S 3920 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUII,DING DIVISION APPLICATION/1'ERMIT PLUMBING-MECHANICAL S 3920
BUILDING PROJECT IDF,NHFICATION
BUILDINGADDRES9 SANITARY NO. APPLICATION SUBMI(TAI,DAR
.E SNAME: PHONE: CONTRACTOR'S NAME: LIC NO:
ADO i NIC CONI'ROL
x
Cl MCI'IENGINEERLIC NO ? S-
1 G30
CONTACT: PHONE: BUILDING 'ERMIT INFO
❑ Consultant Flats Paid by Applicant(Initial) BLDG ELECT PLUMB MECH�
uU
Liss-, � ❑ l ,�
LICENSE a CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
L hereby albino ma I am live...d ender p,a.idon.of chaser 9 Rommetwor, JOB DESCRIPTION
'0Z lith Sa,Tam 700)"1 Dlvi....3ophe Bu,mr,,and Profmdnns Cudu,aml my license'11 PIIR M I I SSUANCE Sa RESIDENTIAL.
H in full force and alt ❑SFDWL ❑KITCHEN REMODEL
Q�U ee C .s L"'� �,^ APVLIANCF_S-RESIDENTIAL ❑ADDRION ❑PLUMBING RE-PIPE
It y Dmf,.�`^'•ufr 2ce., Cnmmcmr •ni./�-[`1..S
ARCIIITfCI"S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL.
PANELS TION
ZpyZ I undersand my it shall R used as one is rwons UPT02MAMPS /� ��ii
c'z—L. ❑I E OR /(\\ ❑3IMNE FAIR
r l�Fw Licensed Professional 201-1000AMPS 1 VEM' ❑ (MMI IS
OWNIiR-RUIhDER DECLARATION OVER "AMPS ❑ EMODEIIRIiPA1R ❑DEMOLI
L C W d I hereby effort that I an,exempt from the Convector's Liceaw
Low for the ❑ T
IF
x a U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ner,
Y:3 LL h¢ which requires a permit ,consumer,^limprove,demolish.or r,pmr any strstructureetu
Fp•��.] j614 o ins i, al
prior to its issuance,alsn re(iuim%the applicant for such permit no file a signet.aatement SPIiCIAL CIRCUIT/M
2, y Ilan he is feen.xH pnrsnanuo thepmvlrlmi.onhe Comm,ohn,hlcemu Law(Chapter9
WtE�0 (commencing with Section 7100)"Mivision 3 of the Business and Profession.Code)or TEMPML'TERORPOLEIN
G a c IY that he is exempt ban(,..uad the basis for the alleged exemption.Any violation of ION ❑DEMOLITIO
..N Section 7031.5 by any applicant for a pormit subjects the applicant to a civil penaltyof POKER DEVICES 1�'QENANT E
=� nut marc Than five hundred colors($500). SWIMMING POOLELIiCIHIC PROVHMENT
❑1,as owner(if napery,the opcny,or my employees with wages as their sole compensation,
F will Jo Ne work.and theswmurt is not imm�dW onafcrcd fm sale lSec.]OW.Business
El OTHER
�3m and Professions Cale:the Comment's License Law does nor apply a an owner o OUTLETS-SWITCHES-FIXTURES
pr,u ny who builds or iinpruva,thereon,and who docs such wank hieraltor through
his own employees,provided that such Impmsetnme,arc nor'Intended or o0'ered far NEW RESIDEN I'I Al.ELEC IS SOFT
solei(,however the building or improvement is sold within one year ofcnmpletinn,the SQ.P1'.FLOOR AREA AISQFI'.
.
owner-M1uilder will have the human of proving that he did not build or impress,for pro,
,,,a of sale.).
