S 3078 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILKING-ELECTRICAL PHigi P NO. O
78
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL l`
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NU:
(es4� N/C CONTROLM
ARCHITE /ENGINEER: LIC NO: ADDRESS rr ❑
3 G} L A J
[io
TACT: PHONE: BUILDING PERMIT INFO
�-E �x ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECEC{H
� \^ O 5 LLp ❑ �L ❑I.ICENSF.D CONTRACTOR'S DECIARA'I'ION QTY ELECTRIC PERMIT FEE JOB DESCRIPTION
1 hereby affirm that 1 am licensed under prvisions mf Chapter 9!commencing�ZO Section IlXla)ofDoisionJofthe Businessend Prnlession.a Cale.unJmylicenxIn pERMI]'ISSUANCe [` RESIDENTIAL:
Fll farce mW t. .�V 5 d1��D - ❑SI'DWL ❑KITCHEN REMODEL
UUrc�` � Lic.p ,q APPLIANCES_IJES'D1?NTIAI. ❑ADDITION PLUMBING RE-PIPE
We Conua••
'n 0. ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
TANIiLq MODIFICATION
v�^ 1 understand my plans shill be u.d as public mord..
_pp 'PTO 2do AMPS ❑IN•I'ERIOR C1 CHIMNEY REPAIR
Nil
Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
6 .11 OWNER-BIIIIDER DECLARATION OVER Iqq AMPS 11 BAT REF/�DEI/RFJ'AIR ODIiyjQLIT10N
C 1 hereby union that 1 am exempt from the Connector's License Law for the 11�� ,Q\qC C� r4 e-IVPG'�
following earn.(Section 7011 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. OUT
HER
which requires u permit to construe,aer,improve,demolish,or repair any outcome l G
F':OreJ poor In it,issaanca,alsemporex me nod mI forsuch permit to file asignedstalnmem ` SPECIAL CIRCU IFIM ISC.
} that he is licensed pursuuni to the provninns of the Contemor's License Law(Chapter 9 COMMERCIAL:
OC (commencing with Section 700(p of Division 3 of the Business and Profession.Cade)or TEMR ME MR OR LOLL INST.
a p,oy that he is exempt therefrom and the basis for the alleged exemption,Any violation of ❑NEW BLDG/ADDITTION ❑DEMOLITION
xmLL Section 7031.5 by any applicant for a permit subjects the applicant or a civil penalty of POWER DEVICE) []TENANT ❑FOOD SERVICE
} not more than five hundred dollars(ESUn). IMPROVEMENT
S< nLaxownerof the property,to my employees with wages as their holt compensation, SWIMMING POOL ELECTRIC
R�m willdofhework.andtheamnwe is not intendedoroReed foreae(Sce.)1k14,Business ❑QT'If1iR
F 3 r
and Professions Cale:The Contractors License Law does not apply to an owner of OU'fLLTS-SWITCHES-19%TURES
property who builds or improves(hereon,and who does.such work himself or through
his own employees,pro odal that such improvements are and intended m oRered for NEW RESIDENT[AL ELECfR SQ ET.
sale.If,however,the building or improvement is sold within one year of completion the I'.PLOOR AREA E/SQ.FT.
-builder will have the hurden of proving that he did not build or improve for pre-
,,,,a
ar- /
puafcof arta.).
