S 3950APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMI'1' PLUMBING. MECHANICAL
RUII,DING PROJECT IDENT'IF'ICATION
PERMITNO.
S 3950
RUILDINOADDIUXS: q /
a/88S LJ r,46v,r De-
SANITARY NO.
APPLICATION SUBMITTAL DATE.
(IWN[H;S NAMIi: PEIONP.:
n -7+4K LL; �� ^USI I
MI'RACTON'S NAME:
11117/ ^/d
NIC
IDT
CUNTROI.p
ARCHITECT/ NGINEER: LIC NO:
A D SS.
Vii/ P4. s.u.
CONTACT: PHONE:
It
J S �1 1-�lD�'9as
ElConsultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
RLDG ELECT PLUMB MECH
F-1❑ 2 ❑
I-ICENS17D CONTRACTOR'S DECLARATION
at
I hereby about thI am licensed under p,a,,, n a of Chapter 9 (colummang
with Sation]0011)of DivisionJof the Nosiness end Professions Ctdn itmy license is Lm.#
full force and effect. t-� _
License Class C' 3 ���
�Contreaor l
QTY. ELL'CTRIC PERMIT FEE
JOB DESCRIPTION '
RESIDENTIAL
❑SFOWL ❑KITCHEN REMODEL
[]ADDITION [I PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
I ❑INTERIOR El CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
❑ BATH REMODF,UREPAIR El DEMOLITION
[]OTHER
PERMIT ISSUANCE
APPLIANCES - RESIDENT 'HAL
ARCHITECT'S DECLARATION
1 undcrnund my pions shall be uscites public rcco d,
PANELS
UPT02MAMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I um exempt from the Cnnwdor' Lluase haw for the
following reason. (Section 7071.5, Business and Professions C :Any cit m coamy
which he iirts a permit to tametruct, aIle,, improve, demolish,,, pair' y stmemrc
prion, its issuance, also reyulrcs the upplicom lar such Mrmit ,In edsmtmnem
that he is IicensW pumuam to the nvniotls of the Comm a Lt use Law (Chapter
(commencing with Section ]IX or Uivision3nf the Basin Professions Cale)or
that he is exempt sherefmnt n I the osis t'or Inc 011e • e tp' m. Any vinlmlan of
Station 703 LS by anyapp'nm for. permitw is the p t m a civil penalty of
t mnrtthan five hand,, dollars an
❑Lasowrerofihepro try, or my employ ea snoutolecvmpnnati,n,
wdldathework,andth :"acture is not in lot fere or sale (Sec. 7044. Business
and Professions Cale. c Co.- -'a Liccs not apply to an owner of
pmpeny who builAs or i mart anJ w d •s such work himxlf nr through
h¢ own employees, provldud t t a imToo Max ore not intcndal lir offered fur
sale. IL however, the building or i revemcm is sold within one year of completion, the
owner-huilder will have the hr a of proving that he did not build or improve Torpor.
pox nl sale.).
❑Las owner of the property, am elusively contacting with licenxd contmcion io
construct the prvina (Sec. ]014, Bu.'ness and Pmfessinns Cale) The Cnmranor'e Li
close Luwdoexnor npplytanumvne nrproperty who hands or import thereon, and
who counters for such pmjwts with a contractor(s) licensed pursuant to the Contractor's
License law.
❑ Ia,it esemptunder See ,B&P C for reason
201-I010OAMPS
OVER 000AMl'S
SIGNS ELECTRICAL
SPECIALCIRCUITNISC.
S
TEMP. METER OR POLE INST
(/Lf�
El NEW BLDOIADDITION ❑DEM LITTON
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHRR
POWER DEVIC17S
SWIMMING POOL ELECTRIC
OUTLETS - SWRCHHS -FIXTURES
NEW RBSIDhNTIAL ELBCfR SQ Fp.
SQ. FT. FLOOR A REA
VSQ. F1'.
TOTAL:
-
QTY. PLUMBING PERMIT FRE
_JSM
PERMIT ISSUANCE • / [/
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby off rat under penalty of perjury one m the following dealan tions:
❑ I havvied will maintain a Cenifimteof Cons em toself-imme for Worker's Confer-
sationatCadet,, we provided for by Section 37M of the Lr C, Troche Tamfonnence of the
work for which this permit is i11.1d.
I have and will maintain Worker's Compensation Insurance. as required by Section
3700nf the SLabor Coddde, form, rbrrourno f the work for whichthis pel.hit is issued.
