S3397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PE IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 3397
BUILDING PROJECT IDENTIFICATION
SANITARY NO APPLICATION SUBMITTAL DATE
BUILDING ADDRESS:
- Alcy 1z - 3 itel'�
OWNER'S M PHONE: CONTRACTOR'S NA_i?cs ��-,-. �'�'. _/ J
/ p� ' �AV s //' '/ l.I -NIC CONTROL#
ARCHITECT/ENGINEER: ` LIC NO* Yj ADDRESS* f-� ❑
20 f S ia, Tr 95 _
CONTACT: PH E: S'c��riti y f/0. t' BUILDING PERMIT INFO
,^ ❑ Consultant Fees Paid by Applicant(Initial) _._ BLDG ELECT PLUMB MECH
GJ El ❑ 1:1
LICENSED CONTRA TOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
1 hcrebv affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WZ with Section 70W))of Division 3 of the Business and Professions Code,and my license is PERMIT ISSUANCE >�J RESIDENTIAL:
H W c) in lull force and,fl D � "� r ❑SFDWL ❑KITCHEN REMODEL
Q U U License Class Lie# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
V)d W Dale Contractor r
la� ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
F]V) MODIFICATION
Z O .Z. 1 understand my plans shall he used as public records
CZUP TO 200 AMPS Z O [_1 INTERIOR El CHIMNEY REPAIR
Ca
Licensed Professional '_01-10110 AMPS IMPROVEMENT ❑SWIMMING POOLS
aa OWNER-BUILDER DECLARATION OVER 1000 AMPS L1BATH REMODEL/REPAIR ElDEMOLITION
a
0
4 Q hereby affirm that I am exempt from the Contractor's's License Law for the
k0.0 following reason.(Section 703 L5,Business and Professions Code Any cry or county SIGNS ELECTRICAL, ❑OTHE� /j l
W 3[L which requires a permit to construct,alter,improve,demolish,or repair any structure /'-
E-' prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC
W�. that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
Wa A (commencing with Section 7000)of Division 3 mf the Business and Professions Code)or 'TEMP.METER OR POLE INST. COMMERCIAL:
0.a a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
k u" Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
W not more than five hundred dollars($500)
Q ❑1,as owner of the property,or my employees with wages as their sole compensation,
SWIMMING POOL ELECTRIC IMPROVEMENT
L. will do the work,and the structure is not intended or offered for sale(Sec.7044.Business []OTHER
W3� and Professions Code:The Contractor's License Law does not apply to an 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 intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA S/SQ.FT
owner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.) TOTA
L] 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law dues not apply to an owner of property who builds or improves thereon,and QTy. PLUMBING PERMIT
Fer t,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA.GOND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37(10 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
7700 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA SYSTEM-I INC 4 OUTLETS OCC GROUP APN
My Worker's Compensation Insurance carrier and Policy number are:
Carrier:
Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INDUSTRL W
COMPENSATION INSURANCE ""�� -- BUILDING DIVISION FEES
(This section need not he completed tithe permit is for one hundred dollars($1001 SE TRryr;.z� ��I
I or less) PLANCHECK FEE
1 certify that in the performance of the work for which this permit is issued,I shall R-SANITARY-STORM EA.20(
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
Q Z sauon Laws "fornix Dat T R HEATER WNENT/ELECTR
z Q Applicant ' - GRADING F
i..i NOTICE O AYYLICANT:I,after making this Certificate of Exemption,you shout TER SY ATN PFEE
become subject to the Worker's Compensation provisions of the Labor Code,you must !
W ; forthwith comply with such provisions or this permit shall he deemed revoked �✓ATER SER t
p" Q CONSTRUCTION LENDING AGENCY E _y-,- "'�-^m^'$0.","1'.
U Z 1 hereby affirm that there is a construction lending agency for the performance of to Receipt#
U
O the work for which this permit is issued(Sec.3097,Civ.C 1 TOTAL
OU Lender's Name
U Lender's Address TOTAL
1 certify that I have read this application and state that the above information is E
��..( C/y correct.1 agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
(� Z building construction,and hereby authorize representatives of this city to enter upon the
i--i shove-mentioned property for inspection purposes U
PERMIT ISSUANCE E(We)agree to sate,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. Ein consequence of the granting ofthis permit.
\\I 1 \1)11\11[\\I)" 1\I)\\ILL('O\11'11 R1f11 \IL\O\-I'OI\I AIR HANDLINGUNIT(TO10,000CFM) FEERI(1I I \1 IO\� AIR HANDLING UNIT(OVER 10,000 CFM) N TAX
Signature of Apphcant/Contraetor Dale EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
HEATING UNIT(OVER 100,0011 BTU)
Code,Section 25532(a)?
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID Date Receipt#
Will the applicant or future building occupant use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOT
District! BOILER-COMP(OVER 100,000 RTU)
❑Yes ❑No
��
I have read the hazardous materials requirements under Chapter 6.95 of the Call-
AIR CONDITIONER EfA
foruia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH SQ FT / S _
budding does not currently have a tenant,that it is my responsibility to notdy the occupant /J
of the requirements which must he met prior to issuance of a Certificate of Occupancy
Owner or authorized agent Date TOTAL: ISSUED BY:
OFFICE