S 3943APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATION/I'F,RMIT PLUMBING - MECHANICAL
11111LDIN(i PROJPLT,IDF.N IFICATION "
PERMITNO.
S 3943
BUILDINGADDItES'S
as nw�i o a ��e C ev or
SANITARY NO.
APPLICATION SUBMITTALDATE
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(lW BR'S NApyI1a�' a I' ONL: p O
1 •lit aV p'�
CON9'R 'S NAMFi: LIC NO:
N/Q
❑
/'� CON'1'ItOL it
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Q 41 ' HITF.CDENGINEEB:"`Is O- LIC NO:
dIl//))WW
ADDRESS
CONTA `. H E .-7
❑ Consultant Fees Paid by Applicant (Initial)
) r ;t!;t „ }iBUILDING(/PERMITINFO,,,
BLDG ELECT ESLEE�CTT PLUMB MECH
tl LGl ❑ ❑
I. CENSF.D CONTRACTOR'S DECLARATION
I nereny arum mram liecaaed Ceder% rest.brta+orenante9(cotmneaaiag
z wim force 9deffecDivisioo9onhe BUSinesx one Profeseloos elide, eta my licenreis
in a Class and effete.
License Claps LieM
4I Dom Contractor
QTY.,"_
ELL'CTRIC PERMI'1'r is i
r fit, ,urlr arf,. 0, �.t,,).
r no'r' '-
tI FEED
+.Jlafa hilt
JOB DESCRIPTION
RESIDENTIAL
❑SFDWL ❑KITCHEN REMODEL
El ADDITION C1 PLUMPING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
. MODIFICATION
❑ INTERIOR C1 CHIMNEY RI3PAIR
IMPROVEMENT
❑DEMOL SWIMMING POOLS
❑BATH REMODFiIJREPAIR El DEMOLITION
❑ OTHIiR
PGRMI'1' ISSUANCE.
APPLIANCES - RHSIDEN'I'IAL
l ARCHITECTS DECLARATION
land my plvns shall be used as puM1lic reronl.v
y Licensee Profession °I
� OWNIi. BUILDER DECLARATION n to, oulnuc
6 hereby n(Sect tat I am excntpt from the Cessions Co e: Any Law for the
following reason. (Section ]a3L5, Business and improve, demob h, or Any city (it county
n
prior rM1 requires n peals re asmwn, alter. Improve, demolish, or repair any smmer,
nirc iauance,also rato Chet rosmic.,ol for Comeorm, traoc Law statement
�tcimma, licensulpuryuom to the of Diviaas of the Cnnlnmmr'snd P,.f Low (Chapter 0
(commencing with Satiun]IX10)of Division 3nftne BUSinenv and Profev+iore Code)
Z that he is exempt therefrom and the basis for the alleged exemption. Any violation of
n Section 91131.5 by any applicant for a permit subjects the upPlicanno o Civil pennlry of
s, not mom than five hundred dollars ($500).
a� E] Las owner ofthe property, or my employees wit wages as their sole compensation
wiH do nhc work, and thestnemre is not intended nmffered for all (See ](W4. Business
and Professions Code: The Con ramor's License law does not apply m na owner of
property, who builds e, improves thereon, and who does such work himself., through
his own employees, provided that such improvements arc not intended or offered for
sale. ll; however, the building a improvement %,odd within one year or consplctioo ,the
e,limilder h t burden ofprovingthathedidnotbuildorimproveforpm-
l 1. t
se o' caner t p:ny, am cWtoi,ely unu ant, with licensed mmnarmello
trey t the project (s 70vU Business and Profics,mas Cola) TM1e Contr..... 1'
ve Law does not apply t owner f propeny who loulds an improves thereon and
who nacns '01 Such projects with v contract (s) licensed porsa.ot mthe Contracnnx
Licemc Lax''
❑Iame mptunder ,B& P C for this rcasnn
PANELS
UP TO 200 AMPS
201- I00IAMPS
OVER IWO AMPS
SIGNS GI,F,CTRICAL
SPECIAL CIRCIII "I' /MISC.
�l� AML
::7)5'
TEMP. A1FfF.R OR POLE INST.
O
COMMERC AL:
❑ NEW BLDG /ADDITION ❑ DEMOLITION
❑TENANT ❑FOOD SIiRVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
-
SWIMMING POOL ELECTRIC
OUTLET'S -SW ITCHES - FIXTURES
I NEW RESIDENTIAL ELECfR SQ FE
SQ. FP. FLOOR AREA
ESQ. FE
OF L:
...
QTY. PLUMBING PERMIT jsl t 11'
', FEE,
PERMIT ISSUANCE,
ALTER - DRAIN &VENT - WATER :A)
)wnet' m
1 VALUATION
1 Q• d�
I /0, C)00.
