S 3804 ,Y APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3804
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
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OWNER' NAAfo: I PPI)NE: CONTRACTOR:S NAME. LIC NO �` NT
NIC CONTROL a
AR CII I'I'EC'ill?NGINIiEN', LIC NO�� ADDRE55: ❑ C/
15
CONI'A : PHONE: BUILDING PERMITINFO
❑ Consultant Fides Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
510 - i -'17oy ❑ ❑
LICI;NSEDCONTRACIOR'SDECLARATION QTY ELECTRIC PERMIT FLEE
1 hereby artirmthat 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
ad'Z with Section 70(a)of Divisinn3al'the Bueinmsand Profession,Code,and my license is RESIDENTIAL,
W 00 PERM I"f ISSUANCE
FALL= in full force and effect. ❑SFDWL ❑KITCHEN REMODEL
Q,VV License Class Lic.x APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F Z W Dam Cnmradaf
N611. [I MULTI-UNIT El STRUCTURAL
ECI"S U CLARATION
p.,D m PANELS MODIFICATION
Z O r Z I rand my plans she wpnblic tecoNs
OZ=a 1 UPT02MAMP$ [I INTERIOR El CHIMNEY REPAIR
F W IJ�eased Pro 201-10(r)AMPS IMPROVEMENT 0SWIMMINCP001.N
. -BALDER DECLARATION
C x Q I herebyffinn that I am exempt from 0e Contractor's License Law fur the OVER 1009AMPS L3 BATH RF:MODEUREPAIR [I DEMOLITION
° ❑OTHER
V following mason.(Section 7031.5.business onA Profession,Code:Any city or county SIGNS ELECTRICAL
3 W y which reyulmx a permit to construct,alter,improve,demolish,or repair any swdye
OJ priory ee
its issuan ,also requires the applicant for such permit m file o signed statement SPECIAL CIRCU ITIMISC.
o. ohm he is licensed par,aanfto mr,ansmonx of the Contractor's Licanec Law(Chapter 9
Cep (comntemcing with Section 9000)of Division 3 of the Business and Professions Code)Or TEMP.M ETER OR POLE INS'f. COMMERCIAL,
S a e C that he I%exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
0. Secuoa 9031.5 by any applicant for u pennll subject,the applicant to o civil penalty of POWER DEVICES 1QIUENAN7 ❑FOOD SERVICE
V, m more than five hundred dollars(5500).
=Q ❑hmowner of the property,or my employees with wages as their sole compensation. SWIMMING POOL ELECTRIC ❑QTHERVEMENT
P. will falls,work.andde sbmmetw
ucre isnot edmmrered lorxale(Sec.7(M4,Business
13 m and Professions Code: The Commoners Limas,law dee.run apply m an owner of OU'11.17,15—SWITCHES-11t S
property who builds or improves thereon,and who does such work himself or Ihmugh
his own employees,provided that such improvements are noi SQ FT.
sale,IL however,the buddingor lntproveran1la sold withinow year of cnmpiniom the SQ.1"R FLOOR AREA S/SQ.FT.
owner-builder will base the hu sea of peeving that he did not build or improve for par .00
pt. ,of sale.).
Ias owner of the property,ant exclusively onamlin,with licensed contract eo
o crud the Project(Sm.9044,Business and Professions Codc:)'Me Contractors Li-
mom Law does not apply to an owner of prnMny who builds or improves thomon.and QTY. PLUMBING PERMIT FEE
who contracts for such pnJecls with u cormrtmmt(s)licensed pursvnm In the Rrmmdors
License Law, PERMIT ISSUANCE
❑ 1 um exempt under Sec. .B&P C for this rwmn
ALTER—DRAIN&VLM—N'A'I'I!N TEM VALUATION
Own<r 111im
WORKER'S COMPENSATION DECLARATION MACK PLOW PROTECT.DEVICE ` "^
I hereby affirm under Cendly of of ory one of the home]or d Worker's
J lJ
❑Ihave and will maintain a Cenificmeof Consent m.sede.Grc for Workefs Gmpcn- DRAINS—FLOOR,ROOF.ANIiA,COND. STORIES TYPE CONS'THUCI'roN
scion,as provided fur by Section 3"!00 of the labor Cade,for the perfomtunce of Ilm
work or which this permit is isnucd. FIXTURES—YL'R'1RAP
n 1 have and will maintain Worker's Compenwlion Insurance,as required by Section
PW ofthe labor Code,for the peAormamce of the work for which this permit is issued. GAS—EA.SYSTEM-1 INC.J OUTLETS OCC.GROUP 3j6 CJ AI'N/s
My Worker's Compensation Insurance canis and Policy number arc: /V
Carrier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' C)
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Thiawinumnmdnot bemmplutul ifthepermil sfironehundreddolar,($101) GREASE'TRAP -7
a,less.)
