S 3910 APPLICANT TO 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 3 910
BUILDING PROJECT'IDENTIFICATION
BUILDING ADDRESS. nn 6- 7—(77
SANITARY NO. APPLICATION SURMITTALLDATE
2b -f.0 -�,o 0 - & S C k �`o k
O IRS NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
s , tiny-��` WC 'CON///ROLX
\RCIIIIECDENGI�' IR LIC NO: ADDRESS: ❑ Q y Z3
I�wdr'`.t� / /
CON'I'nCf: PIIDNF., k/ BUILDING PERMITINFO
1r�0.Y•f,^\' ^f— Z� Z�Z6"' ❑ Consultant Fees Paid by Applicant(Initial) BLS ELECT PLUMB MUCH
-LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE C IJ
I hereby anion that 1 am licensed under provisions of chapter 9 mommenemg JOB DESCRIPTION
wM Sermon 7BlX)cf Dlahiet3of)he Btsinexs.nd profession,Cale,and my Iver,,is RESIDENTIAL
W O p 1'ERMI'1'ISSUANCE
FU^ Licenfull e class
CRccI. ❑SFDWI. [I KITCHEN REMODEL
U F License Class Lim.p
6 U APPLIANCES—ftES1UENTIAL ❑ADDITION El PLUMBING RE-PIPE
y�LLl Dnte Can DECL
11 ARCHITECTDECL
'S ARATION ❑MULI'hUNIT ❑STRUCTURAL
Z pm Z, I understand my plans shall M used as public records PANELS fi MODIFICATION
OZ4G UP TO 200 AMPS '�I� ❑INTERIOR 0C IMNEY REPA IR
W Licensed Pod!'es..coal 201-1000AMPS NMI e IMPROVEMENT SWIMMING POOLS
J OWNER RUILDIiR DECLARATION OVER 1000 AMPS ' U ❑BATH RF.MODELREPAIR O DEMOLITION
C W GI hereby AT.mail Contractor's
t Ian:exempt from the License Law for me
W UF. 1.11coving mason.(Section 9031.5,Business old Profession.Code.Any city or .aalY S GNS ELLCI'NICAL ❑OTHER
3 o.N which requires a Permit tar conx0ua.aver,Improve.demolish,or repair any nmcuse Ali
DF�OQ prior In its issuance.also requires the applicant for such permit in flea signed statement SP AL CIRCUEUMISC.
�y that he is licensedp lawal 1.theprovixi.... of the Comraemr's Licenxc haw(Chapter9
(YQ� (commencing with Section 7000)of Division 3 otthe Business and Professions Code)or TER POLE INS'p COMMERCIAL:
c.E C that he is exempt therefrom and the basis for me alleged exemption.Any violation of Q LDC/ADDITION ❑DEMOLIT10N
vi Section 7031.5 by any applicant for u ninth subjects the applicant to a civil ploolly of POWE .VI is EMENANT
[IIbOD SERVICE
FZQnot more than Eve hundred delta.($500). IMPROVEMENT
❑ 1.as owner of the pre,two,or my employees with wages as their cote compensation. SWIMMING ECFRIC
dot......aorle,The Cont is not s License Low does
o,apply 1. a cowi nexs ^ COTTER
m�]—m and property
who
Code:The Contractor's rheas' License law s such
oat apply s an owner of OVTLf TS SWITC ' IX'TURES -z—,
0
6 3^ property who builds or improves thereon,and who Joel ash work himself or through
his own employers,provided that such lioprovnnemis are not intended or offered for NEW RF.SIDEN EL SQ PT.
sale.If.however.the building or improvement is sold within one year of completion,the SQ.T'L FLOOR AREA $/SQ.IT
pawrM1 r will have the burden of proving that he did not build or improve for pur-
soled.
