S 3371APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PE IT NO.
K 31
7
VV 1 ..LL
BUILDINGA RF;SS
L////<�('�')SEA
SANITARY NO.
APPLICATION SUBMITTAL DATE
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PHONE
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CONTROL#
19'F,Cf .NGINEER: LIC NO:
DRESS: t
CONTACT: PHONE:
BUILDING PERMIT INFO
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❑Consultant Fees Paid by Applicant (Initial)
BLDG LLISCT PLUMB MECH
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LICHNSED CONTRACTOR'S DECLARATION
1 Thereby affil", Baat I ..lieenaed ender poor aWa�a of Chapter 9 (mmmnne„amg
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
whhSerbian 9(100)af D'.....en 3 ofine Hiem—and Professions ode andmyliwmeTs
In Enll levee and' ec O ',
License ss o
Connector •
Doe _ nnm
PHI11111 ISSUANCE'
RESIDENTIAL
0SPDWL O KITCHEN REMODEL
ADDITION PLUMBING RE -PIPE
❑ ❑
-
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTHRIOR El CHIMNEY REPAIR
IMPI2OVF,MBN'F 0SWIMMING POOLS
OBATiI REMODELIREPAIR ODEMGI..'(IDN
0 DTHBR d
y
APPLIANCES -RESIDENTIAL
ARCIITEQT'SDECLARATION
I understand my plans shell to usedaspublic records
PANELS
UP TO 200 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Low for the
following reason. (Section 9031 5, Business and Pmfe,,mr, Code: Any city Orcoumy
which requires a permit to construct, other, Improve, demolish, or repair any structure
201-1000AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
_
SPECIAL CII:' LSC.
prove o its issnerve, also requires the applicant for such permit to Ne a signed statement
Ihw hu is licensed pursmm to the previsions Of the Cnntramar9 Liwnm Luw (Chapter 9
(commencing with Section 7000)ofDivision 3othe Business ed professions Code) nr
TEMP. ME O LINS'll
COMMERCIAL:
Wal he le exempt therefrom end the basis far the alleged eveneptinn. Any vmjadon of
0 NEW BLDG/ADDITION 0 DEMOLITION
Section 7031.5 by any opplicam fora permit Objects the applicant na a civil penalty of
not more than live hundred dollars ($500)
Dl, as owner of@e purpren, mmy employees with wages as thcirsole eoaiou, ....t
will do The work, and the structuress not Intended or oHoed for sade(See 904, Business
unit Professions Cade: 'Ihc Contractors License Lao does not apply m on owner of
POWER DEVICES
O ❑FOODSERVICE.
IMPROVEMENT
❑OTHER
SWIMMING ECTRI
tea.
OU'ELL'I'S-SWI' II XTURP_ Ut u
NEW RHSIDP.NTIAI, E .. SQ PF.
pmpeny who huildx or improves thereon, end who does such work himself Or through
his awn employees, provided that such improvements are not intended or altered ror
saler if, however, Um building or Improvement is mid w.Wineneyear of comp.. ...... the
SQ. FT. FLOOR AREA
$/SQ. ET
er-beilder will have the burden of proving that be did not build Or improve for p..r-
pswe made.).
El 1, asowner of the property, am exclusively a mmming with licensed commarms To
ma¢uct Wo projmt (Sus. 904Q Bminexa end Professions Cadc:) The Contractor's Li-
cense Law cities not apply to an owner ofproperty who builds or improves thereon, and
QTY.' PLUMBING PERMIT PEE:,
,he contracts ror such mejecls with a canwands) licensed pumaan0o the Contractor's
PERMIT ISSUANCE
License Law.
❑ I am exempt under Sec ,B& P C for This reason
Owner Dam
ALTER - DRAIN & VIN 'I - WA[ FR (EA)
VA LUA'1'ION
WORKERDf CL9B9TION
BACK PLOW PROTECT. DEVICE
under'SCir,of rATION
1 hereby ..(Erre antler penally..(perjury one of the following declvm(i..ns:
Ihnve and will restore:.. aCertifiwm of Consent to eelGlnsure fou Warkcr's Conapen-
satian, as provided for by Serbian 3]00 of the Labor Code, for lie permanence..1 the
work for which this permit is: saved.
0 i have and will maintain Workers Compensation Insurance, as required by Section
3700..f the Labor Code, for The perfonmmceaf the work for which mi,samr it is issued.
