S 3179 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELP:QRICAL PER(f ff NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBNG-MECHANICAL. J 3179
BUILDING PROJECT IDENITFICA'I'ION
BUILDING ADDRESS; ::Nl IARY NO. APPLICATION SUBMITTAL DATE
11 J 2 r pier) da
OW S NAME: PHONE: COMA 1'OR'S NAM Ii: LIC NO'
0 r F O�Op nn-"SA
f- NIC CONTROLN
ARCHITECOENUTNEER: LIC NO: C ADDRESS: J -7 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH
e' ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTY ELPERMIT FEE
I hereby affirm mat 1 am licensed under prom
visions of Chapter 9lcamencing JOB DESCRIPTION
O fEZ with Section 71NN11 of Division 3 offer HusinessunJ Professions Cade,andery dicenseisad RESIDENTIAL
m p p PIIRMIT ISSUANCE
=UE- L one Class deflect. ❑SFDWL ❑KITCHEN REMODEL,
aVU License Class Lic.b APPLIANCES-RFSIDENTIAI. El ADDITION C3 PLUMBING RE-PIPE
Fs7,W Upto Contractor
m e. ❑MULTI-UNIT El STRUCTURAL.
FOy ARCHITECTS DECLARATION PANELS
Z p v2` 1 understand my plans shall he used as Public records MODIFICATION
p Z-.� UPTO 20H)AMPS ❑INTERIOR 0CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEM17NT C]SWIMMING POOLS
OWNIik-BUILDER DECLARATION OVER LIMO AMPS ❑BATH REMODELtRERAIR [I DEMOLITION
d I Withy affirm that I am exempt from the Contractor's License Law for the
fixx'p 6 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W ay which requires u permit to construct,alto,inhpmve,demolish,or retail airy seuemre
F'�'0 pdorm its iswancealso requires theapplicant lorsuch permit m file.,dowdsmemeatSPECIAL.CIRCUIT/MISC.
Syy that he is licensed parwmp Ed the previsions ofthe Controctors License Law(Chapter 9
..00 (commencing with Section 7lNNlptf Dlvixlon3ol the ilusintsa and Pmfesslonx Cade)art 'TEMR.M ITER OR POLE INSI'.
6 q M C
that he is exempt thercfmm and me basis for the alleged exemption.Any violation M ❑NEW BLDGIADDITION ❑DIiMOLITION
Section 70315 by any applicant torn permit subjects the applicant to a civil penalty of POWER DEVICES TENANT ❑FOOD SERVICE
or nm more than Five hundred dollars(S500).
H Z> IMPROVEMENT
d0 ❑Las owner ofthe propeny,or my employees with wages as their sole compensation, SWIMMING PODLELELTRIC
wdl dothework,paile he Contractors
License offeredformlelply 7044,Business ❑OTHIiR
and property
whiob CW e:The Cpmmetoh License Ww toes nut apply s if owner of OUTLETS-SWI'fCHF_ti RES
propeny who builds or improves thereon,and who does such work himself f through
his own employees,provided that such improvements are nm intended or offered for NEW NESIUENTIAL C:1 SG FT.
sale.If.however,the building or improvement is sold within one yeandc0mpletion,the SQ.14.FLOOR AREA $/SQFT.
.
owner-builder will have The moven of proving that he did not build or improve for par-
pand of sale.).
❑1,as owner of the propeny,am exclusively reproaching with licensed commenra Ed
construct the project(Sec.7044,Business and ProRsioes Cade:)'".Contractors Li-
sa,Law dews at apply tp an owner of propeny who builds car improves rheirm,and QTY. PLUMBING MI FEE
who contracts for such projects with a contraterms)licensed pursuant o the Cmarurnr's
License law. I'I:RMIT ISSUANCE 4117
❑1 P Ipt under Sec .B&P C for this reason
ALTEk-DRAIN&VFW-WATER(E VALUATION
Ownr Dae ^ ®w� {'FY
WORnder PCOM PENSjucry on DECLARATION BACK FLOW PROVE-ICT.DT:VICF. (,J
1 hereby a[Erm under penalty nl'perjury one or fnlhwing dwlnoatnar.
