S 3079 APPLICANT'TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PF G`NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. � � 3079
BUILDING PROJECT IDENTIFICATION
RUILDINGADIIRISS SANITARY NO. APPLICATION. IIMITTAL DATE
s ;1Kg_ -,2 111 9
OWNERS NAME: PHONE: CONTRACTOR'S NAME. LIC NO:
r N/C CONTROhp
�I ARCHITECGENGI EER: LIC NO: ADDRESS: J ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) IILIH'i ELECT PI ME
w ❑
LICENSED CONTRACTOR'S DECLARATION- QTY ELECTRIC PERMIT FEIi
1 hereby affirm that Icon licensed under provisions of Chapter 9(commencing JOE DESCRIPTI N
WOO with Section]0001af Diviom,3oflhc Boinessand Pimfinxions Codst my license is RFtiIDENTIAL:
WOO 1 PERMIT ISSUANCE. s ,
Fa W.. in full force and ef(y1. s -,1 ❑SFDWL' ❑KITCHEN REMODEL
�Ugo License I's r�Le�A5•`J6 Cuba -�L�L1. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RETITLE
Fab Da1C— ConUatlor
N ARCHITECT'S DECLARATION ❑MUITI-UNIT C1 STRUCTURAL
1..7 t PANELS
Z p i Z 1 understand my plans slmll M used as public recmdz MODIFICATION
OZ�-'p 01110200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
W Licensed Professional 20l-IIIf10AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
CY , OVER I001AMP5 [I BATH REMODEIIREPAIR [I DEMOLITION
C a 1 hereby affirm that am exempt from the Conwmnrs License Law for the
O d U followin•resin(Section 7031.5.Rusinessund Prnfessinns CMe:An t t ❑OTHER
iq$ gy ci y nr conn y SIGNS ELECTRICAL
F which requires a e,also re nmsahe alma improve.demolish,nr repair any twcmm S'_&All
��� prior to issuance,also requires the applicant for such permit lofile aicenssigned s,(Chlement SPECIAL CIHCUIT/MISC. In -.� �lG
$�} that he is licensed pmomnno thelsownansofthe Contractor's License law lClmpI SME
��qp (n+mmencing wire Senion]flolR of Divisinnlof the Business and Pndeszinns Code)or 'FEMI'.MEI'ER OR POLE INSL COMMERCIAL:
W oy� that ha is exempt therefrom and the basis for the alleged exemption.Any violulian of ❑NEW BLDG/AUDITION C DI MOLT HON
ALL• Section]o31.5 by tiny applicant for a permit subjects the upplicam to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
�' nm mote than live hundred delta,,F Z} IMPROVEMENT
pQ Luz owner of me pmpeny,or my employee wire wages ns their sole compensation, SWIMMING I'(NIL ELECTRIC
j� will do the work,and the stroctum:s not intended nr offered fir%ale(Sec.lfR4,Business ❑OTHER
m_ and Professions Codc:'The Contractor's License Law doer out apply at un owner of OLT I LETS-SW ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own emdc,ol,x,provided that such impmviderms are nm intended or offered for NEW RESIDENTIAL F.LF.CTR SQ FT.
sale.If.however•the building or improvement is sold within one year of completion,the .(RIR AREA S/SQ.FT.
As eohuilder will have the burden of proving dust he did nun build or improve for pur-
pnetil sale.).
❑ I,a%owner of the pmpeny an,exclusively contracting with licensed contractors to 'TOTAL:
comma the projttt(Sec.]DW,Process and Prom"ions Code:)The Contractors Li.
