S 3869 (2) pAPPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
�C1TY OG CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 3869
BUILDING PROJECT IDENTIFICATION
B�LDING oAq. SANITARY NO. APPLICATION SUBMITTAL DATE
(ssS*1 . LL(cl a a ,
ERS DAME: PHONE: 44(V CONTRACTOR'S NAME: LIC NO: NIC ONTROLN
t LAAS, Sura 3 o�/v�
EC9411ING E R: LIC ADDRESS: ❑
cPn . C -Iqsz - Z
.ONTA �1. PHONE: BUILDING PERMIT NFO
1 • I l q� ()y h L n ❑ Consultant Fees Paid by Applicant(Initial) BLD ELECT PLU? MECH
ERr
��`�' LIC.NSED CONTRACTOR'S DECLARATION —1 V' Q� ELECTRIC PERMIT FEE CJ IJ
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Section7")of Division 3 ofthe Business and Professions Cods,and my license is
I, full force and effect. PERMIT ISSUANCIi
0.,WUr in FDWL [:1 KITCHEN REMODEL
aUV License Close Lic.p APPLIANCES-RESIDENTIAL [D ADDITION El PLUMBING RE-PIPE
r G W� Date Contmeor
ARCHITECT'S DECLARATION ❑MULTI-UNIT []STRUCTURAL
F to PANELS
z O n 4 1 understand my plans shall be used as public records MODIFICATION
OZUPT02MAMPS El INTERIOR OCHIMNEY REPAIR
tq�i Licensed Pmfelional 201410())AMPS IMPROVEMENT []SWIMMING POOLS
L5`.Py'f� OWNIim toomptfrnc the RATION OVER 10N)AMPS ❑BATH REMgDEUREPAIR ❑DEMQLITION
1 herchy offrm the 1 nm eaetnpt Irmo the Comrndor's License Lew for the yt 1�
W WO y U followinguires a(Section]1131.5,Business and Profession Code:Any city or county SIGNS ELECTRICAL fes'OTHER
OI" which requires a permit re,merlon ai¢n Improve,demolish,or repair any structure al d11� /1 QG.I J
priorto
y its res Npermit statement SPECIAL CIRCUTMISC.
Nat he islicense)pursuantuto the provisionsofthe
Contractor's License Law(Chapter 9
(commencing with Section 7(XX))of Division 3 ofthe Business and Professions Codc)or TEMP METER OR POLE INST COMMAS
C.,l3 o e' that he is exempt thereGom and the basis far the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^ao Section 71131.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not mom than five hundred dollars(5500).
IMPROVEMENT
Ser ❑ Las owner
k,niche pnpeny, remyentntended with wages r their ce.70mpenmion. WIMMING POOL ELECTRIC
� O will do the work,and die structure knot intended oroRered for sale(SaA044.Business ❑OTHER
(til and Professions Code:The Contractors License law does not apply in an owner of O TS-SKITCHFS-FIXTD
A.3 property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impeaverm nn arc not intended or offered for N .NTL ELECTR
aide.if,however,the building or improvement is sold within one year ofcomplcuon,the SQ.FE FLOOR AREA SISQ.FT.
owner- der will have the burden of proving that he did not build or improve for put.
pose sale)
- ,as owner of the pmperY,am exclusively connecting with licensed contractors to TOTAL: 3 s� i 906 J
oosome,,he project(Sec.7044,Business send Profevsionx Code)The Contractor,Li-
cause law does not apply to an owner of property who builds or improves chance,and QTY PLUMBING PERMIT FEE
who contracts for such projects with a commarons)licensed pursuant to the Conuactnrs
License Law, PERMIT ISSUANCE V
❑Ism cxcmp,u ,Sec. N .B&PCfor this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
net Dam rq t�
Wo MPENSATIO CLARATION BACK FLOW PROTECT.DEVICE
Ihereby affirm tder penalty of perjury d of the following declamations ✓✓✓ CJ `/ LJ
I have and willamaimoma Certificate of Consent no self for Workers Compeb- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
tion,as provided for by Section t](N1 nl'in,Labor Code,for the performance of Ne
mk for which anis pcmtit is issued. FIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3]1X1 of the Labor Code,for performance of the work for which this permit is issued. _ GAS-EA.SYS'I'EM I INC.4 OUTLETS OCC.GROUP APN
My Wants, Compensation Insurance currier and Palley number are:
Came,: Policy No.: GAS-EA.SYSTEM OVER 4(FA)
CERTIFICATE Git EXEMPTION FROM WORKERS' d0�
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE.INTERCEPTOR
BUILDING DIVISION FEES
(This sectianneed not ho completed if the permit is hamm hundred dollars(1100) GREASETRAP
or less.) PLANCH KFLLIr
O
Icenifythatin Oo Nrfunnanceoftheworkfurwhichthispermitisissued.Ishall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner ser as subject o become subjeco the Workers'Compen- ENE 7 Z O
Z ,Z, sction Laws of California.Dare WATER HEATER W/VENT/ELECTR
O Applicant 1 GRONGAE
NOTICE TO APPLICANT:If,after making this Certificate of Exemisom,you should WATER SYSTEMOMEATING
a , become subject,o the Workers Compensation provision of the Labor Code,you must
12J foMwiNcomply with such provisions.,his permit Nall he deemed revoked. WATER SERVICE
d Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDEM'IAI.PLMH. SQ,FL PAI Data Receipt s
I hereby h,hi that w
them is construction lending agency for thm
e perforam nof
the work for which,hi,,permit is visited!
ued(See.J09].Civ.C.1
0 U Lenders Name A
WLender,Address TOTAL'
I certify that I have mad this application and state chat,he shove information is BUILDIN
tF". nV1� comcrlagreemcnmply with all tiny and county oNinmces arta sem laws rclaungm QTY. MECHANICAL PERMIT FEE
U ,Z building conswction,and herchy authorize representatives of this city to enter upon the SEISMIC 3
above-mentioned property for inspemion purposes. PERMIT ISSUANCE.
(We)agree to save,indemnify and keep handess the City of Cupertino against ELE F. /
habililics,judgmcros,costs and expenses whichtnay,in any way acemeagaiml,md City ALTER OR ADD JO MECH.
in ennsequsnceof thegmntingof thisiscrmit. PLUMB FEE 3
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO 1001OCFM) /
MECH
SOURCE REC .ATIONS. t ICAL FEE
6 / AIR HANDLING UNI'1'(OVER 10cM)0CFM) CO RUCTION TAX
Signmurt ill Appli n nr / Dee EXHAUST HOOD(W/UUCP) HOUSI GMITIGATIO EE
A' MOUS:1d
I DISCLOSURE
Will the upplicact or future bucvpamstoomisandla hazardous coaled.] HEATING UNIT(TO 100.0N)BTU)
as defined by the Calamine Municip ,Chapter 9,12,and the Health and Safety
Code Section 2553200" HEATING UNIT(OVER IN),"BTU)
❑Yes Fl No VENTILATION FAN(SINGLE RESID) PAID
Data Receipt is
Will the applicant or Boort bccupant use equipment or devices which BOILER-COMP(JHP OR 1110.[100 BTU)
mit hazardous air acmaminanu as Jy Nc Buy Aren Ai,Quality Management Asmut? BOILER-COMP(OVER 1(X1,000 BTU)
❑YIL
es ❑NuI have meal the huadies nmuirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Coe,Section ,8533 and 2554.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT.buildingdoon currently have a meaicismyresomadailitymnoufymoecupantofNe,cel ntswhichrpm,bemissuwtce of a Certifccam
Owner m ate TOTAL: ISSUED BY:
OFFICE
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