<'
DRAINS- FLOOR, ROOF, AREA, COND.1
\' A
STORIES
'fYPIi CONS'FRUC'I'ION
FIXTURES - PER TRAP -"S •\v'
GAS -EA. SYSTEM -I ING.4OUTL'FS
DEC. GROUP
APE
My Worker C mpnasmi In conte n ..hero el
Carrier: -�y���-Qy�}-�-(��—
• r <
GAS -EA. SYSTEM-0VLrR A (LA)
' CERFIPICAfLC -OVEXF;MF'fION FROM WORK&S'
COMPENSATION INSURANCE.
(TF.s.mctionnee riothese..ap.ctedifthepermiiisforonehundreddnllars($IMI
Far less.)
c i
GREASEJINDUS'FRL WAS'FIl UHHRCEPTOIt �-
+ s - ` BOILDINd UIVISIO pBl'y$
GRP.AS5 TRAP �' /
\ -7
PLANCHE,CK FEE b
-
I caBly that in thepaformanceof the work for which thispermit is issued, l shall
nalempl�yanypeanninanymm�nwsoasmhccemesuhjecllatheWnrkers'Cnmpcm
scion Lnwsof Cdifirims. Dote
Applicant
1
SEWER -SANITARY -STORM EAl�011 BII O <�ENERGY
PEE
GRADING FEE
WATER BEAT FR WHEN' I'/HLECTR
NOTICE. TO APPLICANT: 1C after making this Certificate of Exemption, you should
became subject m the Workers Compensation ......ions of We Labor Cnde, you ones(
WATLk SYSTEM(FREATING
SOILS PCB
ry
WATER SERVICE
forthwith comply with such pmvisiom or this permit uralt he deraned revoked.
CONSTRUCTION LENDING AGENCY
IherebyeffimaThai (here tsaconstrucdon lending agency forthe performtmce of
PAID
Dvt Receipt#
NEW RESIDENT IAL FLMU SQ Cr
the work for which this permit is issued (Sec. 309], Civ. C.)
Lender's Name
TOTAL:
Icnder's Address
PHIAL',
BU FEE
1 ccni.'y Thal 1 h -c road this application rnd state that The above information is
--
baror<t l agree m conn ywith all city and County ordinances and state laws relmingm
' construction, d htrmby authorize representatives ofthis city tourer upon the
ns
QTY. MECHANICAL PERMIT FEE
SETS FEE
PERMIT ISSUANCE ISSUANCE
ELECTR FEE
it v' -me ed prop ty on inspection purpos se
WIOR atoave, Indemnify and keep harmless the City of Cupertino against
arm
ALTER OR ADD TO MECH.
PLUMBING EE
ih ludgn nts,m Is ad expenses which may immy way accrue against said City
nc. Ceg n "got his"can.
AIR HANDLING UNIT' CTO 10,000CF10)
MECHANICAL FrF.
PP ]e V1 D S'ND, AND WILL GO r TIED ALL NON -POINT
S E L ION
AIR HANDLING UNIT (OVER 10,000CFM)
CONSTRUCTION TAX
e Heart/Coneravem Date
HADISCLOSURE
MATERIALS DISCLOSUR
EXHAUST HOOD(W/DUCT)
DOUSING MITIGATION FEE
HEATING UNIT (TO 100,09)(1 BTU)
Will The or future buildinguccupantsmrc or handle hazmill materia.
as defined by the CupeninO Municipal Code, Chapter 9..2, and the Heahh and Safety
Code, Section 25532(3)?
1 EALING UNIT (OVER .00,000 BTU)
El Yes E) NO
PAID -'
Uate Bar,.pl#
VENTILATION FAN (SINGLE RESID)
m lity Management which
WIIt the appllcdnl inants as bnthdirg y the Baynt Area
mit hazardous air enmvminvme as defined by Wo Bay Mea Air Quality Mdmgemrart
Air Quality
Distncl4
El Yea NO
❑
BOILER - COMP CHP OR 10OU00 BTI)
T , O
BOILER - COMP (OVER 100,0001,(NIU O'rU)
AIR CONDITIONER
I have vena the huwdouc materials mquimmChapter order 095 of the Cali-
fomia Health & Safety Code, Sections 25505,25533 and 25534. 1 understand that if the
building does nal momently hate n erznt. that a is my reapomia
bilo, , notify the owupice
ISSUANCE DATE
`� =� AR
NEW RESIDENTIAL MECH. SQ. PF.
OF the ra,mrunents which must be ntct prior to issuance of a Certificate of Occupancy.
/
ISSUED BY:
TOTAL
Owner m arflorized agmn Dom
OFFICE