awmr of the property,am exclusively convening with licensed armmdors m .T 1" r ✓ V CJ r�J
construct the project(See.7044.Business and Professions Coder The Contracmr'S Li
-
roLuwdoesnotapplytoan(wneraf property who buiIds or improves therew,mal QTY PLUMBING PERMIT FEE
who contracts Ian such projecu with a contractor(q Iicemed pursuant to the Contractors
License law. PERMIT ISSUANCE
❑ Ito eenra under Sec. .B&PC far this reason ncr Dam ^1
x ALTER—DRAIN&V17N'I'—WATER(EA) VAI.UA'1'ION
q
W(IRKF 'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE u O
• I hereby fifirm under perall,of criaryanenf the fallowing Jcdamians:
❑I have and will maintain a Certificate of Consenuo self-insum for Worker's Coal DRAINS—FT.00R.ROOK.AREA,COND. STORIES TYPE CONSTRUCTION
sari..,as provided for by Section 3700of the Labor Crile,far the performance of the _
work lin which this permit is iaxacd. FI%TURES—I'1!R'TItAi' /
I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the pertormance of the work for which this permit is issued, GAS—EX SYSTEM-I INC.4 OUTLETS OCC.GROUP
My Worker's Compensation Inwrunce Carrier and Policy manta arc:
Carrier: Policy No.: GAS—F.A.SYSTEM-OVER 4(G)
CERTI PICATE OF EXEMPTION ROM WHIR KERS' GRIiASFIINDUSTRI.WASTE INTERCEPTOR PLANI!4 FGE J�1
CUMI'ENSAIIUN INSURANCE BUILDING DIVISION FEES
jl�
nr less.)
(Thissecion used nm be completN ifine permit is for one handled dollars IS 100) GREASE TRAP KSJL)
I cemly that in the verfimnonce of the work liar which this prnit is'nsucJ,Im.l1 SEWER—SANITARY—STORM EA.210 FT,
act..,toy aa, aas in anynanrrcr-ax m become subject a the Worker<Comlen- ENE PF, ell O,
,Z cation Laws of Califomia.Dom WATI!R HEAT17R WNEN'DELECTR
Applicant G CNG 'F.E
Z NUI ICE TO APPLICANT:It,atter making this Certificate of Exemption,you should WATER SYSTEMOREATING
become subject to the Workers Compensation provisions of the IwWr Castle,you must SOI FF
forthwith comply w,pi sach pnwkionso,this p{,all shall be decnredmvaked. WATIIR SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.FT. PAID
I hems,Ainn thm there I...or,oadton lending agency for thuperformnna of Dam ReeuptX
V ti the work hn which this permit is issued(Sec.3197,Civ.C.) e�
C) U
UC" F Lender's Name C�
Iwmdcrx Address TOTAL: BUILDING EE D p
y I unify that 1 have read Ibis application and suite that the above information as
F Tn corms.l agree to comply with all city and county ordinances and.state laws rehttingm QTY, MECHANICAL PFRMIT FEE Z—. 3
U building m.ioadon.t.d hereby suthnrim representatives ofmiscity to anter upon the SEISMIC FEE
alnm<nnentioned Employ fur inspection 11-11ses. PERMIT ISSUANCIZ
(N'c)agree m cove,indemnify end keep hannlces the City of Cupertino ugainat ELECTRIC FEE S
Iiahilillcx.juJgmmnt...... :mJ cxpennns which mnymany way uccmc against sail Ctty AITERORADUTOMECH,
in asequence of the grunting cit this Permit. O PLUMBING FEF.
APPLICANT UNDERTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.00i MECHANICAL FEE Q Q
. )URCF,REGULATII
AIR IIANDhING UNI'1'(OVER I0,010CPM) CONSTRUCTION TAX
Signature of Applican Contractor Dale 7 EXHAUST HOOD(W/DUCq HOUSING MITIGATION FEE
II ZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupam store or handle hazvdous material HEAPING UNIT(TO 100.000 BTU)
saw defined by the Capertlno Mtatieipal Gds,Chapter 9.12,and the Healthand Safety
Cole.Sectow 25532(.)! EINGOVER Im.(w1 B1'U)❑Yes ❑No AN(SINGLE.RESIDI PAID Dae RmciplX
Will the applicant or l mum btdlding:nxupam use ayw,avol or devlems which pH POR I W,BW RI U)emir huardous air armaminuntx as defined by the Bay Arta Air GuulitynlanagcmcmDistrict'❑Ycx ❑Na (OVER 100.Igq BTU)I have read the hemrdnus materials requirements under Chapter 6.95 of the Cali. ER / ISSUANC�DATE it
loran Health&Safety Cade.Sec a,25.5115.2553'3 tool 25534.1 undectund that if the NEW RESIDENTIAL MECI I. SQ.FT. / T Q_ C2
building does not corneal,to nant.that it is my responsibility to notify the occupant tttYYY /� (((
min reyuircmems which mm a time,
uance ofd Cen'tlicae ofl`<u cy.
)wna or amhorizcJ.gem 1,10 Date ISSUED BY:
OFFICE