S 3937 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3937
BUILDING PROJECT IDEN'TIFICATHIN
BUILDINGADDRPSS: SANITARY NO. APPLICATION SUBMITTAL DATE
3 Se lka„ pl'ut G- 9 l`^9
WNF.RS NAME: PHONE: C NTRACfO 'S NAME: I LIC NO
�� (J� � G�/��g./v; / ^fW N/C CONTROL#
RCIIITECT/ENGINEER: `•{ LIC NO: ADDRESS: l•-IL 1�,� 5 C 511 ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMII MECH
W6— A,5-31:1 ❑ ❑
LICENSED CONTRACTOR'S DECIARATION QTY ELECTRIC PERMIT FIE•
I hereby affirm mat 1 am licensee under provision.of Cmpmr 9(commencing JOB DESCRIPTION
wo, who section]alB)oroiv;a;nn3ofine Baseness ane Prormamm coda.and myna...;' et'^ RHSIDENTIAL:
11a WF in Gdlfnerandeller /, ']�Q� I', IT ISSUANCE .D
�UU License Clgss�Lie# -'"f 3(, � ❑SFDWL ❑KITCHEN REMODEL
P z W Date `1 Contract.. APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ie, // �. � ��CIIITE j DIiCLARAT(ON C]MULTI-UNIT ❑STRUCTURAL.
zon4 //Aq(ersmrd' lID )Lr _-- 11'w'haY- `I l as'public records PANELS MODIFICATION
OZ—O d / UPT0203AMPS [I INTERIOR ❑CHIMNEY REPAIR
[=�E"W Lir sdL rvul 201-1000AMPS IMPROVEMENT
ay.Y�j OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
W 6 1 hereby affirm that 1 am exempt from the Contract License L w 10T the OVER IIXX)AMPS [:1 BATH REMODEIIREPAIR ❑DEMOLITION
O t1 U following reason.(Section 7031.5,Business and Is browns C Any ai or county SIGNS ELECTRICAL
OTHER
W y which requires a permit to construct,alcor,improve,demolish,or my suumurc _
F COQ pA�rrw ib issuancq sa rryuirts me applicant for such lin IeesignW sutemem SPECIAL CIRCUITRAISC.
Gf mat he is licenxdp suannu the Provisions of the comm t n.e law(Chapter9 I
(ccaninnem,with, ction7(1f1bofDivision 3,amc n rte ebssions CoJe)an 'TEMP.MFTIHR OR POLH INST. COMMERCIAL:
a a e that he is exempt t reform and me basis 4 allege) axe puna Any violation of C)NEW BLDG/ADDITION El DEMOLITION
Senior]03 LS by ray applicant for a permits h3 the pliant to.civil Penalty of POWER DEVICES
�y OTENANT ❑FOOD SERVICE
ZCnot more than five undred della-(SSW). IMPROVEMENT
0Lnsowomef eprnperty,nr pinyce, th wagesmmair sale cnmpenmtion SWIMMING POOL ELECTRIC ❑OTHER
will Jnmework, 'an
mmcwr• not hat
a ffmmJbrsale(Sad7B44,Bminass
L and Professions ode:The Cc maters se Law does not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who bu m or impro s thereon cd who does such work himself or through
his own employ thinsuch imp 'mwpt are not in¢ndW or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.IL however.the in
improvemenn, oldwithinine yeat", nmplenim the SQ.FT FLOOR AREA VSQ.FT.
owner-builder will have rat oda.of,prvir,that he did not build or improve for pur-
pox urade.),
❑1,as owner or the propery m exclusively contracting with licensed comncmrx to OT
construct the pmjcet(Sec. Business and Pro&sslow Code.,The Conuacmr's IJ-
nsel.aw does mn apply to an owner or property who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a cnmradorp)IicenxA pursuant to the Contracmrs
License Use. PERMIT ISSUANCE
I am exempt under Sec. .B&P C for this ream.
