S 3840 (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 3840
BUILDING PROJECT IDENTIFICATION
ItUlLDING AUI>RliS �! SANITARY NO. APPLICATION SUBMITTAL DATE
OW 'R;S N3MF. 1'10{ONE: CO,y'RACIORN SME, LIC NO,
w�� !L`"s OyiN P/ — (vn7Y9Gs we CONTROL
ARCUITECfIENGINEEW LIC NO: ADDRSS: ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
i Gni( "�X l Q' ❑ ❑ Q— ❑
Y. LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z
p with Section 700(1Did.ion 3 of In, and Profesl„ns Cede,ow my license is RESIDENTIAL:l O
in full force and,Rat. PERMIT ISSUANCE
C uyF ❑SFDWL ❑KITCHEN REMODEL
V 4cen.0 Class Lic.#
I,ZM Dam Contractor APPLIANCES-RP_SIDENf1AL ❑ADDITION B'RC9LBING RE-PIPE
F D rn ARCHITECTS DECLARATION PANELS D MULTIUNIT D STRUCTURAL
ZOh.Z+ I underxmnd Illy ileo,shall be used as public rcamh MODIFICATION
OZ-0 UPT02MANIPS []INTERIOR ❑CHIMNEY REPAIR
t:W Lievnsel Professional 201-1000AMPS IMPROVEMENT
p,Y2= OWNER BUILDER DECLARATION ❑SWIMMING POOLS
C C Q 1 hereby affirm that 1 am exempt from the Contractor's License Law Initial 0 OVER 1000AMPS BATH REMODEUREPAIR 0 DEMOLITION
�3 LU following reoasn,(Section 7031 5.Business and Professions C-1,Auy uity or amply SIGNS ELECTRICAL D OTHER
(Awhich requires u permit to construct,alter,improve,demolish,or repair any strvcturt
F„=ApriunI,us issuance.also qm
uires e applicant ottoman permit to file asignedsmtarmnt SPECIAL CIRCUFUMISC.
y� rethat he is licensed pursotm mthe poo,Wunsof the Commerce,License Law(Chapmr9
uW'y_'00 (emmmenem,with Section 900r Division 3 of be Business and Professions Cods)a, TEMP.METER OR POLE INST. COMMERCIAL
ca{y o C that he is secmp,ihcrefrum and he lot for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION 0 DEMOLITION
W..y Sation lOJ LS by any applicam for apemBt subj¢ie the applicant toacivil penalty of POW ER DEVICESOTENANT C1 FOOD SERVICE
o,more mon Ove hundred dollars S500). IMPROVEMENT2=O F1 L as owner of the propcny',or my employees with wages as their.side compensation. SWIMMING POOL ELECTRIC
p. will do the work.and the s,rvcmre is not intended or offered for sale(Sa.]Ofq,Business DOTHER
W m and Professions Colo:The Comeri License Law doe,not apply ,,m owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not amended of offertJ for NEW RESIDENTIAL ELECTR SQ FT
sale.IL er,howevthe Wilding or impmvemem is sold within one year of completion,the SQ.IT.MOOR AREA $]SQ.FT.
