S 3991 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3991
RUILDING•PROJECT IDENTIFICATION
BUILDING AI)URESS: � SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'SNA NE: C RACT 'S F: LIC NO:
NIC CONTROLM
�I ARCHI CTIENGINEEK: LIC NO, q ❑
CONTACT: NjaPHONE: BUILDING PERMIT INFO
Z J 151 ❑ Consultant Fires Paid by Applicant(Initial) BrLIDEGG/ ELECT PLUMB MECH
MMU
LICENSED CONTRACTOR'S D ARATION Qpy ELECTRIC PERMIT FEE
1 hereby areae max 1 am fie.aed ander pro a. sof Chapter 9(commencing JOB DESCRIPTION
WOO with Secood"aX1)af Divixion9 ahM1e Ruxiness and essime Code,and my license is RESIDENTIAL•
F O full fo.mda PERMIT ISSUANCE
a U V Lic we as L,c.M - ❑SFDWL ❑PLUMBIKITCHENG
REMODEL
yZQa Dam
Co.,-
ARCHITECT'
nr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Fay ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Zp�7K I undersand my plan,shall be used aw,blienconds PANELS 'MODIFICATION
OZ-, UP TO 201 AMPS [I INTERIOR ❑CHIMNEY REPAIR
F.y-t:m Licensed Professional 201-11"AMPS IMPROVEMENT []SWIMMING POOLS
94U OWNER-BUILDER DECLARATION OVER I KK AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
1 hereby affirm thea 1 am exempt from the Contractor's License Law for the
{iL506U following mason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
sR�O F which requires a Permit to conswca,alter,improve,demolish,m repair any ammum (p
I prior to its issuance,also requires the applicant for such Permit to rile a signed statement SPECIAL CIRCUIT/MISC.
HHyo" but be,,IlcensW pursuanno thepro,kion,ofthe Comramor's Li.nse Law(Chapter9
(commencing with Section 7000).f Division 3 ofthe Biomessnnd Professmns Code)., TEMP.METER OR POLE INST. COMMERCIAL:
K that he is exempt therefrom end Rm basis far the nllegrxt exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLG ION
I.
LL
Section 7031.5 by any applicant for a penrvt subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT GFOOD SERVICE
� } t more than five hundred d.11...($50)(E. IMPROVEMENT
Q C I,as owner of the pmpeny,or my employees with wages ex their sole rompensetion, SWIMMING POOL ELECTRIC
will do the work,and thesuuamehour imended.,.11hred farted,Sce.7044,Business ❑OTHER
W
RE and Proussions Code:The Contractor's License Law does not apply m an owner of OUTLETS—S W ITCHES—FIXTURES
6' property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL F.LECTR Q FT
sale.IL however,the building or improvement is sold within oneyeaofcompletion.the SQ.FT.FLOOR AREA $ISQ.FT
owner-builder will have the burden Of proving that he did not build or improve for pur-
pa,e ar ame.l.
