous ten contaminants as destines)by the Buy Area Art Quality Management BUTLER-COMP GHP OR I00.000 BTU)
Di-primp HOILER-_COMP(OVER HI BTU)
❑Yen �-.
I have head he nanmdrrs mmedm.c tryuimnems coda Chapter 6,95of the Cali Alli CONDITIONER ISSUANCE DATE
lomia Hexhh&Safety Gds,Sections 3.505.;sIklisag!
n c 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
huildiagdmsnmcurendy have y Innelbility to notify the occupant
oftherequirean I IN 2 s ofa Cenifcam fHire,
O ralho TOTAL, ISSUED BY:
OFFICE