S3911 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 3 911
BUILDING.PROJECT IDENTIFICATION - w
BUILDING ADDRESS: SANITARY NO. APPIJ TION SUBMITTAL DATE
4 - p
OWNER'S NAME PHONE. CONTRACT'OR'S N�7AAMIi: '_'� LIC NO:
Leo /.( O rU 6 Z7 NIC CONTROLp
ARCH[TECrlENGINEER:I LIC NO: ADDRESS C„ 1 ] ❑
a,46 C-El C T
CONTACT: PHONE: - - BUILDING PERMIT INFO
01 "J k a ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MI CH
e a a1. 365-/460 LK' El 1:1 El
EE RACTORS DECLARATION QTY ELECTRIC PERMIT, FEE
1 haehy in.that I am fie n. d d p f Chapter 9 mar menang JOB DESCRIPTION
OmZ Ih Section]DIXDo13 :oo3 ofthe Rus' and i s fxssom'Code and my license is RESIDENTIAL
Iy van PERMIT ISSUANCE
am u:F- to fall forceand cffe�s.24 2 33 ❑S17DWL ❑KITCHEN REMODEL
QUU Liccnsc Class Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y41 Data S.an 1' 7 - 9f Cnntanor 'Og-k'
ARCHITECT' PANGLS S DECLARATION Ll MULTI-UNIT El STRUCTURAL
p.7 to
Z O m 2. I understand my plans shall he used as�public records „,,..,,MODIFICATION
OZ=;,
UP DO 200 AMPS ❑ f9
INTERIOR CHIMNEY REPAIR
FEnF ad Licensed Professional 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER BUILDER DECLARATION OVER IIX10 AM11P5 L3BATH REMODEL REPAIR ❑DEMOLITION
C C Q I hereby affirm that I am exanpl from the Contacnn'%License Law lar the
kid A.Ufollowing reason.(Section 703L5,Business and Professions Code:Any city m county SIGNS ELECTRICAL ❑OTHER
h which requires a permit to construct,alter,improve,demolish,or repair any soucmrc
5 prior to itsissuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUITIMISC.
fey— that he is licensedpursuannutheprovisionsoftheContractorsLlmnxcLaw(Chnpter9
III y CO (commencing with Section 7000)of Division 3 of the Business and Profession Code)or TEMP.MEILR OR POLE IN ST. COMMERCIAL:
Q.ac C Lha he is exempt Humberto and me basis fm the alleged exemption.Any violation of DG/A-DDITION ❑DEMOLITION
211, Section 7031.5 by any applicant for a permit subjects the applicant to a civil penahy of POWER DEVICES ENANT/'�'--�LOO1)-fERVICE
1-,Z} mil marc mon live hundred dollars(SSfNB. Ann''' MPRO �k
�9n ❑ 1.as owner of the proporty,or my employees with wages as their sole compensation. SWIMMING POOL ELFOTI "\
p.� will do me wnrk,und dremahwrefinish imendedoroffered forssle(SmJ7044.Business THER
1Wa1 m ad Professions Cade:The Contrai License Luw does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or inopruvw thereon,and who docs such work himulf or through
his own employees,presided that.such itnwuvemcros are not intended or purred for NEW RESIDENTIAL ELECTR SQ FT.
