S 3934 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 3934
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
o 1 do6plen." C caw": C-eP&Iw o & z y- F P
GWNERSN ME PHONE: - CONTRACTOR'S NAME: LIC NO'�y
�IuA�Yn g 3277 G d ,tl LaQ NIC CONTROLa
ARCHI'VEC'UENGI EER: LIC NO: ADDRESS: O Wti� � ❑
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CONTACT: /��PIIONE: G J BUILDING PERMIT INFO
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� �)6� ❑ Con..Hard Fees Paid by Applicant(Initial) BLD ELECT i PLUMB MOH
LICENSED CONTRACTOR'S DECLARATION QTY FLECTRIC PERMIT FEF.
I hereby ofrrm that 1 out Eeer.Sad ender provisions of chapter v(commencing JOB DESCRIPTION
�aX 'm section 7(NN)ptf Divi:inn3 30 he and prn[nsslmts elle.and my Fccnae is �7 RESIDENTIAL
LL1Q0 w Z�U PERMIT hl'5IlANCIi -J
CSF n toll Rtrce and eRea. ❑SFTJWL El KITCHEN REMODEL
QVU Liccnu Clas: w Lic.X— G APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
FXuI Orae Comseor�_
mQa ❑MULTI-UNIT ❑STRUCTURAL.
FDH ANCHITECI"S DECLARATION PANELS MODIFICATION
m Z 1 understand my plane shall l e used as public records
OZ— UPO 10 2M AMPS El INTERIOR ❑CHIMNEY REPAIR
I-+n,F'„W Licensed 11...firsxinnul 201-IWftAMPS IMPROVEMENT SWIMMING POOLS
Qa,yE�
OWNER-BUILDER DECLARATION OVER I"AMPS
C)
REMODEUREPAIR ❑DEMOLITION
{�yy K Q 1 hereby affirm that I am exempt from the Commmor's Li ase Law for the
%Z d O tollnwing manor.(Section 70315.Bnsinesa and 11 flat x Code' ray lily sr county SIGNS ELECTRICAL ❑OTHER
41 LL I- which requires a permit ns nmsul ,akar,improve,demo repair any structure
F-�-05 prisons its issuance,atm requires the applicant for such pe isofileadinard.statement SPECIAL CIRCUIT/MISC.
gpgp } that he is licensed pnrmanus the previsions of the tors License Law(Chapter9
kyC�p fcommencing with Srctisn70p0)sf Division 3 of i t andProfassimo CsdOul TEMPMEAERORPOLEINST. COMMERCIAL'
a e.o tY than he is exempt Ihctefrom and the basis.for t c till tncscmptlsn.Any violmion of ❑NEW BLDG/ADDITION ❑DEMOI.IT'ION
x�N Section 70315 by any applicant for a permit mal the applicant nn o civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
nm mora on.fivehmin red dollars(%51X)1. IMPROV
fS� ❑1,as owner of the ropeny.or my employ 's wilt wages as their sole cnmpcnsation, SWIMMING POOL ELECTRIC ❑OTHER
F. Nilldmhework,anJ estrectutersnotimmnde uroffereiformle(Ser.7044,Bosiness
W m and Professions Cal:The Contracav ,Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
A.a.. properly who builds r impmvcs thsrcnn, d who does such work himself nr through
his own employees, must that tach imp menu am non intended or offered for NEW RESIDENTIAL ELECI'R SQ FT.
sale.IL hnwcvec the uildingnr ovement is sold within one year efcompletion,the SQ.FT.FLOOR AR 5/SQ.rr.
tar-mdlderodiht ethebltnl sl proving that he dlA not M1uild nr improve far par- W
pttm areatus).
