S 3839 (2) APPLICANT TO 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 3839
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY IS APPLICATION SUBMITTAL DATE
OWNF. 'SNAr I..: PIIONE' CO CI'OR'S AME: LIC NO:
�!G 16 N/C CONTROL#
ARCHITECAENGINEER: LIC NO: AUUR- ❑
CONTACT': PHONE HUILIJINC PERMIT INFO
❑ Consultant Fecs Paid by Applicant(Initial) BLDG ELECT' PLUMB ECH
El E"❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby amm Nal
r1 am licensed under pow'iamr,of Chapmr 9 Retroaction, JOB DESCRIPTION
Matz Seciam 900X)A Division 3 ofthc Business and Profa,ion,Code,and my licenu is RESIDENTIAL:
W O p PERMIT'ISSUANCE
W W_ in full force and etfea. ❑SFDWI, ❑KITCHEN REMODEL
<UU License Clas Lic.p APPLIANCES-RESIDEN'TAL OADDITION B4L4MBING RE-PIPE
'Fact Dmc Contractor
F.D N
ARCIII'I'F.CI';S PANELSPANELSDECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZOonZ IunJentanJ my plans shall be used as public recoNs MODIFICATION
OZ�C UY1'02IXIAMPS 1 ❑INTERIOR ❑CHIMNEY RC;PAIR
F W Licensed Prom,ionul 201-1(IVUAMPS IMPROVEMENT SWIMMING POOLS
9,1' OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH RIiMODF,f/REPAIR C:1 DEMOLITION
C C d 1 hereby affirm that 1 em exempt fromacmr
m the Cor 's License Law for the
iU following reason.(Section 7131.5,Business and Profession,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
Isl'3 W y which m,ciros a permit to con,uva,Tire,improve,demolish,or repair any,mo mor
d prior to its issuance,also requims the applicant for such permit to file a signed statement SPECIAL CIRCUIT/M ISC.
f }-J 'hat he is licensed pursuanuo the provisions of the Contractor,License Law(Chapter 9
��OQ (Co.nmenem,with Sect ion 700)of Division 3 of the Routine,and Prom,ion,Code)nr TEMP.METER OR POLE INST. COMMERCIAL:
E.a ey ant he i,exempt thcrcfrom and the Wria for the alleged exanptimi Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X_N Section 9031.5 by any applicant for apermit subjects the applicanrto a civil penalty of POWIiR DEVICES ❑TENANT ❑FOOD SERVICE
nut more than rive hundred dollar,(S50(d. IMPROVEMENT
0 La,nwnen,I m.pmperty,or. mnpinyces with wages as their snlcmmpensminn. SWIMMING POOL ELECTRIC
E IY-,O will do the work,and the sanctum is not intended ureteral Or sale(Sec.]U44,Business THER
and Pmfmsion,Cade:The Contrac or%License Law docs not apply to an owner of OUTLETS-SWITCHES-FIXT'UXES
property whir builds or improves thereon,and who does such work himself.,Through
his own cmployccs,pmvided Nat such improvements ore nm mocu cd or uffTmd for NEW RESIDENTIAL HLECTR SQ FT.
sale.ILhowever.the building or improvement is sold within one yearofcumpletmmNe SQ.14,FLUOR AREA $/SQ,FT
nerbuilder will have the burden of proving that he did not build or improve polar,
po'c tet sale).