❑ Ihvvr andwill for bySe Ceni 3700 of the
Labor self-in further Workersce of the
DRAINS-FLOOR,RODE,AHIiA.GOND. STORIES TYPE CONSTRUCTION
when,as provided for ea Section d. of rhe Tubo Code,ha the perfamtunc<o(rhe
work for which this permit is issued. TEXTURES-PER TRAP
I have and will ode,fon Workers Compensationfthw rkfor which
of required by Section
3700 aflhe Lahnr Cewlo,for the perfpnnuncenRhe work for whie�m this pemtit is issued. Ons-RA.SYS'TEM-I INO:�-'O 'Lis OCC.GROUP APN
My Worker's Compensation Insurance carrier and Policy number arc:
Cartier: Policy No.: GAS-IiA.SYSTEM- ) �-
CERTIFICAI'E OF 17XFNFI ION FROM WORKERS'
COMPENSATION INSURANCE CHPASI%INUUS ASTP fERC2FIkl BUIIAINGDIVISION_FUES_
IThisscctonneed nor hecompldulil the permit is for one hundreddnllars(51110) GRP.ASE TR "?
mless.) �t PLANCIIECK FI?E
l omify that in the performance of the work bn which mispermit is nsueJ,I shell `4
not employ any person in any manner so as nth become subject to rte Workers'Compen- SEW13R-SAN Y-STORM EA- ENERGY TEE
zmrinrte California Dad WATER HEATER W /1eLEC R
n lows of 9
ZO Applicant GRADING FEE
NOTICE TO APPLICANT:IL after making this CcnlOcac of Exenptlon,you should WATER SYS I'EVIL REAL'1 i[' SOILS THIS'(, Leconte subject to the Workers nsLe
Compeation provisions of me ber Cerk,yw must v ,
4Jforthwith comply is ah such provisions or this penaitshall be deemed revoked WATER SERVICE
C'. Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'll .Flt PAID
U0 1meet,affirm thatthe,,is a vonametion lending agency forth,perOhmtenca of a Receipts
F me work far which this road is issued(Sec.309],Civ.C.) TOTAL
Q Icader's Name
Lender's Addri TOTAL:
I certify that 1 have mail this application and state mat the above art ennmion is BUILDING EI?
Ncomera.i agree to conhply with all city and county on irmaxes and state laws refuting to QTY. MECHANICAL,PERMIT FEE
V Z building construction.and hereby authorixe representatives of this city m enmropon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
IWc)agree to not,indemnify and keep harmless the City of Cupertino against F;LECfRIC 'E
Iiabilitax.judgmcnts.costs and expenses which may in any way aceme against said City ALTER OR ADD TO MECH. PLUMBING Fri
in consequence of the granting of this permit.
APPLICA.14X,UNDERSTANDS A D ILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI T 0010.01X1 CFM) MECHANICAL FEE
S Ukc-RE WLATIONS
AIR HANDLING UNIT(OVER 10,1100 CPM) CONSTRUCTION TAX
Sign pplicaCColuffetor Date EXHAUST HOOD DIODUCT) HOUSING MITIGATION FEE
IIA9ARDOUS MATERIALS DISCLOSURE;
Wilirheappdietat or future baildipgoMcupun.store or handle Enormous material HEATING ON IT(TO 100d)(1I BTU)
as del ined by the CrEadren Municipal Chale,Chapter 9.12,and the Health and Safety
Cash,Section 25532(e)? HEATING ON I'1'(OVER 100,000 H'I'U)
❑Yes []No VENTILATION FAN ISINGLE BESIDE PAID Dae Receipt M-
aad nes applicantcontaminants
future building occupant Bt yA ea Air a or Quality
Maces nagement
nt BOILER-COMP OUT OR 100,000 BTU)
emit huzanlnus air ammminants ate defined by Thr:Bay Arca Air Quality Management L:
DistdcR
E]Yes ❑Na BOILER-COMP(OVER 100.000 BTU)
I have readthe hmardous maenadsu under Chapter 6.95 ofine Cud;- AIR CONDITIONER ISSUANCE DATE
equire
fomia Health ne Snurea Code.e a ime ,that,2s my and 25534.1 umktnmd that ifthe NEW RESIUF.NTIAI.MECH. SQ.f?.
efdre re uirenotts which
have thtone,,matois myreapm.Ceniytoroilycc tecupant
of she requirements which must be ren prinno issuonee of.CeniOcate of Occupancy
Ownermamhrnsed agent Date TOTAL: ISSUED BY:
OFFICE