PLANCHECK FEE /G
I certily that i n the performance of the work for which this permit is issued,Ishall SEWER—SANITARY—STORM EA.200 FT
not employ any p_non in any manner.annsmbeeome wbjecuo the Worker,Cnmlrm- ENERGY FEL!
Q Z saloon Lawn of Califomia.Doc WATER HEATER WHEN DELECIR GRADIN
Z(2 A,hsam
y NOTICE'1'0 APPLICANT:IL ufmf nwking this Ccnificate of E-Inee a,You should WAI ER SYSTI'.M/TRE/O ING S011,s
become subject to me Worker's Compensation Provisions of the Labor Cade,you must
U.l forthwith comply with such provisions or this permit shall be deemed rooked. WATER SERVICE
0
= Z CONST RUC1ON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.E1. PA Date Necciptp
V thereby affirm that is a consimanion lending agency for the performance of
W t—t the work for wlsich Die pmmh is ts,ued(Sec.31197,Ci,.C.)
0 h' LenJeh Name TOTAL.
V L,ndre,Add.,, TOTAL:
r G I,ably that I hove rend thio application a I sum that the above infunmotinn is BUILDI G IgiE s
tH. rn corect.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICALPIERMIT FEF
U Z building moOmetion.and hereby authorim mprexnmtivc,of this city m enter upon the SEI5M1 Plili
ahuvcmaninncd pmparty far inspection purposes. PERMIT ISSUANCE
(We)agrte to eve,indenmify and keep leandc Y the City of Capcnino against ELECTRIC 'iE
Iiabilitics,judgments costs and expenses which may in anyway accrue against said City ALTERORADDTOMECIT UMBING FEE
in o...c'm m of the graming of of.perm... !\
APPLICANT UND AND WILL COMPLY WITH ALL NON-POINT AI R I IANDLING UNI T'(TOCFM) {ANICAL FEE.
SOUR EGILATIONS. 10
Sk 3AIAIR HANDLING UNIT(OV ,003 CFM) STRU=ONTAX
Signature nor Y Date EXHAUST HOOD(WMUCIVIA )SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingec,,ath store or handle hu.nousmalarial HPA'1'ING ON I'I'(TO 100J f
1H'1'U)
as defined by the Cupertino Municipal Code.Chapter 9.13.and the Health sod Safety
Cod,,Section 25532(u)P HEATING UNIT(OVER I
ElYes t VEN'IRATION PAN(SINGLE RESID) P IU Date It<cciptp
Will the applicant or future building occupant use equipment or devices which BOILER—COMP CUP OR 11x1.001)DDI)
e
mil hanrdous air cnotamm:on,a dclincd by the Bay Arca Au Quality Mmr,ca ah OPAL:
Distrix? BOILER—COMP(OVER 1(10.000 BTU)
❑yes
I base mad the hamNequ
oas materials rimments under Chapter fi95of Ne Can AIN CIINDI'1'IUNER ISSUANCE DATE
fomia Health&Safety Code.Sections 255115,25533 and 25534.1 undeatand then if the NEN'RESIDENTIAL MECH. SQ.FT. Tn
hndifing does not cru "renan6 that it ismyresrym,ihilnytn notify mcomnpam Z -7
of the uimn)en¢which mu. nt issuance of x Cern care of u cy.
\ ,gem U:nc TOTAL: ISSUED BY:��1
\ OFFICE