S 3998 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY ON CUPERTINO BU I LIIING-ELECTRICAL. PERMIT NO.
BUILjpLNG DIVISION APPLICATIONIPERMIT P
L
UMBICNG•MECHANICAL.
`, NumunNU PROJECT IDENTIFICATION V 3998
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
to " 2-
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OWNE N E: ['HONE: CONTRACTOR'S NAME: LIC NO:
/ L3[JO NIC CONTROL
ARCHITE /ENGINEER: LIC NO',77 ADDRESS'. ❑
TACT: PHONE: I BUILDING PERMIT INFO
/\V��'/ ya���9s��9U ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MF.CH
LICENSED CONTRACTORSDEitan—I ION Qom' ELECTRIC PERMIT FEE
1 hereby morn„that t 1 a r a d p " rcnapm 9(commencing _ JOB DESCRIPTION
DMZ
with
Section ln(In)on>' r5ion3onnL Bmsi arta Profess.nse.ae arta rayl eenseia RESIDENTIAL
I� infullfrmi,todeRect r PERMIT ISSUANCE p r�,�- ��
NNi, (o7 y� / ❑ADWL [_1 PLUMBIFN NG
l.icens<C's5 Lick µESIDENI'IAI.
�QV pPPL1ANCEg-
i Uma ConOucmr A>_Z El ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
~o Z 1 understand m ]n hall be used as Public mOxrds PANF.1,5 MODIFICATION
ZOy— )'pass
pZ�0 UPTO 200AMPS ❑INTERIOR [I CHIMNEY REPAIR
1-r3,F.; Licensed Prnfessinnal 201-III(X)AMPS IMPROVEMENT E]SWIMMING POOLS
'1�.4 OWNER-BUILDER DECLARATION OVER 101MAMPS ❑BATH REMODEUREPAIR El DEMOLITION
4' Q I hereby affirm Thal I am exempt from the Contractor's License Law for the
W 3 6 U following reason.(Section 731.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
0.y which reyvirec a permit m c msbaa,aper,nupnsva de....lkh,m repmr any slmemre
F'LL� priorm it,I...an....[,itreyui,ee thevpplUanl fnrsuch permit'.fileasignedmgemenl SPECIAL CIRCUITIMISC.
QE that he is licensed pursuant o the provisions.fthe Contractors License Law(Chapter 9
fA�CO (commencing with Seclinn 90IXq of UivisionJ of'he Business and Podusions Code)or TEMP METER OR POLE[NST. -
that Lea,exempt Iheodrom and the basis for the alleged exemption.Any violmion of N BLDG/ADDITION ❑DEMOLITION
�m Section 103 L5 by any applicant for v permit subjects the applicant to u civil penalty of POWER DEVICES ANT ❑FOODSERVICE
^zQnot more than fee hundred dollars($500). PROVEMENT
❑L as owner ofthe prodry.or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
will Bo the work,arta thn n,ruewrc la na intmWOd OndY.rcd l,ale(Scc.9(94,Baeineve OTHER
W m and Profusion,Cmla'fhe Cman clots License Law does not apply 1.vn owner of OU'fLf TS-SWI TCHES-PI%TURLS O
6 3 property who builds or improves thereon,and who does such wort himself.,through
his own employees,provided that such improvementsam not intended.r offered for NEW RESIDENTIAL ELECTS SQ Fr.
sale.If,however.the building ar i tnprovemenllasold wiffimaneyem of completing the SQ.PL FLUOR AREA $/SQ.FT.
owner-budder will have the burden of proving that he aid nm build.r improve for pur-
pose of sada).