YW
01
Gamer: ks �r''CI:RTIFICATG Za OF r/EMPI'Policy hON FROM WORKERS'yJ 3oYY-0
COMPENSATION INSURANCE
('1 his.uctinn need nw be completed if theermit pie (m ono Initiated JnllmxfSlbad
or less.)
I certify mat in the perfomlanttof Ne wnrk(urwhich thispermit is issue4[shall
not employ any person in any manner so us to become subjurto the Workers Cont
sation laws ofculifomia. hate
Applicant
ALTER -DRAIN dt VENT -WA9'ER TA)
VALUATION
BACK FLOW PROTECR DEVICE
DRAINS- FLUOR, ROOF. AREA, COND.
STORIES
TYPE CONSTRUCTION
FIXTURES - PER TRAP
GAS - RA. SYSTEM -1 INC.4 OUTLETS
OCC. GROUP
APN
GAS -HA. SYS TEM-OVER 4 UA)
GREASUINDUSTRLWASTE INTERCEPTOR
BUILDING DIVISION FEES
ORE, TRAP
PLANCHF.CK IEE
SEWER-SANITARY-SIORMEA.2WpT. _�` ate^
<-a`-'
[?NERDY FBF,
WATER HEADER WNIi'/F.LECIR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Cenirium of Exemption, you should
thereon, subject m The Worker's Compensation provisions of the Labor Cone. you nmst
forthwith comply with such ptavisionsor this permit shall he deemed resided.
CONSTRUCTION LENDING AGENCY
I herebyaffimuhtudere is. ro..mallian lembri,itimey for the performance of
the work for which this permit A issued (Sec. 3097. Civ, C.)
Lender's NameTOTAL:
WA'I ER SYSTEM/TRl7A'1'ING
WATER SERVICE
SOILS FEE
PAID
Dat Receipt#
NEW RESIDENT IAL PLMB. SQ. PT.
Larder's Addass
OT
BUILDINGFElit
1 certify that 1 have mad this application and state Nat the mase information is
courreca. race, to comply with all city and county remittances and slam laws relatingto
building construction, and hereby announu representatives of this city to enter upon the
above-mentioned pmpeny for inspection Impact, u.
(We) agree to savq indemnify and keep hmmle,s the City of Cupertino against
Iiabilid ,judgments,costs and expenses which may in any way accnteatimmi said CitypLTL'It
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
OURCE REGULATIONS.MECHANICAL
g .-/C,99
Q'TY. MECHANICAL PERMIT ILEE
SEISMIC FEE
PERMIT ISSUANCE
OR ADD TO MIiCH.
ELECTRIC FE
PLUMBING TEL'
AIR HANDLING UNIT (TO 10,I1p CFM)
FIiE
AIR HANDLING UNIT (OVER 10,000 CFM)
CONSTRUCTION TAX
S1,1141amal AppllconVCnmmctor Dote
HAZARDOUS MATERIALS DISCLOSURE
Will theapplicarrim future Wildingacupanl mom or handle hm.Nnusmatmal
as defined by the Cupertino Municipal Cafe. Chapter 9.12, and the Health and Safety
Coda Section 25572(.)1
E3 Yes 0 N
Will the applicant or future building occupant use equinticna or devices which
emit hamuous air comaminanu as depeal by the Boy Area Air Quality Management
District?
❑Yes 0 N
I have maul The haude, Se toms 255(p, 2ils 5533 ntsan under , 1 undcrxe of the Cali
Potain ileulth & gufety, Cuda Sections 25505, 25577 and 25534. I undersuuW that II rho
hf lin gJces urn currently hev<a tutor. That it is my rcsrymsihiduricanotifytheplawy.
f them uirements whiyp m he met pdono issuapce of a CeniOwm of (kcupency.
yLc 7
EXHAUST HOOD(W/)UCT7
HOUSING MITIGATION FEB
HEATING UNIT90100,000 BTU)
HEATING TINT T'(OVER 00,000 BTIJ)
PAID
Dam Reccipt It
VENTILATION FAN (SINGLE HF_SID)
BOILER -COMP (3HP OR 100,000 BTU)
TOTAL
BOILER- COM P(OVER I Output BTU)
AIR CONDITIONER
ISSUANCE DATE
L
ISSUED BY
NEW RESIDENTIAL MECH. SQ, FT.
_
r aa0ndxd agem Den
TOTAL:
OFFICE