JUN 0 7 11111
vale.IL howeresthe building monmvement is sold withinone ycaofcompletion,the SQ.FT.FLOOR ARYA' S/SQ.PC
owaroburider will have the buffer,of proving that he did not build or improve for put-
itsale.). 58y
1,n owner of the property,am exclusively c omroning with licensed aour...I vs us TOTAL:
construct the project(Sec.]ON,Bre inevs and Professions Code:)The Contractor's Li
cane law does not apply to an owner of property who builds or itnpmves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with o contastogs)licensed pursuant to the Contaemt's
Laccmc Law` PERMIT ISSUANCE
I am esempt under Sec. R sF P C for this mason
Owner Dam ALTER-DRAIN k VENT-WATER(EA) VALUATION
WORKERS COMPENSATION NSATIONDECefbilo irm RACK FLOW PROTECT.DEVICE �QO
Iherebyaffirm under penahyor perjoryoneofthefollowing orker tiro:
�Ihave and will maintain ation 37W of ComGm to are,for the performance of
DRAINS-FLOfIR.ROOF,AREA.GOND, RIES TYPE CONSTRUCTION
smirk,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which tHHpanthe is issued. FIXTl1RES-PfiR TRAP / -
❑1 have and will maintain Wofkrfr Gan a of
n work
which
h his par by Section
My ofine Labor Code,for the Performance the work forwhich Ibis pemoit is issued. GAS-EA.SYSTIiM-1 INC.aOUTLLTS OCC,GROUP �(”
My N'ork 'eC tnlpe ti Inw ce famcrand Policy number are' �/`/� 3 p �q
Caress ��41 C,a 1'y A Policy Nu.:_Q y 6� 9 Cl GAS-EA.SYSTEM OVER i(EA)
CERTIVICATE OF EXEMPTION[BOM WORKERS'
COMPENSATION INSURANCE GREASEINDUS'rRL WASI1i INTERCEPTOR o
BUILDING DIVISION FEES
(This section permitterbecomplemd from permit is forone hundred Author IS IIID) GREASETRAP
or less) PIANCNECK FEE
I ormly shat in the ltcrfmmanceatthe work lin which this permit is issued,l%hull SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so at to become subject to the Workers Compen- ENERGY FEE
O Z cation taws of California.Date WATER HEATER W/VENEVELECTR GRADING .E
Z Applicant
= NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/TREATING
(ti > swarms subject la the sMakarx Compensation pummons of the Lnbrr Calc,you mux, SOILS
forthwith comply withmch pmvi,imso,this permit shall toe deemed brooked. WATER SERVICE
a �
= Z
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID ata Receipt%
1 hwmby affirm Etat there is sued(Set.3 n lending agency for the perliormmpce al
U O Leaders Name
far which this perch is issued(sec.31y9],civ.C.)
lender's Name TOl'AL:
O {vIJ Lender's Address TOTAL: BUILDING -EE
nom ps I craoly that I r it da, ppltcat L state that lh b - f tut t Is _
N correct Iagree in comply with all ly and county ordinance& ad.tat,laws mining I,, Q'TY. MECHANICA L PER M I F FIEE. SEISMIC E
UZ building comaractmm,andhreby marrow reprecemaives of lh: 'p to emeT upon the 0
%boom rntioned property for inspection purposes PERMIT ISSUANCE
(We)agree to wove,indemkily and keep hamdew the City of Cupution against [LECfRI PE'
liabilhics,judgments,erns and cxpemca which may in any way acme agaikxlsaid City
AU]FIR OR ADU'TO MECfI. PLUMBING h1iE
to n,,ucn,c of the gra mar,of tbi%permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
MECHANICAL FEE
$(IURCE REGULATIONS. ///seise
\—\, A A//' J!^�` .4 AIR HANDLING UNIT(OVFR 10,00!1 CfM) CONSTRUCTION TAX
Signature of Applicandcontitractorr V Date EXHAUST HOOD IW/DUCT) HOUSING MITIGATION EEE
HAZARDOUS MATERIALS DISCLOSURE
Will theapplleunt or future building occupant stare lir handle hazardous material HEATING UNIT LTO 100,000 BTU)
as defivul by the Cupertinn Municipal Code,Chapter 9.12,and the Heallll and Safety
Code,Section 25532(a)? 11177ATING LINE I-(OVER100,000 BTU)
❑Yfs C3'NT VENTILATION FAN(SINGLE RESIDE PAID Dae Receipt#
Will the applicant nr future building occupant use equipment or daviccs which
emit hamNous air conmminams as detimal by the Has Area Air Quality Management BOILER-COMP(3HP OR 100.00C1IO U) T L. O
❑Ye,Dimia? BOILER-COMP(OVER 100.000 BTU)
L}Na
I base read the Mena dons materials requircnocats under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE
favors Health d Safety GNe.Sections"5505,M533 and 2553a.1 understand That if the NEW RESIDENTIAL MECH. SQ.ET. C7J
building does not crorem vea ter t thmit is my respomihility to and therceepanl — C
reynireanantsw ' hit
to
lir to lssuunee ofa Cr9vam of Oecupnney. T/ �
r awhodl agent [)amTOTAL: ISSUED BY:
OFFICE