S 3339 (2) --APPLICANT-TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING.MECHANICAL 3339
BUILDING PROJECT IDENTIFICATION
f01BUILDING`ADDRESS SANITARY NO. APPIACA'I'ION SUBMITTAL DATE
ZZy RSSNAME: —THOSE: CONTRACIO EREMASONR1fIGNO
G/ON/C ONTROL#
,ARCHITECGENGINEER: LIC NO: ADDRESS: CAMPBELL.CA 95009 ❑
CONTACT: PHONE: BUILDING PERMIT"INFO
❑ Consultant Fees Paid by Applicant(Initial) Lg pG. ELECT PLUMB MECH
LICENSED CON'1'RACI' R'S DECLARATION QTY. ELECTRIC PERMIT FEEI� ry. ❑ ❑
1 nereny arm that am Imenaea ander provisions tar chapter 9(a. ndna JOB DESCRIPTION
DaZ with Section f 3ofthe Bu,irm
WoC)
in full force y/�/ PERMIT ISSUANCE RESIDENTIAL:
/ se ❑SFDWL ❑KITCHEN REMODEL
PUV License Cl.'s Lip#
Pzcj Out Conlmc APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBINGR -PIPE
'
ARCHITECT'SD N ❑MULTI-UNIT El STRUCTURAL
MODIFICATIONz ' drsmnd y ptshall heuls Public eoe � � PANELS
oci)
UP T02(NI AMPS
❑
.Q.t INTERIOR MNEY REPAIR
Cujv OWNER-BUILDER UECLARA'IION LicerAful Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
C W d I hereby affirm that 1 am exempt from Ne Corona,.,',License Law for the OVER 10(10 AMPS El BATH RF,MODEfJREPAIR [I DEMOLITION
O following reason.(Section]11315,Business and Professions Cede:Any city or county SIGNS ELF,C'I RICAL ❑OTHER
W a 0.y which requires a penult to construct.alter,improve,demolish,or repair any,structure
F�yOy prior tops issuance,also requires the applicant for such permit to rile u signed statement SPECIAL CIRCUIT/MISC.
that heis licensed pursuant to the provisions ofthe Cmntmctors License Law(Chapter 9
(commenting with Section romper Division Sof the Businessland Profession,Code)., 'I EMR MET ER OR POLE INST. COMMERCIAL:
0. e LL that he is exempt Ihumfmm and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
'^
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑
ti TENANT FOODSERVICE,
not more Than five hundred dellms(8500). IMPROVEMENT
F�7�d0 ❑ L as owner of the property,or my employees with wages as their,role compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended or offered for sale(See.]IMT BusinessTHER
ilt
and Professions Gale:The Commuters License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property wbo builds or improves thereon,and who docs such work himself of through
his own employees,provided that such improvement arc not intended or offered for NEW RESIDENTIAL ELECTR SQ FT
sale.IL howevets the building or improvement is told withinone yearofrompidion,the SQ.Fr.FLOOR AREA $/SQ.FT.
er-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.)
❑I,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the project(Sea.7644,Business sad Profession,CM,:)The Contractors Li-
active Law does not apply to an owner ofpmpeny who huilds(ir improve,thereon,and QTY PLUMBING PERMIT FEE
who eoartaet for,uch project with occurrences)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑ 1 um exempt under Sec. ,B is,P C for this reason
Owner Dom ALTER-DRAIN A VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE 1//O
I hereby affirm under penally of perjury one of the followrr
following declaes
❑ Ihove sect will mvinmiv aCenlMate ofCon,ent nr pelf-insure far Worked,Cmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIBS TYPE CONSTRUCTION
action as provided for by Section 3700 of the Labor Code,for the performance of the
for which this permit is issued. FIXTURES-PER TRAP
coo I have and will maintain Worker's Compensation Insurance,as required by Section
01 effNC Labor Coit I Inc f t ee eft he work fu whi' a GAS-EA.SYSTCM-I INC.40UTLETS
Per '''I� OCC GROUP APN
My Wor I ban cn' Folia br �-'/ ss GAS-EA.SYSTEM-OVER4(EAJ
Carrie cy Ns
CF.R IFICA PE SATION1I EXEMPTION WORKERS'
COMPENSATION INSURANCE. GREASEIINDUSTRL WASTE,INTERCEPTOR
BUILDING DIVISION PEES
(This cairn need not be completed if Oto permit is forone huvdrod
or less.) //dolhns($1p/ GREASETRAP
/ PLANCHECK PEE '
I eenify that In the perfrrmanecofthe work far which this permit is issued,I,M1v11 SEWER-SANITARY-STORM EA.200 FT.
net employ any person in any manner so as to become subject to the Workers'Coupon- ENERGY FEE
z 6ation lows of C.Iddrant Date WATER HEATER W/VENT/ELECTR
Applies, GRADING FEE
rn NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTE 117REATING
a become subject ,,the Worker's Compensation provisions of the Labor Code,you must SOILS 17EE
forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
� z CONSTRUCTIONLF,NDINGAGENCV / NEW '1DENTIALPLMB. SQ.FT. PAID
rifi
I hereby o ,,.thatrheaemiissaconstruction onstion lending agency for the per4a
nmnce of Dote Receiptb
V the work for which this permit Is issued(Sec.31197,Civ.C.) /
QE" Lender,Name o TOTAL:
Lenders Addre„ s �If TOTAL:
I certify that 1 have read this application and state that the above inform( BUILDING ME
rr h correct.I agree to comply with all city and count ordinances and,mte laws rel mg tr QTY 7 ECH ICAL IT FEE
V building censoaation.and hereby sathoriu representatives orchis city to enter pp SEISMIC PEE
above-mentioned property for inspection purposes. y .O
(Wc)agree m save,indemnify onJ keep hardens the City o[Cupertino ago . PERMIT ISS CP' ELECTRIC FEB
liabilitieqjudgment,rosin and expense,which may in any way seems again,said City LTER OR ADD TOM
in amsegaence of the granting of this permit PLUMBING LEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NONPOINTAI DLING UN IO,000CFM) MECHANICAL FEE
SOURCE REGULATIONS.
AIR HAND NIT VER 10,000 CFNE CONS'rRUCUON TAX
Signature of AMIierngAultracm, Data EXHAUST HOOD( /DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the ipplicamor furore Iding ocwpant store or handle hudidusi material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Mu tpel CWe,Chapter 9.12,and the Health and Safety
Cole.Section 25532(u)? HEATING UNIT(OVER 100,M)11 BTU)
❑ye, No VENTILATION FAN(SINGLE RESID) PAID
Data Reccipl#
Will the applicantor
future building eecupunt ux equipment or devices which BOILER-COMP(JHP OR Ib(I,INIO BTU)snit hazardous air carbon an odcfined by the Bay Area Air Quality Management �,
District' BOILER-COMP(OVER 100.000 PTU)
❑Ye,
AIR CONDITIONER
I have real the N12
aos mat rials twryiremenix under Chapter 6.95 of the Cad- ISSUANCE DATE
'fn &Safety Cod4 Se n 25505,25533 end 25534.1 undettaad Nal if the NEW RESIDENTIAL MECH. SQ.FT.
til 'marine notcurr mly lmv tmmnt.drat a is my respoasihnity m obythe occupant _
or d be paionoissn act ifrc e,,focc p' cy.
omM1odu em ate TOTAL: ISSUED BY:
OFFICE