S 3938 (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 3938
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
O
3o E Z e t -1
QWNER'SN ME� �1 ♦ P+i4[JF:: CO v;Cf�;' NA LIC NO:
dT♦{V\ `��/JN NIC CONTROL
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
�A ' 1� �g�g�k al c 1�Q t ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
R V LGN' C.L� ❑ c2i ❑ - ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby action that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Woo thScctim1]IV0)of Division 3ofthe Business and Professions Codgandmy liceaaeis RESIDENTIAL:
F�0 in our full force and effect. I PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�zW License Cl ss s ' Lic.# APPLIANCES ❑ADDITION ❑PLUMBING RE-PIPE
n wuE Dam Convactnr_
ARCHITECTS DECLARATION ❑MULTI-UNIT [I STRUCTURAL
p.7 rn PANELS
Z p 1 understand my plans shall be used as public records .'T MODIFICATION
OZ—runderstandUP T02(k1AMP5 Z r 2 O El INTERIOR ❑CHIMNEY REPAIR
.5
�� ',Yl Licensed Professional 201-IOVAMPS IMPROVEMENT SWIMMING POOLS
�WF,; OWNER-BUILDER DECLARATION OVER Ifgg1AMP5 El BATH REMODEI/REPAIR (]DEMOLITION
C 04 Q 1 hereby alRtn that 1 am exempt from the Cmi nacaue,License law for the
60 L U fallowing reason.(Section 7011.5.Rosiness and Profeszians Code coy my or unty SIGNS ELECTRICAL ❑OTHER A
'3 LL which requires a permit to ronswn,alcor,improve,JemolisM1, y note
tEl prior to issuance.also requires the applicant for sucM1 pent ion file a,rne statement SPECIAL CIRCUIT/MISC.
�!(}� thouheis Im,wit pursuannothe.&visions 3the cB., w(Chupmr9
m..p0Y chamrescingw,therafroin ad a(Division3 of the Bus o(en,vi Cade)or TEMP.MIifER OR POLE INST.
a n Se he is exempt Ncrefrom and the bnsis for the aIle d prat Any vimminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
-,N genion]tD1.5 by any applic rlora permit su ' ns nth pp tto ucivil penahy of POWER DEVICES ❑TENANT ❑FOODSERVICH
f-Z
t mare Nen five hundred am Y IMPROVEMENT
_< ❑Lys owner of the trope Y. rmY employM wa their sole c.m,Business SWIMMING POULIiLECfRIC
..Q
will Jothe work.and they ctore isnot in dad or mm for sale(Sec.]IW4,Business []OTHER
W"� and Pmiessams Code:' a Commctor n cot 1,w does not apply t.an owner of OUTLHIS-SWITCHES-FIXTURES
property who huilds nr mprnves
be
on,an who docs such work himself or through
his awn employees, that chimp. cots are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,hawevm.,he building improvement is sold within one year ufcompletion.the SQ.FT.FLOOR AREA S/SQ.PT.
owner-builder will have the bur a of proving that he did not build or improve for pur- na
pose of sale.). a
TOfA
1,ac owner n(the pmpeny,am clue vely contracting with licensed ce tncron to
container the project(Sec.7014,Bu.ness and Professions Chep The Contractor's Li-
censeLaw does not apply toanown erofproperty who builds or improves thereon,and QTY, PLUMBING PERMIT
whaeanaacts forsuch projects with acnntrucmr(s)licensed pursuant mthe Contractor's 6616 o Nor
License Law. PERMIT ISSUANCE
❑1 am exempt under Site ,B&P C fur this reason
Owner Dam ALTER-DRAIN&VENT-WATER(EA) VALU
. WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
m
I hereby aRrunder penalty of perjury one of the following declarations:
E]I havermd will maimeina CertiOcam of Conserv mself-inmre for Woroo,Compen- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
ration,A provided for by Section 3700 of the Labor Code,for the performance of the
week for which this permit is imued. FIXTURES-PER TRAP
❑1 base and will mai main Workers Compensation Insurance,as required by Section
37M of the lalo,Code,for the performance of the weak for which this permit iaissued. GAS-PA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workeyik ypp lnppTTn����ee,�<��r�(panit Policy
Cartier:�S e G ClJN VI{dicY No.: GAS-EA.SYSTEM-OVER4(EA7
CfiRTIPICATE OP E%EMpf10N FROM WORKERS'
COMPENSATION INSURANCE OREASFIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This arm need nm be completed if the permit in I...ehundreddollas(SIM) GREASE TRAP
or less.) PLANCHECK FE[
I certify that in the perfoornmerofthe work for whichthis permit is issued,i shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to became sobject o the Wadden'Camper- ENERGY FEE
O z sation Laws of Califomia.Date WATER HEATER W/VENTMLECTR GRADING FEE
O Applicant
V2 NOTICE TO APPLICANT:IL after musing this 171mlotm of Exemption,you should WATER SYSTEMG1t1ATING
(, become subject to the Worker's Compensation provisions of the Labor Cale,you most,
SOILS FEE
Wforthwith comply with such provision or this permit shall h deemed revoked. WATER SERVICE
Q
z CONSTRUCT PON LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Dat eipt#
U Iherehy affirm Nmthere isaconstmnion lending agency f.nhe perfoamance of
the weak for which Nis permit is issued(Sec.At Civ.C.)
Lenders Name TOTAL:
U Lender's Address TOTAL:
Ty,.. U.l1 cenify Nat 1 have read this upplienion and conciliar the shove information is BUILDIN
o
Lt Tp correct.I agree to comply with all city and county ordinances and sum laws relating to QTY, MECHANICAL PERMIT FEE
Uz buildingasnstmmion,and hereby authmire opreamativesmNtscity mercer upon the SEISMI PEE
above-mentioned propeny for inspection purposes. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to save,Indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said CityALTERORADDTOMECH.
in consequenceofthe gmmo.gaf N' perm. PLUMBING FEE
APPLICANT UNDER ANDS D .COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
MECHANICAL
SOURCfi�+�'ULAT10 5. �/gI
h _ &9 L--a• AIR HANDLING UNIT(OVER 10.WO CFM) CONSTRUCTIONT
igwwm App` wmmCsmm.m Dote EXHAUST HOOD(W/DUCT) HOUSING MITIGATION HE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or farm building tscupant,amem handle handrail.,material HEATING UNIT(TO 100,0(g)BTU)
as dRmed by Ne Cupertino Municipal Cade,Chapmr,9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER 1(VpW BTU)
[3 Yet [-I No VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or future building occupant use m or devices which Dam Receipt#
pp g pan ea Air BOILER-COMP(3HP OR 100.aV BTU)emit hazardous air cnnmminamz os defined by the Bay Area Air Quality Management L: O
District? BOILER-COMP(OVER 101000 BTU)
❑Yes ❑No
Ihevereadthehaeardo16505
s requirements under Chapter 6.95 of the Cali. AIRCONDUDONER ISSUANCE DATE
(.min Health&Safety . rand Nmifthe NEW RESIDENTIAL MECH. SQ.FT.buildin notcure.d havitis. nymminaftheOccupant
o(Ne menta which trusor to 'o Certificate of Oc upancy.
]wnenr orizcd agent •Date TOTAL: ISSUED BY:
OFFICE