I,m caner of th pro exclusively contracting with licensed contractors to TOTAL:
antatmet the project S• IW4, ss and Professions Ctde:)The Contractor's Li.
verse Luwdessnatapply lnmt incl pmpeny who huilak or improves fuercon,sad QTY. PLUMBING PERMIT FEE
who contracts for such projects with a contrachass)licensed pursuant tit the Contractor's
Licenm Law, P17RMIT ISSUANCE
Ll [cin exempt un der Scc. ,B&PCfu LhisrraVm
AULER-DRAIN&VENT-WATER(FA) VALUALION
Owner Dane
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
l hereby affirm under penalty slperjury one of the following dvclamnon.v:
p[lharc unJ will maintain uCcnilicmc ofCnn.amtu self-insure for Workers Cnmpcn- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPE CONSTRUCTION
ration,as provided for by Section 371X1 of the Labor Clot for the performance of the
work for which this permit N oomed. FIXTURES-PER TRAP
1 hall and will maintain Workers Compensmisn Insurnmce,as regeired by Section
37M ofthe Labor Craft.for the performance ofthe work for which this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLEI;5 OCC.GROUP APN
My WorkG+ntsensa— _.y��In.� and Policy nu bcru '
Carrier. 00AIrt,6/r- T ( oliuy Nn.:�F� LD�� GAS-L'A.SYSTEM OVER B!A)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASL%INUUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
('I Ins sell on aced sol be completed if the R uit is for one hundred dollars(31 W) OREASETRAP
or Is,,,.)
FEE
I unify that in the padonwncesfthe work for which this pe unit is issued.[,hall SEWER-SANITARY-STORM EA.200 FT.
not employ any ferson in any manner so as to became subject to the Workers'Cortaro- ENERGY HE
O z vation Lows of California.Dune WATER I117ATER W/VLN UELECTR GRADING FEE
.Z Q Applicant
DI NOTICE TO APPLICANT':If,after making this Certificate of Exemption,you should WATER SYSTEMIfRFATING a SOILS FEE DI become sublcet w the Worker's Csngmnnausn lnovisinnx ol'the Lulea Code,you must
forthwith comply with such provisions or this permit shall be clamed revoked, WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMH. SQ.FT. PAID
V C) I batch,intonation l here is.const ruction lending agency fol itirpedlammmcerat Date ReeeiptN
f" the work for which this permit is issued(Ser.3197.Civ.C.) TOTAL'
C) V Lender's Name
xtidm's Address TOTAL:
Q. 1 vanity that 1 have real this application and state that the above information is BUILDING .li
F' 0 correct.l agree m comply%ith all city and county ordinances and state laws relating in QTY. MECHANICAL PERMIT FEE SEISMIC FEE
V building amstmaimn,and hereby amthsrize representatives no enter Upon the
abuse mentioned propeny lin Inspection purposes' PERMIT'ISSUANCE
(Wr)agree to save.ialemmfy and keep harmless the Ciny of Cupcnino against ELECTRIC FEE
Iiebilities.judgmems,costs and espcnss which may in anyway accrar against said City ALTER OR ADD TO MECH. PLUMBING F[iE
nseqummo rf the granting o1'Ims Parol.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10.000 CFM1 CONST'RUCfION TAX
SignattuurectAApplicant/Comracmr _�—Date FXHAUS'r HOOD(W/DUCI) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wit I the applicant or tamru he'ddi ng ocetytant store or handle hazardous material I IEATI NO UNIT(TO 1(0,000 BTI)
as defined by the Cupenion Municipal Cade.Chapter 9.12,and the Health and Sale,,
Cale.Section 25532(a)1 AAA...///��� HEATING UNIT(OVER 100.000 BTU)
[I Yes s VIiNT11.AITONI'AN(SINGI.ERESII) PAID Date Receipnp
Will the upplicam or future building occupant use equipment car Leviers which
.emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR 100.000 BIG) TOTAL:
D'nnict4 BOILER-COMP(OVER I00.000B'I'U)
❑Ycs XNo
I have rend the hamrdoos naverials mimremenw under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade.Scat s 255115,25533 and 15534.1 understand that it the NEW RESIDENT]AL MECH. SQ,FI'.
huildingdtt mactutentl haveaten , anitismYmspmsibilitytonWfytkoccup=I /
m1he rementsw ' rust be ap arm insuuncest a Cenifie ffkc l
Kill ammriAxi egcn, Data TOTAL: ISSUED BY: it, �
OFFICE