S 3979 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMETNO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL S 3979
BUILDING PROJECT IDENTIFICATION
BUILD!N0 ADDRESS: SANITARY NO. APPLICATION SUBMITTAL.DATE
► BSD Pf1 PI a e do f7-
OWNER'S NAME: PHONE:
AHCHIT (/-e CUn( G$ NAME:
L�IlIC�nN[O:�2tQ
N/C CONTROL q
ECTdINGI EI iACNO: ADDRSS:G
so'N �
CONTACT: ��//� PHONE: BUILDING PERMIT INFO
�eia5®a'(/'15 �I47-qs-q! F_] Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
/ 7 ❑ ❑ ❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am hc...cd under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO rh Smtim% 00m,fDivision Sof he Businessa dPmfessionx Cade.e dmyliccnse is RESIDENTIAL
F-W� ntfull force and clkG^/ �l PERMIT ISSUANCE ❑SFDWL El KITCHEN REMODEL
�U{{]] laccase Cbus /5 tic.p
�Wl Unto6'0J�"/��Cammcnrt APPLIANCES-NPSIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARCHITRCPS DECLARA—Iff5if ❑MULTIUNIT ❑STRUCTURAL
PANELS
Z O m Z I understand my plans shall he used as public records MODIFICATION
OZ-`rJp UP'I'O 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
<�XF Licensed!Pmfessionel 201-HgOAMPS IMPROVEMENT 0SWIMMING POOfS
y.�W,O OWNER-BUILDERxemptDECLARATION OVER]"AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
0.'LV Q I hereby affirm that 1 exempt from the DECLARATION
License Law for the
PpC� 6 U fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 W y which requires a permit to conswn,allee improve,demolish,or¢pair any slmewre
F�•O; primm its issuance.also requires theapplicam kamch pmnd to file esigned daemon, SPECIAL CIRCUITMISC.
CNQ� that he is licensed function the provisionsofthe Camranor',License Law(Chapter 9 FA a 1
W CO (vummerring with Section 7000)of Divieion 3 or the Business and Professions Code)or TEM('.METER OR POLE INST COMMERCIAL:
Llqx e q ohm he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
WAN Section]W LS by any applicator for a permit suhjuts the applicant oecivil penalty of POWER DEV ICES TENANT ❑FOOD SERVICE
==Y not are than Evc hundred dollars MOW.
QE:1I,asownerof the property.or my employees with wages os their side compensation, SWIMMING POOL ELEA1 IMPROVEMENT
YF will do the work.and the strucwre is not intended muffemd foraele(Sec.J04T Business ❑OTHER
W^m and Professions Code:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES ftES
63 property who builds or improves thereon,and who does such work himself or throng..
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELFCFR SQ FT.
sale.If,however the building or improvement is sold within one year mcompletion,tbe SQ.FT.FLOOR AREA 5/SQ.FT.
costor-lamilder will have the burden of proving that he did not build or improve for pur,
pose of sale.).