1,as owner of the progeny,am exclusively contracting with licensed contractors in TOTAL:
construct the project(See 7044.Business and Prnfessmas Crde:)The Camracmr's Li-
sense,Law does runt and,to on .,a,who builds or inaprovi,sdismad.add
i-sense,Lawdoesnmapplytoonownerafpmpenywhobuildsorimprovestheman.and QTY PLUMBING PERMIT FEE
who conuams former projects with a cantmcmr(s)licensed pursuant o the COntmmes
IAL aria Low. P17RMITISSUANCE
❑ I um exempt under Sec. ,B as P C far this reaxon
Owner Date ALTER—DRAIN&SENT—WATER(EA) VALUJJA•TT�ION /�
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 2 O C! Day
1 hereby affirm under Penalty of perjury one of the following declamlions: -
❑Have and will arrimaina Certificate of Consenttoself-insumfor Workers Compery DRAINS—FLOOR.ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
smite,as provided far by Section 37W of the Labor Code,for the performance of the
weak for which this pandit is issued. FIXTURES—PER TRAP
❑I haw and will maintain Workers Compensation Insurance,as required by Section
370dof a bar aulinthe er(ortnance of the work for whichthis permit is issued. GAS—EA.SYSTEM-1 INC.40UTLETS DEC.GROUP APN
Y MI. s16 nen teener and Policy
CnmerI Pelicy Na. ' GAS—EA,SYSTEM OVER 4(EA) -
CERTIFICATEOFEXEMPTION PROM WORKERS' GRCASEIINDUS'TRL WASTE INTERCEPTOR
COMPENSATION INSURANCE: BUILDING DIVISION FEES
(This sectimimed not W completed ifthe permit is faro.huMrddollurs SI0m GREASEIRAP
tar lass.) PLANCHECK FEE
I cenify that in theperfmanncenfthework for which ahis,coranls issued lshWl SEWER—SANITARY—STORM EA.200 FL
not employ any person in nny manner so as to become subject to the Weakens CompenF.
Z scion lawsi fCelifon,u.Dae WATER HEATER WNENT/ELECTR
O O Applicant GRADING •E
fA NOTICE TO APPLICANT.If,ufmr nwking this Cenifica¢of lixemptinn,you aM1aud WATER SYSTEM/BEATING
a become subject acidic Worker's Cum enation f the Labor Cole,you must SOILS FEE
jp Permit
shall
(11
forthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
aQ
UO CONSTRUCTION LENUING AGENCY NEW RESIUENTIALPLMB. SQ,FT. PAID me Receipt
I heathy affirm that there is sued Semon lsndis,agency for he perrormanca of
0 i" the work for which this pertnh is issued(Sec.3097,Civ.Cd
F" Isndets theme TOTAL:
V Letri Address TOTAL:
aI certify that 1 have read this application and shite that the above information is BUILDI FEE
V) Corset.join..comply withall cityond county Orhodavelmd some lows relaxing to QTY. MECHANICAL PERMIT FEE
buildiri,ems uctim.and herebyamhman repreunntives of this city steer upon the SEISMI FEE
above-mentioned property for inspection puHmses. PERMIT ISSUANCE
(Wil)agree to save,indemnify and keep hnrmles,the Clay of Cupertino against EL NNECAME
Ii abilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the RnntinB ofof t P
APPLICA T UNDERSTANDS AND WIL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10, •M7 C OUC ATIOAIR HANDLINGUNIT(OVER "C AX
7Si,d.,0mdFApplicanti etor Date EXHAUST HOOD(W/DUCI} T S G MITIGATION FEE
I DOUS MATERIALS DISCLOSUREazadommaterial HEATING UNIT(TO 10TOWby the Cupenino Municipal Code,Chapter 9.12,and Ne Health and Safety,
ion 25532(x)? HEATING UNIT(OVER 100,000 BTU)Yes ❑No VENTIIATION FAN(SINGLE RESID) PAIDDace Receipt ssl the applicant or future huilding Occupant use equipment or devices which
tvadous air contaminants n JcfinM by the Bay Arta Air Quality Management BOILER—GOMP(3HP OR I00,(Mp PTU)
TOTAL:
District? BOILER—COMP(OVER 100,000 BTU)
C3 Yes, ❑
YeNO
AIR CONDITIONER
1have th&Stheh are,Sen..2555.2ls 553adunder Chapter 6.95 of the if Cali-, �} ISSUANCE DATE
Ionia Health&t cum Coda Section 25505.255JJ and 255]4.1 a notify th that if Ne NEW RESIDENTIAL MECH. SQ.FT.
buil nccurtentlykveamnant.thaitismy respnniM1ilirymnmify the Occupant L/1�/• ��
in e i ents is usah apnea hn,xnuunce afuCenificme of(kcupancy.
XOwnroramhoduedagc Dam TornL: ISSUED BY:
OFFICE