S 3810 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 3810
BUILDING PROJECT HAWFIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7S-3r Fo E !7 vE or-11-q
WNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
)
M c` *-.qNIC CONTROI.N
iROFTECTAIIIC.EER: I LIC NO'. ADDRESS:
^ >� ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ C'' ❑ C�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby a(fnn That 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
�DO with Scinum 7W)Of Division 3 of the Bminessand Professions Cale.and my licensees PERMIT ISSUANCE ♦ RESIDENTIAL:
aOn afull home and e c. q� ❑SFDWL [I KITCHEN REMODEL
FG.UV License Class C. Com APPLIANCES—RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
NQ Dem x IF7 Contractor
''�� �� 11.. 77 ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZOt^Z I understand my plans shall be used as public words • PANELS MODIFICATION
OZ4G / UP TO 200 AMPS ZZ. P-3 ❑INTERIOR ❑CHIMNEY REPAIR
a„S.,; Licemed Professional 201-1000AMPS IMPROVEMENT E]SWIMMING POOLS
C'f OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑RATE REMODELREPAIR ❑DEMOLITION-
6 I hereby affirm that I am exempt form the Contractor's License Law(o,the
leokd' a following reason.(Section 7031.5,Business and Provision,CMe:Any city Or county SIGNS ELECTRICAL OTMER
W 31y,H which"alms a permit to construct alter,improve,demolish,m repair any structure C
prior to its issuance,dso requires the applicant for such Permit o file a signed statement SPECIAL CIRCUIT(MISC.
lsuss } that heis licensed pursuant m the provisions ofthe Contractors License Law lChapmri)
QO (commencing with Section 9000)of Division 3 ofthe Business and Professions Gde)a, TEMP.METER OR POLE INSL COMMERCIAL:
that he is exempt therefrom and the basis(or the alleged exemption.Any vidadm of ❑NEW BLDG/ADDITION ❑DEMOLITION
^,N
Section]031.5 byaoyepplicud for a Ninnotxubjims theappliwguoa civil penalty of POWER DEVICES []TENANT ❑FOOD SERVICE
not mom than five hundred dollars($500).
IMPROVEMENT
=C ❑ do the aero(the the
sour mmyempleee withwages rsele(sec. 0A4,Business
sines SWIMMING POOL ELECTRIC
will do the Codki: he Contractors
not unleaded icense Offereddoes not apply to an,omen of OTHER
u�l and erly wh ons CMe:The oyes thereo License Lew s such
not apply to on rswner of OVD.EfS-SWITCIIF.S-I1X URES
43^ property who build,or improves thereon,and who Auea each wnrk himself of thmggh
his own employecs,provided that such improvements arc not intended or offered for NEW RESIDENTIAL ELF. SQ PT.
sole.If.however,the building nrimprovemem is toed withinone year of completing,the SQ.FT.FLOOR AREA fISQ.Ff.
owner-builder will have the burden of proving that he did not build or improve for put.
past of salo)
C]1,as nwner of the property,am exclusively contracting with licensed contractors to TOTAL:37, ,2 7q
construct the project(Sec.]trio,Business and Proessinm Cod-The Commatnrs Li
cense Law does not apply to an owner of Impcny who builds Or improves thereon,and QTY. PLUMBING PERT FEE
who contracts for such projects with a commemt(s)I leensed pursuant to the Contractor's
License low. PERMIT ISSUANCE
❑ I am exempt under Sec. .B&P C for this reason
Owner Date ALI'IN-DRAIN&VENT-WATER THA) VALUATION
( WORKER'S COMPENSATION DECLARATION
HACK PLOW PROTLCI'.DEVICE /-1 QQ
- (hereby eflirm under penalty of perry one of onl'the following declarations: (w
I have and will maintain a Ccnificate of Coneentm self-insnm for Workers Compen DRAINS-11.00R,ROORARIiA,GOND. STORIES TYPE CONSTRUCTION
union,as provided for by Section 37W of the labor Code,fur the Performance of the
qa fmwhich,lim,romisi...to. pIXTGETS-PER TRAP 1 7-5/, ?