cense Law does not apply to an owner of property who builds or improves Whereon.and QTY. PLUMBING PI7RMIT FEE
who nntrntls for"t"h'nFul,with n contraemr(s)Iiansol amminuo Wire Contractor's
License Low. kIPERMIT ISSUANCE. :Iji
C]I ata exempt under Sec. .R&P C(or this mason t
AI:1'ER-URAIN&VENT-WATER IEAI VALUA'I'1(IN
Owner Date
• WORKER'S COM ofiser ,on DP.CLARAwOry BACK FLOW PROTECT.DEVICE
I herebyillma under peachymeperjuryoneofthe(ollmeomwmadesCrs:
❑Ihave and will for byeCion 37m of Gam monCoh,for for Workers Compen- DRAINS-ILOOR,RWI'.ANCA. ONE). STORIES TYPE CONSTRUCTION
cation,,, provides for by Sccsan 3]W of the Labor Gwe,for the perfannance of the
work for which itis permit is sand. IEX'TURGS-I'IiH'fRAP
I
have and will maintain Worker's Compensation Instrunce,as required by Section
t(the laMtr Codc.forthe performance of Whe send for which this permit iz ismeJ. GAS-FA.SYSTIiM-I INCA OUTLETS OCC GROUP AI'N
Myier 1rr���m-rc,�y�•vn - 'e{and Polic);m�mlgnra GAS-EA.SYSTEMOVER4(EA)
Carrier_t W�V��SJf'Ci"cy N'a\A,(V�O�6/T/�
CEN'FIFICA'EOI'EXEMPIIONFROM ORKF.RS' �%,0(,
COMPENSATION INSURANCE GREASUINIJUSTRL WAS'I'17 INTERCEPTOR
BUILDING DIVISION FEES _
(ons section need nm M1e completed ifthe pnmil is for aoehundrlar
eddi s($100) GFUASETRAI'
or less.] PLANCfIIlCK FEE
renify WMt in the perfummnce efthe workfarwhich this permit is issued,)Atilt SEWER-SANI'I' -.TIIRM LFT. �•' ;
oat employ any pent.in any mann......tit h.conm subject m,he Worker,Compan.
ENERGY PEP.
O Z "mini Imws of Calilnmiu.Onto WATER HEATER N /til.ATR GRADING FEE 2 Applicant
.Net NOTICE TO APPLICANT:If,aper making this Cenificam of Exemption,you should WATER SYS]VNIGREAn NG soil's PDL
(•^ hereon sthject to tire Coup e Waders Cou ...lioapmvioned,of lire Labor Coale,yon aawt
W AV
fonhwilh comply with such previsions or this permit shall be decreed revoked. WATER SERVICE `
0.
nU• z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PW113, SQ.IT. PAID I Receipt
UO work
hich(Iti that there is.tcomtrunionlending
t.ag"ncyfnnhe per(nrmanee of
the work Iia which Ihia pemtit is issued(Su.1119],Civ.CJ ✓V
W (-' .Lender's Name TOTAL'
lenders Address 'TOTAL: LA Lk HUILUING FF.
I cenify that 1 have read itis application and state that the above information is
sF.a h correct.1 agree m comply with nil city and county ordinances and state laws relating It QTY. MECI IANICAL PFRMIT FEE
U 7z building conanmctionfand hereby authorize m,m,taaliveof Whia city me vil.,om the SEISMIC FEF,
alm.omemioncd prapcny for inspection purposes. PERMIT ISSUANCE
(We)agree to sive,notho nify cad keep hamdess the City of Cupminn against ELECTRIC FEE
iabililics,judgmems,costs and expenses which may in any wily aceoe againn said City MIXER OR AUDI MECH,
in sugtmaea a(thc gmming of ad,permit PLUMBING PP.P.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IIL000 CFM)
SOURCEREGU IONS MECHANICAL FEE
SOURC
AIR HANDLING UNIT(OVER 8).000 CFM) CONSTRUCTION TAX
Signamrc ofApplican umaredor Dam EXHAUST HOOD UMMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicars or future building occupant storeor handle b.uudoe m..told HEATING UNIT OT)I00.000 It UT,
as defined by Etc Cupertino Mumd,,l C ,Chapter 9.12,and the Heahh send Safety
Code,Section 255320)iIIHAI INTO UNIT(OVER I(XUXX)RTU)
❑Ycs I,
VF.NI'ILATION PAN(SINGLE RISID) PAID
Date Reccips 0
Will the applicant or future)wilding occupant use equipment or devices which
,.it b utrbut air conmmineds a,de ft by the Bay Arca At,Quality Management ROILER-CONI'(3HPOR 100,01KRTU) 'I(H'AI.
District!
Yes BOILf?R-COMP(OVER 100,00OBTU)
I have read the hauudousmamrids ¢ower Chapter 6.95 of the Cali- AIN CONDITIONER ISSUANCE DA'Z'E
re,255 p
build Health a S,Jvny Cnde,Sea major.
25505,ismy send 25534.1 understand cont if he ryI:W RESNIiN'I'IAh MECH. SQ.FT.
builJin•dces not currcmly have amnnm,thm it is my responsibility to nntily the wcupam ( 7
u Shemeta which mst M reeluprior m issuasame of.CeniMam of Occu
eror n; sela party.
tore
Owno r agent Dune, 'TOTAL - ISSUED IIY:
OFFICE