1 WORKER'S COMI'I!NSATION DECLARATION
1 I hereby rdtm under penalty of p jury me of the following declvmtions
❑ Ihavcand willumimninu Cenificum al Consent to.celf -insom for Worker's Cori
onion as provided for by Section 3]1X1 of me labor Cock, for the performance of the
work for which this permit is issued
I have and will maintain worker's Compensation Insurance, as required by Section
37W of the Labor Code, for the pard armtmce of the work frn which this penni n is issued,
My Workers Compensation Insurance comma and Policy number vat:
Cartier: Policy No.:
CERTIFICA'T'E OF IIXEMFTION FROM WORK( ?RS'
COMPENSATION INSURANCE
flTissection needoot lNeompleed if thepermitisfnronehundreddollars (EIW)
or lexvJ
Icenify that in the perfotmnneenfthe work for which this permit is issued, Iehell
not employ any person in any manner so as to become subject to the Workers, Cooped-
smion laws of California. [)am
J Affliction
BACK FLOW PROTECT'. DEVICE
DRAINS - FLOOR, ROOF,A D.
E9'ORIES
.TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS -HA. SYSIHM - I INC.4 OU'f1,11
OCC. GROUP
AI'N
GAS - EA. SYSTEM OVER 4 (EA)
GREASE /INDUS'I'RL WASTE INTERCEPTOR
'BUILDING DIVISION FEES
GREASE TRAP
PLANCH KME 2
1 11
A�--�
Q J
SEWER- SANI'I'A RY - STORM EA. 2W FT.
EN' G P:
WAI ER HEATER WNENT /FLECTR
INC lE
j NOTICE TO APPLICAN'E If, after making this Certificate of Exemption, you should
' become subject ar the Worker's Compensation provisions of the Labor Code, you must
fonhw l t comply with such prcvi6v,i or this permit shin l he deemed revoked.
I
• CONS 'IRUCI'(ON LENDING AGENCY
I herebyaffirm that them is a construction lending agency for the performance of
r the work for which this Permit is issued(Sec.30aO, CIV, C.)
idander's Nome
Land .AdJ .
I certify hit I have read d'. npll' t d ,am thuh h 1 1
i correct I agree u c ply with II city d county ordinances and state la relating t
building and hembv authaimrepresentatives of this city m enter upon the
above - mentioned Property ror insprvninn Ptopor,
gate yes which harmless the City f Contrition a ding
(We) a no save, indemnify p y o a g
inemntiecvoccot hecomsiagof [ens es which may in any way eceme against said City
sequence of the gmnning of thin permit.
APP LIC NT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU (': REGO ON
WATER SYSTEWMEA'1'ING
WATER SERVICE?
S TLS I..R
D
NEW RESIDENTIAL PL&IB. SQ. FT.
Dane ReceiptM
TO AL:
t
TOTAL
BUILDING FEE
'r' •'iT" - t I” •
'QTY.r MECHANICAI•PERMIT I r 1 rt
t ' f i vIt n I
-- '.
.r,t - .i;
s �HTF/
i...
SEISMIC LEE
PERMIT' ISSUANCE
ELECTRIC PEE
ALTER OR ADD TO MECH.
PLUMBING FEE
AIR HANDLING UNIT ETU 10,0(10 CFM)
MECHANICAL PER
AIR HANDLING UNIT(OV-
EXHAUST HOOD UV /DUE)
TAX
jv,Rnfir, or Applicam/Contmnor Dane
HAZARDOUS MATERIALS DISCLOSURE:
Will teapplicad or future hnlldingoceupont some orhandle hmeolom ovarnol
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health end Safety
Cult Section 25532(.)'!
❑Yes Li-w-"
N'bl to applicant or furore it building IF the use equipment Cr devices which
emit hazardous sir comaminams as JCfinW by to Ba'Ama Air
Uisuimp B`J�.T //- y Quality hfunagemem
❑Yes
1 have sod the hanadeus nt.cermis ms uiremenls tinder Chi LLr fi95 of the Coli-
Tornio IId &Safety Gat Sections 25505, 25533 and 25534.1 tmdemond ohm it
understand
has Id does not eartennl hweatenenb to it is my mspmsibilirym notify the eecupam
of of yui(e ust ran unarm Lxt ace nb fn Cedifewe of txaaponar.
�,Q -Ory`_
ppCONSTRUCTION
¢IO SING MITIGATION FEE
I IEANNGUNITO-0IWJX T )
HEATING UNIT (OVER E ITT
P D
--
VENTILATION (TAN (SIN(
3SID)
Uam Reeeim#
BOILER -COME (JHPO I
NT
)
T
BOILI21t -CG&1P (OVER
AIR CONDITIONER
ISSUANCP. DATE
ISSUED BY: TQ
NEW IIESIIIP,N'DAL MECH. SO. Er
Owner or amagent Dam
TOTAL'
OFFICE