S 3295 (2) A�PP ICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
rCITYOF CUPERTINO BUILDING-ELECTRICAL PE IT NO.
•-,i I
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL 3295
BUILDING PROJECT IDHNTIF'IL'A'TION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUdMI'1'1'Ah DATE
104-30
NEWS NAME: HO41+G_5_$5 NE: C(INfRACTOR'S NAME: LIC NO:
a LA%4 ATVPN/C CON ROI,k
<CI111ELT/F,NNCINNEER: LIC NNOADDRESS: 1
1,1677,1• F tZ+.vr�{D GA 'bM9 O
CON')'ACT, PHONE: BUILDING PERMIT INFO
^ qct QQ El Consultant Fees Paid by Applicant(Initial) HI.DO ELEECTI PLUMB MIIZ:CH
7(al(J 4rr1 —I K/ � L7 LTJ LTJ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
ozz1 hereby affirm that I am licensed under provisienx of Chapter 9(commencing JOB DESCRIPTION
WOO with Section 7000)of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
WOO PERMIT ISSUANCE
�W_ in full foreeand effect. 'JJ ❑SFDWL El KITCHEN REMODEL
<VV License Cl:s Lic.0 AI'I'LIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
F at Dam Cnmrvno
to L ARCHITECTS DECLARATION ❑MULTFUNIT C1 STRUCTURAL
Foz [undersand my plans sM1all be asci us public records PANELS MODIFICATION
--14— UPIO200AMPS []INTERIOR ❑CHIMNEY REPAIR
I-.';„E-'W Licenced Profc,"marl 201-101RAMP5 IMPROVRMP.NT SWIMMING POOLS
•.1
OWNERBUILDERDECLARATION OYER I(NXIAMPS ❑BATH RI:MOUELIREPAIR �DEMOLI'PION
C st I hereby afOrm(hot l am exempt front the Conuuemr'a License Law for the
O y Vfollowing reason.(Section 70]1.5,Bwiness anJ I'ndccsinns Cale:Any city or county SIGNS ELECTRICAL ❑OTIifiR
413 W I" which mquims a permit to cnrewm,chem improve,demolish,or repair any structure
��0 prior as its issuance,also requires Ne applicant lorsuch permit to file a signed statement S PECIAL CIRCUIT/MISC.
F„!f that he is licensed pursuant to the pause inns of the Cnmractor's License Law(Chapter 9
W..00 (commencing with Section 7")of Division 3 of the Business and Profession Code)or 'TEMP.METER OR POLE INST. COMMERCIAL
c.6 p e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NE I.DG/ADDITION El DEMOLITION
�m Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES =ANT ❑FOOD SERVICE
I,-Z} nonnme than five hundred dollars15501. IMPROVEMENT
6 ,I,as ownernf the progeny,or my employees with wrgca as their sole compensation, SWIMMING POOL ELE
0 will it,,the work.and hheswctureis not inundeJ nr nRereJ for role(Se<.7(W,Busine,s []OTHER
Wand Professions Code:The Commina's License Law does not apply to an owner o OUTLET'S-SWITCH.. -Fl ES
property who builds or improves thereon,unit who does such work himself or throng
his own employees,provided that such improvnaems am not intended or offered for NEW RESIDENTIAL ELE SQ fief. 2
solo ll',however,the building or improvement xsnld within mteyenrof completion,the SU.Pf.FLOOR AREA SItiO.FIT.
pWcrthadder will have the burden of proving chat he did nm build or improve I'or par
vc ol'xnloJ.
