S 3915APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
` CITYOF CUPERTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL.
., BUILDING PROJI?C'T IDENT'IF'ICATION
PI?RMITNO.
S 3915
BUILDINGADDRESS:
SANITARY NO.
SUBMMITTAAL DATE
APPLICATION SUBMITTAL
Y 1 1
PDO
VfliR'S NAh1F.; ONE:
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CO RACIOR'S NAM . ') hIC NO:
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CONTACT. FHUNIc
BUILDING PERMIT INFO
3 -'20eo
❑ Consultant pots Paid by Applicant (Initial)
BLD ELECy PLUMB hat
I � ❑ ❑
LICENSED CONTRACTOR'S DEC RATION
hereby affirm that 1 am heen.ed under provisions of chapter 9 (rommendng
th Station 9000)ol Division 30 the lluslne,seld Profession,Code,and a,, license is
in full torte anddl,
'" %O P
License .la_ Lim.a
Dam cantmrtor
QTY ELECTRIC PERMIT FEE
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JOB DESCRIPTION
RESIDENTIAL
❑ SFDWh [I KITCHEN REMODEL
❑ADDITION []PLUMBING RE-PIPE,
❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
[I INTERIOR ❑cHm NEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH RF,MODEUREPAIR ❑DEMOLITION
❑ OTHER
PERMITISSUANC�:
APPLIANCES -RESIDFMIAL
ARCHITECT'S DECLARATION
Imldcrsmnd nryplan,nhall hcuwJ Is public records
IANELS
Oil 102M AMPS
Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for the
following reason (Station 70315, lino, and Vrufcssions Code, Any city or county
ldch requires a permit to cnn.ct, ahcr, improve, demolish, or repair any somatic
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prior in its misnomer, alm requires the applicant for. such permit to file anginal statement
that he is licensed punuaat to the provisions of the Crerxmr's License To (CM1aptcr9
(commencing with Station 90011)of Division 3 of the Business and Professions GJe)a,
but he In es,mm rharefmnt and the basis for the alleged cxempmon. Any vlulatimt of
201-10MAMPS
OVER ["AMPS
SIGNS ELECTRICAL
SPECIAL CI ' IT/
'TEPOLE MP. MET INST,
COMMERCIAL:
❑ NEW BLDGIADDITION ❑ DEMOLITION
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Section 71031.5 by city applicant fm a pemtit subjects the applicant lo. civil penult, of
rw rc rha" five hundred dri (SNXp.
nLas otheowner mftbe pmpcnv,tor myemployeowith wages
nctle smile compensation.
Licensoroffc does o, a,ec. 9011. Business
CnJo: The over Ih me License Law does nor apply m if owner ofOUTLETS-SWIIr�ES
and dmhewmrk, Coth, le, Contractors
and properly I, ho
t such improvements and whit Atkam n work deed o l or thnmgh
his own employeese provided Nut prov ensissoldw thin nm intended or plfcred for
his own whooyers.uilds or provided that
ILhower itat hwithinon yew of
POWER DE ES
IMPRO❑ TENANT ❑FOOD SERVICEFZY OTHER CML•NT
[I OTHER
SWIMMING POOL ELECT
XTUR
NEW RES] DIiNI'IAL Lli 'Q FT
FT.fI-O�itC`RGG
IT'
ildor improvetfomthe
will hvilthe bodmpmvement
owner will have the burden of proving that he did not build or improve for par-
own
qoc It sale.),
0 I, a, owner of the property. um exclusively contracting with lino It ronwmors 1,
Ay: (
onstruct the project pma. ]OW, Business and Professions Code:) The Con ectoR Li-�'
a�,fAc
UNY199who
r
se Lax does not applym av ownerofpmprrty who builds or improves thereon.vul
QTY. PLUMBING PERMIT FEE
contracts for such projects with a comeacmr(s) licasN pursuant to am Contractor'stLicense
PERMIT ISSUANCE
Law.
I can exempt under Ser. Ii A P C To flan Toulon
Date
Date
ALTER -DRAIN h VENT- WATER (EA)
ON
BACK FLOW PROTECT DEVICE
W'ORKER'S COMPENSATION DECLARATION
I hereby affirn under penalty of Perjury one of the following declarations:
O ✓fl �%
❑ Ih:mr1"tdwilll^uinluinmCenilicumnf Cnnsenttosclf-insure Gy. Workers Comprn-
sation, m' prwideJ I'mr by Section 391X1 nl Nc IrMm Gale, for 1he perfitmmnee nl Ne
DRAINS- FLOOR. ROOF AREA, COND.
