S 3883 (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 3883
RUILDING.PROJECT IDENTIFICATION I
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
0Sd S fj
OWNEWSNAME: PHONE: CONTRACTOR'S NAME: LIC NO:
R , .20 X009 NIC CONTROL#
ARCHI C*Vf NGINCER: LICNO: ADDRESS: ❑
970,16 novo &&W y4ufY M
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLOC ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMITI FEE
1 hereby atrrm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
{D e4Z th Sccdon 70(1(#of DivlsianJ o[tbe Business and Prafcxsion,x Gocs.oddty license le
F C O In full nom and clfw PERMIT ISSUANCE(
C W _ � AFOWL ❑KITCHEN REMODEL
aUU License Clos�LiC09_15771__
APPLIANCES
-RESIDENTIAL pDDil'ION El PLUMBING RE-PIPE
y a Dote l'S Dhmr
ARCHITECTS DECLARA ION PANELS [I MULTI-UNIT CSTRUCNRAL
C)- I understand my plans shall be used as public records MODIFICATION
OZ-, UP T02tq AMPS El INTERIOR El CHIMNEY REPAIR
Licensed Profexeiomtl 201-IOOOAMPS IMPROVEMENT CSWIMMING POOLS
yyF., OWNER-BUILDER DECLARATION OVER IOOf1AMP5 ❑BATH REMODEUREPAIR DEMOLITION
6 C f Q I hereby aRrm th
that 1 am exempt from e Contractor's License Law fa the
Xii:
LL0 U following Mason.(Sectirs 7031.5.Business and Professions Cade:Any city a county SIGNS ELECTRICAL COTHER
b ya which requires u permit to construct,alter,improve,demolish,or main any sanctum¢
prior to its issuance,also requires the applicant for such permit to file a slgnedmmemem SPECIAL CIRCUIT ISC.
F�} that hots licensedpmsuanuotheprovishorofthe Conwcmrs License law IChup, 9
�{ysp0 (commencing with Swtian]0001 of Division3 o(the Business and Pmfcusions Code)or TEMP.MEI'E RPOLELNST COMMERCIAL:
(lint he is exempt Ther from and the basis far the alleged exemption.Any vinlmion of ❑NEW BLDG/ADDITION C DEMOLITION
X 4. Swoon]031.5 by any applicant for o permit subjects the applicant a civil penalty of POWER VICES
C IMPROV C FOOD SERVICE
dot marc than rise hundred deform y employees
IMPROVEMENT
�6 CL.mcwor of theprnpeny,or myemployecswit wages as theiraole comlxnsmian, SWI INGPWLP,LLCTRIC
w111 Jaahawork,and thcswc(ude is not intended or offered for salelSe_."4 Business CDTHEA
0. anti Professions Code:The Contractor's License law does no,apply m an owner of LETS-SWITCHES-FIXTURES
.. properly who builds or improves thereon,and who does such work himself or through
his own cmptnyccs,provided(hat such improvements arc not intended m offered litsNEW RESIDENTIAL ELECTR SQ IT.
soe.ILhowevea(hehuilding orimprovement is sold within ane ywrofromplminn,the SQ.FT.FLOOR AREA 9SQ.Pf.
owner-builder will have the burden of proving that be did not build or improve for pur-
prsc of solei).
C 1,as owner of the properly,am exclusively contracting with licensed convenors to AL:
construct the project(Sec.7014,Business and Professions Cade:)The Comracmr's Li-
cense Law does not apply to an owner of properly who builds or improves thereon.and QTY. PLUMBING PERM(
who contracts for such projects with a conuazmr(s)licensed pursuant as the Contractor's -
License Law. PERMIT ISSUANCE
❑I am de
exempt under Sec. ,B&P C for this reason
ALTER-DRAIN As VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE r�j�. .'IG
I hereby afirm under Penalty of perjury one of the following deshrelions: '/ W V
I have and will maintain aCenificmeofConsentioself-insurcfor Workers Compen- DRAINS-FLOOR.ROOF,AREA,COND. STORIES TYP
E ECONSTRUCTIONsatinn,as provided for by Section 37M of the labor Code,for the performance of the
k for which this permit is issued. FIXTURES-PER . j
1 have and will maintain Worker's Compensation Insurance,as acquired by Section
,of(he Lahur Code,for lheperforreance at the work forwhich this permit is issued. GAS-EA.SYSTF, C.4 LET ( OCC.GROUP APN
My Workers Coytperysmlr)pinsypTr(gppyrlerand Policy numM� a-x/` Qa
Cartier: TT/4f/L.. T 1/AAJ Policy No.:��ri KDO 7/ GAS-EA.SYSTF, { iR4 t
CERTIFICATE OF EXEMPTION FROM WORKP.RS'
COMPENSATION INSURANCE GREASETNDUSTF I ASTE INTERCEPTOR ..
