S 3926APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING. MECHANICAL
BUILDING,PROJECTIDENTIFICATION
PERMITNO.
S 3926
BUILDING ADDRESS: -
SANITARY NO.
A/PPPPLLICATION SUBMITTAL DATE
&✓
OW 'S NAME: PHONE:
CO TOR' IC NO:
/- KI S
NIC
❑
CONTROL#
(may / // 'Y
ARCHITECT/ENGI .R: CND.
ADD Sy_ ��
J
CONTACT: PHONE:
❑ COnSU[Mnt Fees Paid by Applicant (Initial)
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
❑ W ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 herion 7( 0).f that 1, 3 licensed under provisions of Chapter 9 (commencing
with Section ndc of pivisionJof the Business and Professions Code, and my license is
nfull force and eft, n
License Class `+�b Lic.
Dale Cun DELL
{ ARCHITELT', DECLARATION
1 understand my plans shell be used as public records
Laensed Profesvonel
OWNER -BUILDER DECLARATION
' I hereby affirm that I am exempt from the Contractor's License Law for the
following reason. (Section ]03 L5, Business and Professions Code: Any city or county
which requires a permit to construe', at,,, improve, demolish, or repair any swchad
Print In its issuance, also requires'he applicant for such pemut to file anignedsmtemem
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 70315 by any applicant for a pormhsubjects the applicant to a civil penalty of
nen mare than Eve hundred dollars ($500).
❑ 1, as owner ofthe proper, or employees with woes as their sole cora
Y Y P Y g pensation,
will do rework. and the she cture Cmdmon'snot Licennded se
rriffered Law rimepply 1. an Busoveriness
and Professions Code: The Convhereo License Law d«s oat apply toll ownergh
propeny who builds or improves t thereon, and who does such work himself of through
sal own employees, e provided that such improvements arc not year ofd ur offered for
the
f, however, the have tthe bng urden
ownee. r -builder
net-builJer will have the burden of proving that he did not build or improve fur Pur-
ofvement ithat he id n one build or improve
pose of snleJ.
❑ 1, as owner of the property, an exclusively contracting with licensed contractors to
^ edmat the patient (Sec. 7044. Business and potassium Code:) The Contractors Li -
cause Law does not apply to an owner of propeny who builds or improves thereon, and
who contracts for such projects with a carnations) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. , B & P C for lis reason
QTY ELECTRIC PERMIT FEE
-
JOB DESCRIPTION
RESIDENTIAL,
❑SFDWL ❑KRCHEN REMODEL
El ADDITION ❑PLUMBING L PIPE
❑MULThUNIT El STRUCTURAL
MODIFICATION
Cl INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
❑BATH REMODEL/REPAIR ❑DEMOLITION
❑ OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
PANELS
UP TO 2INIAMPS
201-I0fg1AMPS
OVER 1000 AMPS
SIGNS ELECTRICAL
SPECIAL CIRCULDMISC.
TEMP. M POLE INST. I
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑ TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
zk'�k r25
POWER 1
is
SWI G LE C
OUTLE S- ES- .S
NEW RESIDENT E TR SQ FT.
� -
SQ. FT. FLOOR AREA
_
&SQ. FT.
A
QTY PLUMBING PERMIT FEE
PERMIT ISSUANCE
ALTER - DRAIN & VENT - WATER (EA)
Owner Dae
VALUATION ,
-
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:.
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Com
s ation, as Compan-
provided forSection 3900 of the Luhor Code her the perbnmenca of the
ark for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 mdm Labor Code, for be performance of the work far whichthis Permitis issued.
Cy Work Otfiaetitupoferia cecancer olity No.and ys-/�TnS^7 •a
�[j'
CERTIFICATEOFEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
orless(This section need onthe completed ifthepermit is for one hundreddollars($100)
Icenifythat inthe performance ofthe work Car which thist is issued, i shall
not employ donor
p y any person in any manner an as In become subject the Workers' Compen-
sation Laws of California. Date
Applicant I
BACK FLOW PROTECT. DEVICE
c
DRAINS OR, RO EA, CO t
STORIES
TYPE CONSTRUCTION
FIXTUR R TR 'm .
GAS -E TE .4
GAS- YSTEM-0VER4(BA)
OCC. GROUP
APN
ar
GREASE NDUSTRL WASTE INTERCEPTOR 1
GILDING blV76(ON
q(
CREASE 0
PLANCHECK FEE
SEWER - SANITARY -. 00 FT.
STORM PA2
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: If, ager making this Gismos of Labor food you should
femme subject to the Workefs Compensation provisions b the Labor Code, you must
forthwith comply with such pavisions or permit shall be deemed rcvnked
CONSTRUCTION LENDING AGENCY
I hereby affirm that mac is a construction lending agency for the performance of
the work for which this permit is issued (Sec 3099, Ci, C.)
Lender's Name
WATER SYSTEM?REATING
SOILS FEE
WATER SERVICE
PAID
Receipt M
NEW RESIDENTIAL PLMR SQ. FT.
TOTAL:
Lender's AddressTOTAL:
I certify Net 1 have read mi., application and nate that he above information is
correct. I agree to comply with all city and county ordinances and state law, relating to
building construction, and hereby amhoom auasentatives ofthis city to enter upon the
above-mentioned propeny for inspection purposes.
(We) agnea to cava indemnify and keep harmless the City of
of Cupertino against
inconsequence mentees ting of this es Permit which may in any worry come against said City
nscquence of the graining of this permit.
APPLICAIIF��jTTT UNDERSTANDS AND WILL PLY WITH ALL NON -POINT
SOURCE IJECOLA NS.
�f
BUILDIN E
QTY. MECHANICAL PERMIT FEE
SEISMICP.
ISSUANCE
ELECTRI E J U
ALTER OR ADD TO MECH.
PLUMBING
PIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIH HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
ignchmof Appi OContmetor Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
C.S. Section 25532(ay/
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
mit hazardous air contaminants as defined by the Be, Arca Air Quality Management
District'
❑Yes ON.
I have read the hadeadous materialsAIR
requirements under Chapter 6.95 of to Cali-
Poria Hwddj& Safety Cade, Sections 25505, 25533 and 25534. 1 under -stand that if the
building dce not curruntl haveatem thorn is my responsibility m notify the occupant
ofthe emswhi u,t be pdonoissu niBaceof Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION PEE
HEATING UNIT (TO 100,000 BTU)
HEATING UNIT (OVER 111),000 BTU)
PAID
Date Receipt is
VENTILATION FAN (SINGLE RESID)
BOILER - COMP (3HP OR 100,000 BTU)
T 4
BOILER - COMP(OVER 100,1100 BTU)
CONDITIONER
ISSUANCE DATE
J'
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. FT.
Own or authn' Date
I TOTAL
OFFICE