51'ORI ..
TVPII CONSTftIJC'IIgN
work far which Nis permit is issued.
FIXTURES - PER TRAP
I have end will maintain Worker's Compensation Insumnm, as required by Section
110I The Labor Code, for the performance ofthe work for which this permit is issued.
My Waders Contpenrnion Insurance carrier and Policy number are:
Currier. Policy No.:
OCC. GROUP
APN
GAS -EA. SYSTEM-I INC.4 OUTLETS
GAS -EA. SYS '1'17M-OVER 4 (EA)
CIiRTHTcxrE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASEIINDUSTRL WASTE: INTERCEPTUR
/BUILDING DIVISION fEIS
(This srNoarmadeotbccomplemea fthepermiT is former hundred dollars (SIM)
mless7
GREASEIRAYE
PLANCf 1 i. S
2 yZ/
which this The Wis issue4 ,face-hall
mol employ any person in any manner so as to become suhjen rube Workers'Compcm
lay anytFersn manyhe manneeof the become
gF,WER-SANITARY- S'IURM EA 2(p IT.
EVER lit
WATER HEATER WNENTTLECTR
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sation Iris of C.ffomi.. Dam
Applicant
NOT ICT: TO APPLICANT: IL after nmking this Certificate of Exemption, you should
to the Workars Compr+mamon provision, of the Lahor Code, you man
fnMwith comply with such provisinno or this permit .shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
thereby affirm that there is a construction lending agency for the pcdonciance.f
the more for which 1h1. permit is ,ourd (Sec 3097, Co. C)
larder's Name
WATER SYSTHMNREAI'ING
WATER SERVICE
SOIL
PAID Date Receipt
NEW RGSIDIiNTIAI. PLMB. SQ. FT
/
TOTAL:
Lenders Address
HUILDINGI EI: `
1 cenify Nat 1 have read this applicatmn and store Nm the abroe information is
correct. l agree to comply with all city andconnty, or dinancesundstatelaasrelatingto
hndout. mnsoue,iun, and hereby uuNnrire reposcnunivcs mflhls city to enter neon The
abnv.-nurmioned prolcny fnr impollin. purposes.
(We) agree to some. indemnify and keep harmless the City of Cuportinu against
QTY MECHANICAL PERMIT FEE
SEISMIC FEE
PERMIT ISSUANCE
ELECTRIC Flili
ALTER OR ADD TO MECH.
PLUMBIN
Iiahilities,judgroems. nota and expenses which may in any may.aceme, against said City
in nwou ( Thu grunting of this permit.
LI NT 1NDERS'fANDS AND WILL COMPLY WITH ALL NON-POINT
APVn
SOU CERPAIA'I'IONS.
AIR HANDLING UNIT ('1010,INq CFM)
MI,CHA 'A FEE
NR HANDLING UNIT (OVER IO,BIX CFM)
CONSTR ION TAX
GYY q
SignaturemA to" tractor Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCD
HO MITIGATION FEE
IIEA'1'ING UNIT (TO 1011,1X11113' Ill)
WIII the applielud tar more building occupant,lore nr handle hazardous mmariul
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Jin, Section 25532m)?
HEATING UNIT (OVER 000,0010 BTU)
VENTILATION FAN (SINGLE RESID)
❑Yes 0N
PAID
Date Receipt4
HOLLER-COMP (3HP OR IIN),INp IT Of
n furore building by the B em ra,uco Air ciaQu m devices which
Will the air communities
_mit mus air n+mmninants us defined by the Bay Arca Air Quality Management
T T
BOILER - COMP (OVER 100,00) BTU)
District?
Dishier?
E3 Yes F1 No
AIR CONDITIONER
I have/ chlnunituv naaeriuls rcgnircnlrntx under Cbupmr 6.95 of the Cull-
IS UANCE DATE �f
NIiW RESIDENTIAL MECH, SQ. FT,
fmorm He ffi & Sar ty Code, Sections 25505. 25533 and 25534. 1 understand Nat if the
tooldin not rmndY haveamnanl zpmsibilitymrotify Ne+ccupant
ss
orthe quimm Bwhich must bee na nceofa Cenifiectiemw e-parmy.
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ISSUED BY:
( rex raid burimd na Data
OFFICE
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