,veer Date ACI ER-DRAIN&VENT'-WATER(EA) VALUATION
IF WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby We.wudn penalty of perjury one of the following declarations:
❑I have and will maintain is Cmificafe ofConsent to self-imure for Makers Compcm- DRAINS-FLOOR,ROOF.AREA,GOND. STORIES TYPE:CONSTRUCTION
salon,as provided for by Section 37M of the[.shot Code,for the Performance of the
work for which this permit is issued. FIXTURES-PER TRAP
O I have and will maintain Worker's Compensation Insurance,as required by Section
37M of The Labor Code,for the performance ofthe work far which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCGGROUP APN
CrtWrsrl.(�y Co qw ya ion sur cr wrier and Policy nunYua qry Q.y^-A GAS-EA.SYSTEM OVER 4(EA)
fIf/J1. Policy No: f11Y/J c.L1
CERTIIBCATE01 XEMITION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUST I BUILDING DIVISION FEES
n ass�Thisxetion need not be completed ifine per mit is lorune hundred dollars(51(q) GRPASET'RAP
PLANCHECK HE
I cenify that in me performance of the work for which this permit is issued.Isbell SEWER—SANIT TOR#EA.2IXI FT.
not employ any pane.in any manner so as to become.subject as the Workers'Compen- I ENERGY FEE
Z sane.Laws of Califon i.,Date WATER HEATER / �Q�a�.$�
z Applicant �v•• O GRADING HE
N NOTICE'TO APPLICANT:If,after making this Certificmu of Empos nn,you shout, WATER SYS'I EM/ 'AGNG
a ? become subject to the Workers Compensafion provisions of the labor Code,you must SOILS FEE
a .. forthwith comply with such provisions or this ppona,hall he dreneA revoke). WATER SERVICE
Q
.0 z CONSTRUCTION LENDING AGENCY NF:W kESNLN'I'IA PAID
U k for
rwhiceby hthi then there issued(S .3097.Ch%agency for the performance of
ReaiptX
Ll. f' the wart far which this permit is issued(Sec.JIN].Cir.C.)
Q U Lenders Name TOTAL:
Leoder''AJdreas TOTAL:
HS I cenify trot I have read this a,hurtion and state mat the above information is BUILDING FEE
V) correct.l agree to comply with all city and county ordinances and sate laws odmingm QTY. MECHANICAL PERMIT FEE
U Z building cnnstrvnion.and herehy authorize rtpmxnmtires of this city to cn¢r upon the SEISMIC FEE
above-.tandemed pro,vny for ins,saimp purposes.
(We)agree to save,indemnity and keep harmless the City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgments.costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this Permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL PEE
SOU .P 1 A ONS.
6cr_ AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
gramme,ofAWficamiContractor _I Date) EXHAUST 11001)(W/DUCT) HOUSING MITIGATION HE
MATERIALS DISCLOSURE.
Wllitha applicantaTfora(,building ceta,vmsbme,handle hazardous mmerinl HEATING UNIT(TO IW,Igx)BTU)
as defined by the C.,ano Municipal Cade,Chapter 9.12,and the Health and Safety
Code.Section 25532(.)7 HEATING UNIT(OVER 100,11011 BTU)
❑Yes ON.
VENTILATION FAN(SINGLE RESID) PAID --
Date Receipt#
Will the applicant edema defiling occupant sexea Air Quality Management
HOLLER—COMP17HPOR 100,000BTU)
emit District?
us air contaminants as Jefincd by the Bay Area Air Quziity hlanagemcnt AL
Dinrict^
❑Yes E]No BOILER—COMP(OVER I(N1,1100 BTU)
1 have mad the hraaMous materials is under Chapter 6.95 of the Cali AIR CONDITIONER
m,2553enISSUANCE DATE
fom;a Health&t ca Code,Section 25505,is ory eud 25534.1 uodemy th that if the NEW RESIDENTIAL MECH. SQ.FC Q
bailJin r not cu tly have mutant,cost it is myrespunsihilitymramify me occupant
oft i �rh The ntct prinrmissumnce nfuCmilio�ol'(�n� ��
mer rauthorzed 4fat
Data TOTAL:
ISSUED BY:
OFFICE