coner-Wilder will have the maden of proving that he did not build or hall for per-
cooluall the project of the pro,Sec. 0 4,al Hasiclusively and commemlng win li The Commerce
omm rce s to TOTAL:
acuse a wM esnot (Sec.o an Business mW Preis ho but d Cadet)i The C s then tor, Li-
Law,doesnotch plyman with
aufuropeny whosedp or improves Constraint's
QTY. PLUMBING PERMIT FEE /J
who amnacts for such pmjeeu win a conua<mr(s)licensed pursuant m the Contractor's
Liceve law. P17RMIT ISSUANCE 3 ,o '� SUN p 1199
D I am exempt under Sec. .B a P C fer,his reason
ALTER-DRAIN&VEST-WATER(EA) VALUATION
Owner Data
WORKER'S COMPENSATION DECLARATION BACK MOW PROTECT DEVICE
I hereby Affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Claudette ofCamentto self-insure for Workers Comper- DRAINS-FLOOR,ROOF,AREA,COND. TORIES TYYF.CONSTRUCf10N
sato..,u,provided for by Section 31110 of the labor Coca.for,hu performance of,hc
work fa� i
o sPermit Numed. FIXTURES-PER TRAP
QfFiuve and wi tl maintain Workers Compensation Insurance,as equired by Section
31(X1 of the LUMP Co�d��av,Lhu me YYperfonnucAmmae of tone work for wbhii,hiyhis panni,is i.med GAS-EA,SYSq'EM-I INC.O OUTLETS OCC.GROUP APN
C:Die 7 4 e zinc/'l-�epand PND'iu�SJ of GAS-EA.SYSTEM-OVER J(EA)
rs o
CLR ICATE OF EX PTION FROM WORK17RS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
(This satinn need nm becomplate,]iOhc permit is for one hundred dollars($hill) BUILDING DIVISION FEES
or leas) GREASE TRAP -
I candy that in the any m n manner
of the work for which his permit it ia'Cl I shall PLANCHECK FEE
notemploy any Person in any manner so as mhen,masuhject,o mM1C Workead Compete SEWER-SANI'fARV-STORM EA.200 IT, ENERGY FEE
z satinn laws of Culilornia.Date
(] Applicant
WATCH HEATER W/V[NT/ELECfR
GRADING FEE
I, NOTICbecome'TO APPLICANT:If,after making this Certificate of of Excmptimn,you should WATER SYSTGMRRBq'I'ING
a ;
become comply
it Worker's Coons or this provisions ofthede Labor evoke you most SOILS FEE
C[I forthwith eomplY with mcM1 provisions or this permit shall be Jeered revoked. WA}'ER SERVICE
aA
U Z CONSTRUCv... LENDING AGENCY NEW RESIDENTIAL PLM,, SQ.FT. PAID
V p work
reby which this ,a ere issued Sectionlending agency for the performance of Dote Receipt is
{LU Ihtwmrk for which thislµrmit is issued(See.31M)],Civ.C.)
U Lenders Name
M I LeadersAddress
rr,r 6. cenily,hat 1 have read mus applic:nion and stem ihm iM1c ahovc infornmion is BUILDING FliE
h comet.I agree to comply with all city and county ordinances and state laws retailing to QTY. MECHANICAL PERMIT FEE
V Z mildingcurntruction.cost hereby authorize representatives of thiscity incineration the SEISMIC FEE
above-mentioned pm,c,for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep Wrrnless the City of Cupertino against ELECTRIC ME
liabilinte,judgmmrb,a,nu and expenen which inay in any way accrue tgaim,said City ALTER OR ADD'lO SUCH.Inconsequence of the gmming of this pcnni PLUMBING FEE
APPLICANT UNDER N L C ITH ALL NON-POINT AIR HANDLING UNIT(TO 10.fp11 CFM)
URCE REC' I MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TA
2agIiIialfrenf App[cmgJ Dole EXHAUST HOOI)(W/DUCT)
HALA DOUS MATERIALS DISCLOSURE HOUSING MITIGAT •FEE
Will the applicant or future building msup im store or handle hazardous material I[EATING UNIT OD 100.(X10 BTU)
as defined by,he,Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(v)" HLXTING UNIT(OVER 100,0110 BTU)
❑Yes ONo
VENTILATION FANS IN'GLE RESID) PAID
Will,he applicant or future building occupeo,use equipment or devices which Data Receipt#
card hoariness air comaminants as defined by me Bay Area Air Quality Management BOILER-COMP(3HPOR 100,000 BTU)
Dhoarinessuln'
❑Yes 1-1NoBOILER-COMP(OVER 100.0(X)BTI[)
I have mad the havanlous mateni requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ///J ISSUANCE DATE
I'omia Heahhffi Safety Crde.Scctiyon�say2�fhf05.25533and255"Aundermardtha,ifthe NEW RF,SIDIiNT1ALMECU. SQ.FT. /z ^ o
holding"� class.,,, nnevor hes,^C (f 'mit is my mspm.ibilitymnntify,rsocs. et (p
-W.•r nn a of a CenificmSe of occupancy.
[late TOTAL: ISSUED B15 �_�
OFFICE