❑ I,as owner of the prope ty,ale exclusively contracting with licensed contractors to TOTAL:
construct Ne prujcct(Sec.71144,Business and Professions Code:)The Contractor's Li-
nt Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE
who comms t,for such pmNc¢with o cimitations)licensed pursuanun the Contractor's
License Law. PERMIT ISSUANCE
0 I am exempt under Sec. ,B&PC for this reason
Owner Dam ALTER-DRAIN.F VENT-WATER(EA) VALUATION
WORKER COMPENSATION DECLARATION BACK[LOW PROTECT.DEVICE
I hereby offirm under penalty of perjury one of the following declarations: p
❑(hove and will for
neCion 3700 of the Consent Code,for
Worker's Compcn- DRNNS-FLOOR,ROOF,AREA,COAD. ST IES TYPE CO UCTION
cation,as hick this
for by Seaton 371X1 or the Labor Code,for the perlinmava of the
work for which this maintain
is ismed. FlXTURES-PF.R TRAP e-1
i]1 have mJ will maintain Workers mance d le w Imuran hi az required by Section
3JW of the ahnr ;e.a peraamance,athe work�far,poll �w�'hpic�h rlhr,. t' ss Aea�d� GAS-EA.SYSTF.M-I INCA OUTLETS OCQnGROUP Py,f /_
I Caurrit" 's t lana cum policy No,Y�+���� GAS-FA.SYSTEM-OVER // rt � -"! 7�
E OF EXEMPI'10y�tOErPs'y(I 7S�(/ I` V
COMPIiNSA'1'ION IM1CIl1lAAACCYYfFOO (( 77 GREASIVINDUS TRI.WASTIi INTERCEPTOR B ILUING DIVISION FEES
(Tons seclam need a,),la,cample ,'the aanLLts Lar dreddollun 15100)
or less) c /y GREASE.TRAP PLANCHECK FEE
(certify that hath performance of the work for wbicA this anilizissued,lshall SEWF.H-SANI'fARY-
nmemployanypermnintroymannersoazmbecnme uhcm m the WnRer9Cmn STORMEA.2fXIFR
,Z sauna Laws.1 California.Date salami pen- ENERGY FEE
ZO Applicant WATER HEATER W/VEN ffELECTR GRADING FEE
y NOTICE TO APPLICANT:If,ifum nmking this Cenificam M Exemption,you should WATER SYSTEM/TREATING
ahmomc mbject ,,the Worker's Compenatim provisions of the Labor Code,you nmst SOI TEF;
I9 forthwith comply with such provisions or this Permit shall he deemed rmoked. WATER SERVICE
a0
CONSTRUCTION LENDING AGENCY NEW RIiSIDENTIAI.PCMB. SQ.FT. PAI
VQ1 for whihthithat Permit i isaumswc.30 len ding agency fortheperformancenl Date Receipt#
Fthe work for which this permit is issued(Sec.JIN],Civ.C.1
0 Lenders Name TOTAL:
L) Lender's Address TOTAL:
24 1 certify that 1 have at this a,plication and state that the above information is L G FEE
lA carom.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE O
V 2 building construction,and hereby authorize representatives ofthis citymemerupon the SEIS CFEE
ahmse mentioned property for inspimoon purposes PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELE IC FEE
liabilities,judgment.costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PI. GING FEE
in asequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,"CFM)
SOUR 'REGULATE S. n a ME A ICAC FEE
�re//w� / AIR HANDLING UNIT(OVER 10.,00 CFM) CONSTRU ONTAX
.ignalure of Appicanl/Cconactor Dale EXHAUST HOOD(W/DUCT) HOUSING MIT MON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicam or future building mcc.panl wor ar handle haamdous comma) HEATING UNIT(TO 100.000 BTU)
as def red by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Gale,Section 25532(a)7 HEATING UNIT(OVER 100,000 BTU)
Fl Yes ❑Na VENTILATION PAN(SINGLE RFSIDI PAID -
Dam Receipt#
Will the a,comm or Tamm building byla,occupant ore co Air em m devices which BOILER-COMP QHP OR 100SUO BTU)
emit hazardous air mntmninunt as defined by the Boy Area Air Quality Managnnent T A
nialdna
❑Yes
ON. BOILER-COMP(OVER I011,000 BTU)
I have read the hazardous materials re i irmorts under,Chapter fi 95 of the Calm AIR CONDI LONER
4 P ISSUANCE D TE
fomia ,does&Safety Cade.Sections]5505.is myand255]4.1uMctify the
Ihmifthe NEW RLSIDF.NTIAI.MECH. SQ.FT.
'ng does not cnrrendy fusee tenanPthat.ony reepon Ce,lly to c,as of the occupant �r
o(Ihe immc h' mvt prior to lxsnnna nfo Ccrtifiwa r�Ocaupnncy.
croriumhuracdagent a Date ITOTAL: ISSUED BY.
OFFICE