❑ 1,is owner of the propcny,am exclusively contracting will,(beamed commcmr,
constoact the project(See.0611.Business and Pro e.sions CWaq The Connector's Lo
cense law does not apply to on owner of property who bonds or improve.Merton,and QTY. PLUMBING PERMIT FEE
who contracts I'or such projects with u commeloos)licensed pursuant bathe Contractor's
License Law. PERMIT ISSUANCE
❑I in excmpl under Sm. .H&P C for this reason
AI TER-DRAIN&VENT-WATER(EA) VALUATION
Doc �J
WOR KIiR'S COM I'IiNSATIUN UIiCLARN'ION RACK FLOW I'HOTECT.DEVICE f / Doc)
saner I hereby affirm under penalty of perjury one of the following declarations:
❑(have and willmaimain eCenificacof Consent molt-inmmfor Worker's Compere DRAINS-FLOOR,ROOF,AREA.COND. STORIES 'TYPE CONSTRUCTION
satinn,as provided for by Section 3700 of the labor Cade,far the performance of the
work far which his permit w i....J, FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensminr Insurance,as required by Section GAS-EA.SYSTEh1-1 INCA OUTLEI;S
3Y00)of the Labor Cale.far the serfs,,came work for which this Permit,..issued. OCC GROUP /
My,'ar��jj`` ComPe �t Insymarc varric Poli Policy num ��js
Cnrricr!��0 / ]AAI I4( Policy No_LaAm ; 80`�S7 gO� GAS-EA.SYSTEM-0OVER
CER'I'IIICATE OF EXEMPRON('ROM WORKERS' GREASFIINDUS'I RL WASI INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Ibis section need not be completed if Blmic
epe ,itisfurmM1undreddollor.(M00) GREASETRAI'
or Icss.) PLANCHECK IEE
fraud,thusintha N,fulmolool'Ihewerkfol'which thispcnnitivi.mcd,isholl SIt.WER-SANITARY-S'rORM EA.200 FT.
not employ any seam in any manner u,as become subjecno the Workcri Compen, ENERCIJ PEE O
Z smion Laws of Czlifoatia.Dote WATER HEATER WNEIGH'ELECIR
Q
Applicant GRAD( 'F:F:
Z NOTICF,TQ APPLICANT:If,apollution, his Cari feam of Exemption,yet should WATER SYSTIiM,TREATING
jRU[LG
P ' become subject to the Worker's Con,pensuom provisions of the Labor Ede,you must
lS1 flmbwim comply with such pmviiansunhis .,,,hail be deemed revoked. WATER SERVICE
Z) z CONSTRUC'T'ION LENDINGAGENCY NEW RESIUIiNI'IALPLMft. SQ.14. PIM
e Receipt
U p Ihvnhy affnrnhet there iso conswdtun lading agency for the perlonnenee all
LL P: the work far which(his pcnnit is issued(Sec.3197.Civ.C.) 2
C U Lonl Nam, O
Landers Addrea. TOTAL: ''')
r D. 1 eenhfy that I hast(cad this nppllcndun and.tme thin the above infsnnmJort i. 4
Frn correct.l agree to comply withal]city and county unbalances and.utc laws relating or QTY. MECHANICAL PERMIT FEE SmS"Ee)
U Z building construction.and family aathanze reptesentativesofthis cirymemer upon the �/•�
ahovc mentioned propcny for inspccJon pub ),es. PERMIT ISSUANCE / V ELECO
(We)agree to cava.Indcmnity and kccp bloodless Iba City of Cupcnino against
Iiabihnics,judgmenrs,costs and expenses which Amy in any way rccmc oguirsa-id City ALTER OR ADD TO MUCH. -7 PLU
in msequence of the germing of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' AIR HANDLING UNITDO 10,(010 CFM) MECe)SOURCP.REGULATIONS.�� AIR IIANDhING UNI"f(OVERIQIIOf1CFM) CONSignature rd npplicanl/Comracmr DatEXHAUSTHOOD(W/DUCT, HOUN FEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplIcanlor future building mcupum sea or handle hmaalou.rural lot I(EATING UNTI'(TO 1001,1110 BTU)
as defined by the Cupcnino Municipal Code,Chapter 9.12,and the Health and Safety HEATING UNIT(OVER 1110.0010 BTU)
Coda Suction 25532(x)7
❑Yes ❑No VENTILATION PAN(SINGLE RESID) PAID Date Receipt no
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(31{P OR 100.000 BTU)
nit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL
DistneC BOILER-COMP(OVER 100.000 BTU)
❑Yes No
I have re ad me haramous mmenals rtquinumms under Christie 695 of the Cali- AIH CONOI'I'IONER / ISSUANCE DATE
fomia Health&Surety Code.Sections 25505.L5533 and 2553,.1 understand thm If the NEW RESIDENTIAL MECH. SQ.IT y
ha0dingdoeemoomaidy haven broom,that hlemyn......milay to rally me reenlist", NN\000 T
of the re"'o ct It must be ater oil la l... ee of a Cenilictnc of OccuPancl.
awM1omeJ agent Dae AL' ISSUED BY:
OFFICE