1,as owner of me pa,sm,and exclusively c„mmcdng wish licenced contractors to
and mm the pmjecl(Sec.9044,Business and P ofe oinns C.tic)The Gmnanors
cents,Law does not apply to an ownerofproperly who builds or improves thereon,end QTY, PLUMBING PERMIT ' f FEB
who comreets Rr such projects wilh a commands)licensed pursuant m the Canlranurs
License Law. PERMIT ISSUANCE
❑ I vm exempt tmdm Sce. ,B&P C for this on,mt
Owner Data ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2— 0 0
I brachy union under penalty of perjury one of the bdIewiri,dcclmmimn:
octave and will maintain a Cenificae ofCogsan to selLlnsure for Worker's Compen- DRAINS-FLOOR,EDGE,AREA.COND' STOR��c TYPECONSTRUCTION
as provided for by Senium PUD of the Labor Code,for the perf.nnance.f the / ��
srk for which this permit is actioissued. f FlXTURF.S-PER TRAP /l/
0 1 have anti will m.inmin W.rke,COmpensuBna Imurunce,as squired by Seton
3700.fthe Lgx,r Cmla for the performance of the work frnwhich mispermil is issued. GAS-HA.SYS']EM-I INC.4 OUTLIUS
My Workers Comy�nsgio}Insurancecarierend Policy num OCGG UP APN
Caner, f-fJ/1U Policy No.:�. " 1C�/ya-9P GAS-EA.SYSTEM-OVER 4 LEA) 6 1_2 Z/
CERTIFICATE OI'EXEMPTION FROM WORKERS' - 0
COMPENSATION INSURANCE GRP.ASFANDUS'I'RL WASTE INTERCEPTOR k eINODVS ,.¢
(Tbissecdon need nosMcompleledifthe panni'isfur one hundred antlers($IIIU) ION
nr IessJ GREASLTRAP CH[CK FEE
Icemdy that in the performance oldie work for whish thiepennit is iesned,l.ball gEWI?Il-SANI'IARV-S'IOIIM DA.200 PP.
nal empl.y any person in any mbecome anner m as to subject to the Workers'Compen- ROM" 1.79J99
Z cation Laws of California.Date WATER HEATER WIVENDELECTR
0 Applicant 4RADING FEE
y NOTICE I'D APPLICAN"1':If,after making this Cenifcum of Exemption,you should WAH?IR SYSTEMU REAL INC,
b,r.me subject o me Workers Compensation provisions of the Labor Code.you most SFEL'
forthwith comply wi,h,.ek Provisions.,,his permit shall Is,deemed revoked. WATER SERVICE
Q
U0 CONSTR u.c..NLENDINGAG[?NCY NEWµIiSIDEN3'IAL PLMIi, SQ.FIt PAID
V � k far Which
lhm.it
i,,.cd(Sce.3D len sing agency fnnhe performance of I 'e Receipt If
[ts F the work for which this permit is ixwea(Sec.JB91,Co.CJ
O ULender's Wane TOTAL:
Landc2
I cittmitya T AI
F 6. rtify that 1 have read this application and sere that me above inf.rmminn is - _ „ ., a ❑IJILDI G 1V I
h e..,.iagree'U comply wim.11city arta rummy uniform,endmne laws relating m QTY. MECHANICAL PERMIT 'FEE
V Z building construction,and hereby umIm,cm,mwdmivc,.fthis citym enlermlmn the SEIS C E C'�Q
above-mentioned properly for ,paction purposes' pERMI'I'ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECT i'1 f Q
liabilities,judgments.costs and expenses which may many wuyacctueagainsl said City ALTER OR ADD*10 MECII. PLUMBING E !�O
.nscyucnce of the gmmingi spermit.
AP 0T NDERSTAN g/ND WIhL COMPLY WITH ALL.NON-POINT qIR IIANDhINQ 11Nl'P(in If1,000 CIM)
SO IRC 'UL T ONS. eCHA FEE
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCIO AS
Sign rent pplicunJCmnrnc or Date EXHAUSTHOOD(W/DUC'TI 1 IOUSINGMITIGATIONFEE
HAZARDOUS A JALS DISCLOS
Will the applies nr fulmrc il ' gmcupam score Ur handle heeaNUus magriai HEAPING UNIT(TO 100,009 BTU)
ns defined by the Cupertino Muni Cotte.Chapter 9.12,and the Health and Safety
Code,Senior,25532WO HEAPING UNIT(OVER 100,000 BTU)
E3 yes ❑Nn VENTI LATION PAN(SINGLE RESID) PAID -
Date Receipt X
Will thetious appliam orf,. building,acupvBayAea Air
ManagemeWhichnt
BOILER-COME(3HP OR 100,000 BTU)
mit hazuNnnx air enmmninams ire defined by the Bay Area Air Quality Menugemmnt 'IOTA
v m?
❑Ya 0 N BOILER-COMP(OVER 100,000 BTU)
I have,etas the hueuous nvneritds regnircments under CM1apter AIR CONDITIONER fi.95 of the Cult � ISSUANCE DATE
ItHealth&Safety Code,Secli.na 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.BT.
buiidingd.sn 'currently has .t ,am,Bad if is my rev,risibility to notify the occupant" Z�/ V
.[ em - tents {fi mat b at pmef a,ieauanee.f n Cenifie eofGOOO/.,ppPq.L�J�u�y.
Owner unlhodud a,c.f DNC TOTAL: ISSUED BY:
OFFICE
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