S 3964 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3964
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S AME: t PHONE', CON ACT'OR'S NAME: �f LIC NO',
NlC ^ CONTROL#
ARCHITECT/ENGINEER: LIC NO: ADDRESST ❑
5 �.dE.4ue
CONTACf: PHONE: BUILDING PERMIT INFO ; ')
❑ Consultant Fres Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT ' PEE
I hereby affirm that I am Iicens<d uMer provisions of Chapter 9(commencing JOB DESCRIPTION
O0Z with Section700p,f Divimort3afthe Busine,iind Pmfessiuns Cmde.mndmy license is RESIDENTIAL:
�I- PERMIT ISSUANCC `
Sin full force and eR'n. 8 T77-
"I.- ❑SFDWL [I KITCHEN REMODEL
i-Zw LiccnscCle G Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
yQG Dam ` Contras C
y.Dm ARCHITECTS DECLARATION PANIRS ❑MULTI-UNIT ❑STRUCTURAL
I understand my plans shall be used as public restarts MODIFICATION
Z O y Z
oz-, [-I 2W AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Fn:; Licensed Professional 201-1 WOAMPS IMPROVEMENT SWIMMING POOLS
agOWNER-BUILDER DECLARATION OVER IOA7 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
K 1 hereby alHmt that 1 our ezmnpl form th<Cootraetor' cense Le for the
3 LLb- following memo.(Semon 9011.5.Business and Pmfessiuns C mAny ci or county SIGNS ELECTRICAL El OTHER
y which requires a permit m cunswct,titan improve,demolish,or ny sWcture O `/
,F]�Og prior m ins issuance,also requires the applicant for such permit to f a signed statement SPECIAL CIRCUIT/MISC.
f(!(y that he is liveried pursuant mthepmviskmi the Co. rose Law(Chapter 9
Ya1_GZO (commencing with Sectbm 9lNKry of Division3mftheBu.` ofesshms Codam TEMP METER OR POLE INST. COMMERCIAL:'
a K c C that mea esempl therefrom and the basis for the alleged s prion,Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 0031.5 by any applicant for a Permit subjects the ap -ant to a civil penally of POWER DEVICES ❑TENANT ❑FOOD SERVICE
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not mom than live hundred dollars($500).Y IMPROVEMENT
�=6 E] Lo the work,the pestruc,mmyemploy with orad avt irsolecompcienamid..11minee, SWIMMING POOL ELECTRIC
rEFO will Bothe work.and Coil:: ho intend Lim Beredf sale(Sly to
Busine.a []OTHER
a and Professions Cale:The Contraaom Limits La not apply to an owner of OUTLETS-SWITCHES-FIXTURIS
progeny who builds or' proves Neuron, nd w docs such work himself or Ihmugh
his own employes,p idcd Ihet such or
men s sur am not intended or aifrrad fm NEW RESIDENTIAL ELECfR SQ PT.
sale lL bowevettheb Idingserimpure Id s'thinaneyeamfmmpletion,the SQ.FT.FLOOR AREA $/SQ,PI'.
crIW ild<r will he the buNen o rovirg t I he d nal build or improve for pun
puts of sola.). .
❑ L as owner of th progeny,am xdusively soar g with licensed contractors to
enhance,the Project Sec.7DW, ss and Professions Cale:)The Canuactmes Li-
nc -
c seLow dues mol PPI rnufpmpeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEE'
nn
whoronwt,mrsoL rojeetswil ontmcnm(s)licensed pursuanuo the Contractor's - t
License Law,
L] lameseavotndcr Sec. .B&P C for thboo.emn PERMIT ISSUANCE (' � V
Owner Data
ALTER-DRAIN&VENT-WATER(EA) 30 �AIBIA
L tJI
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑Iheve and will maintain aCenificate of Conunuoself-Insure for Workers Compcn- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE COn:LR CTION
satin i.as provider
d for by SmI a 3700 of the Labor Coda,for the perform..of the IU ,�
work for which this period is laved. FIXTURM-PER TRAP s ,,.--
❑1 have and will maintain Worker's Compensmion Insurance,as required by Section
3900 of the labor Code,for performance mf the work for which this Permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC,GROUP APN
My Workers Compensation Insurance carnia and Policy num a¢ Q
Carrien S7);'7W x&W Policy No.: -M.AZZ-T GAS-EA.SYSTEM-OVER 4(EA)
CERI'IFTCA9'80F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASERNDUSTRL WASTE INTERCEPTOR
BUILDING
(This section iced not he completed if the Permit is formic hundred dollars($100) DIVISION FEES
nr Icss) GREASE TRAP PLANCHECK FEE
I certify that in the pef.m.fthe work for which this permit Ts issued,l shot[ SEW12R-SANITARY-STORM EA.201 FT.
not employ any person in any manner so as to become subject to the Workers'Co n,an- ENERGY FEB
,Z cation Laws of Callfomia.Date WATER HEATER WNENT/[LECTR
O Applicant GRADING FEE
y NOTICE TO APPLICANT If,after making this Certificate of Exemption,you.should WATER SYSTEM/TREATING
F become subject to the Wmkch Compensation provisions of the Labor Cade,you meal SOILS FEE
forthwith comply with such provisions or this Permit shall b<deemW revoke. WATER SERVICE
d
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
7 '� Ihereby affirm thenhere iso construction lendingagency for the performance of D e Receipt#
U O the work for which this Nonot is issued(Sec 3097,Civ.C.)
u' 17. LcnJ<r's Name TOTAL:
Leadds Address TOTAL:
{�.,..t I cantly that I have mad obis application and state that the#Nice information Is BUILDING PE
i.. f�/f correct.l agree to comply with d1 city and county ordinances and site laws relining m QTY MECHANICAL PERMIT FEE
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building construction,and heroby oubmize representatives of this city to enter upon me SEISMIC FE
above-mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE O
(Wa)agree to save.indemnify and keep harmless due City of Cupertino against
liabilities,judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH,
in asequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WR.L'COMPLY WITH ALL NON-POINT AIR HANDLING UNITITO IQ000 CPM)
SOURCE NEGULAT MECHANICAL FEE
�¢ -99 AIR HANDLING UNIT(OVER IO,IXgCFM) CONSTRUCgONTAI
Signumre of ,fc.no Cco ctmr Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or to..buildo,oceupant somam-hendle hazudous material HLATINGUNIT(TO 101"BTU) Iv
as defined by the Cupemm�Municip:d Code Cheptcr Y.R,and tM1e Health anJ Safety
Cale,Section 25532fa1" HEATING UNIT(OVER 101,1100 BTU)
C3 Yes No VENTILATION PAN(SINGLE RESID) PAID -
Will the applicant or future Wilding occupant use equipment or devices which Data Receipt M
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR BX1,000 BTU)
District? 'roTAL'.
El yes ❑Na BOILER-CLIMP(OVER 100.(Xp OTU)
AIRCONDITIONF,R . L
1 have read the ha,mcces matcrids requirements under Chapter 6.95 of the Cdb ISSUANCE DA�
farms Health&Safety Code.Secdonc 25505.25533 ani x5530.1 undo stall tbut if the NEW RESIDENTIAL MECH. SQ.FT. /�
hail ' daesnatemne, y �erp�nt,that it is my responsibility to notify the mecupara
s there <n t his alb Aet priormissuanee ofa Cyril'utFJjpecLtpaocy. �O
Owner or oath zed.,an, (O / Dat< TO 1 ISSUED BY:
OFFICE