❑ 1,a owner of the property am exclusively contracting with licensed conaednrs m '1(yI'AL', J_R F'
construct the prvj«t(Sec.]1114,Business and Pfofessions C,de:)The Convenor', '�
terse Low does not upply to an owner.fpropeny who builds or improves thereon,and QTY PLUMBING PERMITI
FEE -
whucomntn,pn,tach projects willtmm�trens)r(,)Ilcensed purxunm ,,,he Cunuuemrs
License law. ALI ER ISSUANCE 1 am exempt under Sec. .B h P C for Nis mason
ACI'ER-UHAIN&VENT-WATER( I 141,1 zi
Owner DateWORKER'S COMPENSATION DECLARATION BACK FLOW PROT[CT.DEVICE:IbcrebyafNmanJcr penaltyof of Con ruofell-in reordorker.nsI,ion.a>lwiefor byacion370c.fCnmcmr Code,for the Wformaceofth- DRAINS-PLOOR,ROOP,AREA,COTONI' STRUCI'ION
sation, r provides for n Section 3]W of Ne IaMu Cole,for the peabrmance of Nework for whichthis permit is issued. FI%TURES-PER TRAP1 haveand will mountain Worker's Compensation Insurance,as required by Smion
3](IU ofNe Labor C,debalm perf lance of It.work far which this pemtit iso,imd, GAS-EA,SYSTEM-1 INC.40U1LEOCC.GROUP APN
My Wor 's Come snap ITs'u�r��n-c.qrvm c�r and Policy num
Cartier, ties) HN Policy No.: Q GAS-EA.SYSTEM-OVER 4(EA)
CERTI ATB OI'E%I PTION ItRO WORKERS' GRIiASEIINUU$'TRL WASTE INTIikCEI'H)R
COMPENSATION INSURANCE BUILDING DIVISION FEES(Dissection need not be completed ifhe Permit is f.rone hutdml dollar,(SIOU) GREASETRAY
.r less,) PLANCH[CK FEE
certify that in the crfmmanee ofthe work for which[]its permil is issued l shall SEWER-SANITARY-STORM EA.200IT.
not employ any proton in any manner so as m become subjectto Ne Worker,'Compern- ENERGY IEE
,Z sation Laws of Ca morrio.Date WATER HEATER W/VENTXLECTR
zO Appli. t GRADING PEE
N
NOTICE In APPLICAN'E If,zftef mulling this Cef ificme of Exemption,you should WA'11iR SYSTOPUTREADNG SOILS PER
.�' become subject to the Workers Compensation provisions of the Labor Coda you must
rForthwith comply with such provision,or this permit shall he marred revoke. WATER SERVICE
Q
Z CONSTRUCTION LENDING AGENCY NEW kESIDEMIAI.PLMB. SQ.FT. PAID
G � Thereby affirm that there i,aconstruction lending agency for performance of Date e' ta
Newark or which this Omut is isned(Sce.3097,civ.CJ
O V 1<ndo,,Name TOTAL:
Lender,Address TAI.:
D BUILDING FEE C J
1 certify thin re
1 have al upp
This licmion nnJ,Wm thin the above information is
Correct 1 agree n0 emnply with all City and county ordinance,and state law,relmtng to QTY. MECHANICAL PERMIT FEE
V Z building construction,and hereby cathartic repreunmdves of this city m enter upon theSGISMIC PEE
above am minced progeny for inspection purpnus. PERMIT ISSUANCE
(We)agree to save,indemnify and keep horn I..the City of Cupetimo against ELECTRIC FEE
liabilifes.judgmcnls,costs and expense,which may in any way accrue xgairmsum City ACIER OR ADD TO MECH.
PLUMBING FEE
in consequence of the graining of this n.
APPLICANT UNDERSTAND CO. AWITH ALL NON-POINT AI R HANDLING UNIT(TO IO.IXp CFM) MECHANICAL FEE L
SO Ii REGULA' ON.'
77
90 AIR HANDLING UNIT(OVER I0.00(1 CFM) CONSTRUCTION'fA%
5ignat ))ilea Con racna Li_ Date EXHAUST HOOD(W/WC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicamm future building occupam some or handle haevdn.....hand H17ATING UNIT(TO Uly"BTU)
ns defined by the Calvados)Municipal Code,Chapter 9.12 and the Health and Safety
Code.Section 255320)! HHA'RNG UNIT(OVER RX1,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipts
Will thv applicant or future building.ccupum use equipment.r device,which
• emit himm..,air col,amminonas defined by the Bay Area Air Quality Management BOILER-COMYf3HV OR If111,INq BTU) TO,IAI
ninon? BOILER-COMP(OVER 10).000 BTU)
❑Ye,
ON.
I have=it the hamZcap,
ncyuiremenu un der Chapter 695 oflhe Cali- AIR CONDII'IONiik ISSUANCE DATE
fomia Heald&Safety C J25533 and 355:41.I undenunJ Nat if Ne NEN'RESIDENTIAL MECH. SQ.FLbut Hiro!dces.11!?1ntat it i.s 11" .pnnsilotty to nNy the occupant� r �su'oel,^C�tJec�ci(xcnpow'.
Own t .'.cJa int (� / Dau TOTAL: ISSUEDBY.
OFFICE