0 1,as owner of the property,am exclusively contracting wit chars to (f
construct the project(Sec.7044,Business and Professions C 1 eaes 1'
cense Law does not apply to an owner of progeny who bui)ds -improves in n, PLUMBING PERMIT FEE
who contracts for such project with a comments)licensed pa eco
License Law. 1
O l am exempt under Sec. R&PC fart amu
LT - IN WATERT VALUATION
WORKER'S COMPENSAJ.1raduryoreofON the having BA F PR 9 O '` O
I hereby M.under penalty rl perjury one of the following declarations: D, V
]Ihavc unA will maimainaCertidcnte of ConecnuomlGinsure for Worker's Cnmpcn- DJNJFLOOJffRJaART3A,1D. I STORIES TYPE NS'I'RUM ION
anion,as provided for by Section 3700 of the Labor Cale,for the performance of the
work for which th is permit is issued. PI%'TURES-PGR TN /
37 I lova and will maintain Worker's maws of theaproUt
w Irk f..vshi as his required,i Section
3700 nfthe Lubar Coda,for aha perfnrmanw ol'hhc work for which this l'ermb is issue]. CAS-P.A.S Il'PLD'fd OCC CROUP AI'N
My Worker's Cmpensation Insurance cvrtier mrd Policy number are: 1n
Cartier: Policy NO,: GAS-EA. SM-OV, r JI la
CERTIFICATE OF EXEMPT ION FROM WORKERS' GREASFAN S LWAspEl E EP
COMPENSATION INSURANCE. BUILDING DIVISION FEES
(This section need not becompleted iftheNmit isformahandreddollars(510) GREASETR A ^ O
or less.) PLANCHECK FEE l�
(certify that in the perfontmnce of the work far which this permit is issuad.l shut) SEWER-SA BY EA.200 FT.
not employ any parson)J ymurria,pS�ip}l�tr r`/ytJe object the Workers'Compere ENIiRGY PIiE D o
o z Applaicant sof R'llt(e15Date/�{(tiya.F -i WATER HGAT'R ENT/ELELTR
VVFFYYY" )VVVVV�VVVV111II000C.XXXYJJJJ�����x GRADING FEE
z h NOTICE TO APPLIC :IL after making tonifcate of Exemption,you should WRIER SYS')' G SOILS FEE
f"u became subject to the Workers Compensminn")®r Binns of the Labor Code,you most
forthwith comply with such provisions Or this permit shall he Jeetned revoked. WATER SERVICE
Q
IL
CONSTRUCTION LENDING AGENCY NIiW RESIDENTIAL PLMB. SQ.Ff. PAID
wachymTrm that is a cnnstructlna leadi OR agency for the performance of ) ReeetptK
the work far,which this penult is issued(Sec.3097.Civ.CJ
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fsnakr's Name TOTAL:
Lander',Address T('A
D. I amity that I have read this application and spite that the above information is BUIL NC 'CF.
rFiy career,I agree m Comply with all city and county ordinances and auto laws relating to QTY. MECHANICAL PERMIT FEF.
V z buildingconstmction,and hereby uadmixe representative,ofthiscirymenterupon the SEES 1 TE
aM,vomentioned property for inspection gurprses. PERMIT ISSUANCE^ -3 O O
(We)agme to save,indemnify and keep heart the City of Cupertino against BILE C FEE f .
Iiabil lies.judgments,costs and expenses which may in any way accrue against said Cit Z ph1'F.R f/R ADD TO MECH.
in capacitance of the granting of this permit. PLUME NGFEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING ON]TOO I0.000 CUM)
S(IURCP. n 'TIONS. MF.CI (CAE.t•LF.
AIR HANDLING UNI'F(OVER 10,000 CFM) CONST DON]AS
SignaureofApplicunt/Commctu Date EXHAUST HOOD(W/DUCT') HOUSING TIGATIGN FEE
HAZARDOUS MATE I LS DISCLOSURE
Wilt the applicant Orfuwre building w apart store or handle hamNous material fir.
UNIT(TO 10,INNl BTU(
as defined by the Cupertino Municipal C ,Coupler 9.12,and the Health and Safety
Gyle,Section 25532(a17 HEATING UNIT(OVER 10.004)BTU)
❑Yes IN. VENTILATION FAN(SINGLE RESID) PAID Date Receipt
Will the applicant or future building occupant no equipment or devices which y01LER-COMP(3HPOR 10,INN1 B'N)
nit harnNous air contaminants as defined by the Bay Area Air Quality Management TO L'
utrict? BOILER-COMP(OVER 100,000 It rU)
0Y. INo
I have read the hazardous materials requirements under Chapter 6.95ofthc Cali- AIR CONDO HONER / ISSUANCE DATE
Tanto Ilcalth&Safmy Code Sardi s 25505,2.5539 and 2.5534.1 andirstand that it he NEW RESIDENHAL MECH. SUIT.
building does not currently haven tenant,(hut It Is my respmndilihy to notify the mcaparm (((
nrihere oma est etprionnissunneeefuCenificmeof Occupancy.
Owner Or authorized agent Data /T44 ISSUED BY:
OFFICE
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