�1 have and will maintain Worker's Compensation Insurance.uv requited by Section , l
3 lof the LehnrCMe,for the perfnrmancc of the wnrk fist which thispennit is isnued, GAS-EA.SYSTEM.I INC.4 OUTLETS OCC.GROUP APN
Cy Wotkn's'gttNw` pfnsu `cwm_ranld Policy number arc ra GAS-EA,SYSTEM-OVER 4(EA) /J
if CIBRTIFICATEOFEXEMPTION FROM WORKERS*
COMPENSATION INSURANCE GREASUINDUS'TRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(Oris section need not be completed ifthe permit is for one hundred dollars(S I Wd GREASE TRAP
or less.) PLANCHECK FEE
I cenify that in the performance ofthe work for which this permit is issued,l shall SEWER-SANITARY-STORM PA.200 F..
noeon
t employ any persin any mamm
manner so as to hecov subject the Workers'Compen ENERGY FEE
Z ,Z tabun Laws of California.Data WATER HIiATER W/VENT/ELECTR
Applicant GRADING FEE
y NOTICE TO APPLICANT:If,after making this Ccnifcate of Himan tian,you should WATER SYSTENVEREATING
a ; become subject to the Worker',Compensation provisions of the Iabot Code,you most SOILS FEC
DJ forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
0. 0
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB, SQ.Flt PAID
U O
I hereby affirm that hem is a construction lending agency for the p domance of nice Receipra
fA Hthe work for which this permit is issued(Sec.3097,Civ.CJ
Lender's Name TOTAL:
V Lenders Address IDEAL:
Fy I cenify that 1 have and this application and state that the above information is BUIL
V) tarrcet.lagone tg comply with all city vad county ordinances and state law.crchongmQTY. MECHANIC.AI.PERMIT FF
C.) Z building construction,and hereby amhorim representatives of this to enter upon the SE
above-mentioned pmpeny for inspection purposes. PERMI"1'ISSUANCE e
(We)agree to save,indemnify and keep harmless the City of Cupertino against /` 1 FEEIll . 72.
P6 lu
liahilities.judgments.costs and expenses whichnmy in any way accrue against said City ALTER OR ADD TO MECH.
in ennseyucnce of Ne granting of this Permit PL 1
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNII'(TO 10,000 CFM) MECHANICAL FEE 9s 2
SOU CE REGULATIONS. pp
X V AIR HANDLING ON[-[(OVER 10,000 CFM) Oy ULTION TAX
w w
Signu�Applipmt Cn actor Irv �— EXHAUST HOOD(W/OUCI)
HOUSING MITIGATION FEF.
HAZARDOUS MATERIALS DISCLOSURE
Will the aCa,mor.futurebuildingCode,
12.handle Health
rdandSaety HEATINGUNITfI'D 11040,000BTU)
as Cuts,
Section
by the Cupertino Municipal CMe,Chapter 9,12,and the Health and Safety
Cade,Sermon 25532(01 HEATING UNIT(OVER 100,000 BTU) O
❑Yes IINo VP.M'ILAT10N PAN(SINGLE RESID) PAID - �-9 'yl?b
Date Reonptk >
Will the applicant i furore building occupant use equipment or devices which �0/
emit hazardous air comaminantu o fined by the Bay Area Air Quality Management BOILER-COME(3HP OR IW,g10 BTU)
TOTAL:
District? BOILER-COME(OVER 10ROM BTU)
El Yes
teri
I hove read ma
the hrdu>omaels rryuiremcnu under Chapter 6.95 of the Cali- AIR CONDITIONER `9•yp ISSUANCE.DATE
(orniu Health&S.N y Code.Sections 11105,25533 and 25514.1 cadromnd that if the NEW RESIDENTIAL MECH. SQ.EL
building drat nm rmondly have.mount,that it is my responsibility horrify Ne gecupant
of the re u emswhich mus the metprionnissugnee nfaCenif¢me nl fkcupmcy. 1_
Ow ermine once g Dm TOTAL: '�l. ISSUED BY:�/Oe'
OFFICE