('DTs section need not be completed if the permit is for ne hundred dollars 1$100) gxa 1,OUILUINO DIVISION FEES
or less.) GREASE TRAP PLANCHECK FEE
I cenit,that mthe perfrimnre of the work for w5th�hic�hthis permit is issued,Is hull SEWER-SANITA Y
not employ any permm in any manner so az bac e f t .the Workers'Compem ENERGY FEE
ZZ sound Laws of Califrmia.Date rp9� WATER HEATER WNENDELECTR
O Applicant /1'l�) fts.�l7)'� GRADING FEE
NOTICE TO APPLICANT.IT.offer mak (g this Certificate of Exemption.you should WATER SYSTEMOT EATING
a , becodm subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
w forthwith comply with such provisions or this permit shall W deemed revoked. WATER SERVICE
Q
� Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ.FL PAID
L) Q Ihercby Norm that Ncre isaconswction farthing agency fanhe performance of Dote iptIt
D-1 Hthe work far which this permit is issued(Sec.3197,Civ.C.)
Lenders Name TOTAL:
WLenders Address TOTAL:
y 1 certify that 1 have read this application and state that the ehnve information is BUILDING FEL
i.r y correct.I agree to comply with all city and county announces and sma laws relating m QTY, r MECHANICAL PERMIT FEE
C„) '� building construction,and botchy authorize representatives of this city to enter upon lM1e SEISMIC FEE
.have-mentioned property for inxpemion purposes. PERMIT ISSUANCE,
_ (We).grec to svva Indemnify.ad keep harmless the City cf Cupertino agninx( ELECTRIC FEE
labllities,judgmems,costs and expenses which may in any way.ecme ogainst suid City ALTER OR ADD TO MECH.
in nm,mird,of the gnotingof this perm(. PLUMBING FEE sJe 'D
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT GO 10.000 CFM)
MECHANICAL FEE
' SOURCE REGULATIONS. /J
'/AQ _'6 / L� AIR HANDLING UNIT(OVER 10,"CFM CONSTRUCTION TAX
lelLt.(.C•I-i V /
Signawre of Applicant/ mmaor Uate EXHAUST HOOD GVDUCT) HOUSING MITIGATION FEE
HAZARDOUSaMATERIALS DISCLOSURE
Willytthe eCupertino future Wilding e,Chanutoreor handle Heart urs and Suety HEATING UNIT(70100,0011 BT
as defined io the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 23532(n)? HEATING UNIT(OVER IW BTU)
❑Vas 9,4< VENTILATION FAN IS GLE MID) PAID —
Will the applicant at future building occupant use equipment or devices which Dam Receipt#
emit icl? TOTAL:hazardous our contaminants as Defined by the Bay Area Air Quality Management -COMP POR 1(111,0008711)
Disvia?
❑Yes BOILER-CO (OVER 100,1X1)BTU)
(have read the hazardous materials requirements under Chapter 5.95 of the Cali. AIRCON TONER ISSUANCE DATE
famia Health&Safety Cale,Sections 25505,25533 and 25534.I underaor I that if the NEW SIDENTIAL MECH, SQ,PT. / /
building doesne,ramely h.ve enam,(hntitis myrespsmsmili(y to nnlify the occupant (D a" a
of the requncerems which our the ormisxuance of.Ce/�j�r ty5.f(ksmppey.
R/7 VcaI % 7
Loan, cdn m a— 1> . TOTAL: --f--��
ISSUED BY: / d/
OFFICE