1,mwn
s oer of the prupcny,am exclusively consul with licensed contractors It TOTAh;
construct the project(Seo.70,14,Business and Professions Cele;)'Ihe Comtactar's Li. /
cense Law does not apply to an owner of property who builds or improves thereon.unit QTY, PLUMBINGPERMIT FEE
who coutonU for such pmjeets with a eome<for(s)IiecnsW punuvm m the Cnnvumnrx
License Law. PERMIT'ISSUANCE e Q
Tum exempt under See .B&P C for Nis reason
ALF12R-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT'.DEVICE. Ll r I hereby wiirm under penaltyofperjury one oflhe following declarations —\ O ^_
(]I have and will maintain a CtriOcmcot`C.mzmt Ioself-irrN a for Worker's Coepen- DRAINS-FLOOR,ROOF,All A,CON I STORIES 'TY PE CONSTRUCTIOI
cation,as Provided for by Section 3701 of the Labor Cade,fm the scofmmance of @e -
work for which this perndt is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compen.wtion Insurance,as malmo rl by Section
] )of the lien Code,for the performance nfthe work for which this permit is issued. GAS-FA.SYS'ITM-I INC.S OUTLETS OCC GROUP APN
CmnoaMy Wo eCnmyn 1Mr:d vrenea e�'(`h nd Pnliey,�ynPMrnmst 1 OAS-EA.SYSTEM OVER 4(EA)
y�'�y��fY•LtS.I'�diey No.���(�%' y�.�-Cpl,
CLRI I A SNOO'TION(ROM WORK S' 4 y�
C(]MPENSAHON INSURANCE 7 lock GRI?ASFIINDDSfR1.WASTE INTERCEPTOR BUILDING DIVISION EIiES
Ghisucdon need antbemropletW lfhbelmnnit is moon,hundreddollan(E too) GREASETRAP
or Jews.) PLANCIIECK FEE
Icimify that in the performance-1 the week for which thispernit is issued,Is hall WE - -STORM EA.2g1IeL ENERGY PEI?
not employ any person in any manner so as to become&objectto the Workers'Compen-
z anon Laws of Culifiands Date ;R IT 51C ENT/F. CIA GRADING FRE
z 0 Applicant
NONCE TO APPLICANT:If,after making this Cenificute of Exemption,ycu should TER SYSTEM/RFATIN SOILS FEE
rf't bavme xahjO,t to the Worker's Compensation pevisimm of the Lvlhor Code,you must
air fonosithnnnply with such pr mons ,this permit shall be deemrsl revoked. WATT' A IC2
W Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLM Q.IT. ('AID
I hereby of ran that is a constmction lending agency for the perl'onnvnce ml' Or Rt iphp
It. w0a the work(or which this famout is ko ed(Site 3097,Co.C.) Y TA'
0 U Landers Name Ad
Caner'.Address TOTAL:
>a G T cenily that I have read this application and state that the Nice infammtion is HUILDING FEE
nF. y cornea.I ogre o,comply with all city and county ordinances and state laws mining to QTY. MECHANICAL PERMIT FEE g1iISMIC IRE
L) ,Z building conswctim.and hereby ambooze representatives ofthis city toenserupon the
aMwe-mentioned property lot inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree a save,indemnify and keep harmless the City of Cupertino agamont
liahil'iies,judgmems,coersand expenses which may in any way acetic against said City ALTER OR ADD TO MECH. PIAMBING FGE
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI]'H ALL NON-POINT AIR HANDLING UNITITO 10.000CF1,11 MF.CHANICAh FEF;
SOI` F.REGULATIONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signatiour7csApplumnifCondeactor Dane J EXHAUST HOOD(W/DUQq HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will henpplicamoo future building car upuntmreoo handle Mnallous mutacial HEATING UNIT(9O I00,010 BTU) 100 Ill (Z,
as defined by the Cupertino Municipal Cork,Chapter 9.12,and the Health nad Safety HEATING UNIT(OVER 100.1100 TO)Cale,Section 2553200? -�`
❑Yes �o VENTILATION FAN(STNGLI!RESID) PAID Data ReceiptI
Will the aoiduarm m future building Igall vu apapmcm or devices which BOILER-COMP CHP OR 100.0X1 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL. X
District'? / BOILER-COMP(OVER IW,gIDRTV)
❑Yes Fal e
I have revelza
the hardoum
s nteoal.v mquiremu un
ender Chooser 6.95 of the Cali ATR CONDI'I'IONIiR �0 a ISSUANCE DATE
format Health&Safely Calc,Secninas 25505,25533 and 25534.1 understand that if the NEW RESIDEN'FIAT.MEC((. SQ.FT.
build,,g enotcarrenay have a nem.,,thio hinny rexpnnsihility no notify the occupant / v / `( 1,
of,he ms�fylhi�ck�nmsnhmef pestis to issuaneeufu Cenificamof Occup(a�n��T,.,
Owner m nutbodred agent Dart TOTALr ISSUED BY:
OFFICE