S3929 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 3929
I. BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATF.
r I O ER'S NAME 1 _.44ONE I CO ACTOR'S NAME: LIC NO:
/ C �.�.� NIC CONTROLp
ARCHI'f:C/IIID IN ER: LIC NO ADDRESS: ❑
CONTACT: PHONE: - � BUILDIN[/G PERMITINFO
.Q�/ ,� ❑ Consultant Fees Paid by Applit ant(Initial) BLDG ELECT PLUMB MECH
/G s car 7-11 - I ❑ � ❑ ❑
LICENSED CONTRACfORSDECLARATION QTY ELECTRIC PERMIT - FEE
I hereby atoms th t l m Tc naed trd p ' ns of Chapter 9(romme mg JOB DESCRIPTION
O�Z wird Section 7f0m of Di ' 3 fthe Business d Prfssioni Cid,.and my license is RESIDENTIAL'
WOO PERMIT ISSUANCE
H Iy in full force nnJ ¢a /1 C� ❑SFDWL ❑KITCHEN REMODEL
aUV License lass �/ LIc.M C! APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
hQW Uate Comroaor
F-Dw ARCHITEC's DECLARAION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O ti Z 1 understand my plans shall W used as public records MODIFICATION
O Z_ UP TU 200AMP5 ❑INTERIOR ❑CHIMNEY REPAIR
F4LW Licensed Professional 201-1100AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
C 1 hereby vRnn that ion exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATA RIiMODEWREPAIR El DEMOLITION
X 31 U following reao.,(Section]031.5.Bilnro,and Pmfessinn,Code Any city nr mrumY SIGNS ELECTRICAL []OTHER
til LL a h which requires a Permit m conswet,alter,improve,demolish,or repair any structure
F.Oa prior in its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC. 00,
that he is licensed pursuant tat the provisions of the Contractor's License Law(Chapter 9
Wap0 (commencing with Section70(soof Divisi,,n Jot'mo Bnsinasuand Profession,Cude)nr 'I'EMP�METER OR POLE INS'I'. R t
d d c C that he is exempt therefrom and the basis lin the alleged exemption.Any violation of W BLDG/ADDITION ❑DEMOLITION
X^_�
S. 90]1.5 byte applicant I.,.permit.mbjerts the appli,mama civil penalty of POWER DEVICES
W '� no,more than rive hundred dollars(50).50TENANT El FOOD SERVICE
I-Z> IMPROVEMENT
f=C ❑ I.asowne,mDWErv1o1,ormyempl1,n,,whh wagesysaheirsolecompereminn, SWIMMING I'OUL ELECTRIC
W E-e will do the work.and the.not is not intended or o6'ered for sale(Sec.Tl4l,Business ❑OTHER
L3 m and Professions Code:The Cewhwaa's Llccnsc lyw docs noa apply a.an owner of OUTLETS-SWITCtIES-PIX'I'UNES / /r
property who builds or impmvess thereon,and who does such work himself or through
his own employees,provided that such imp..vemenm are or intended or offered for NEW RESIDENTIAL ELECTR SQ ET.
sale.If.hwxcvea the building or improvement is sold within one yew ofcompleaion,the J p�'((pp SQ.FT.FLUOR AREA ESQ.FT
er-builder will have the burden of proving that he did nor build or improve for the
IJ /rVv-.j
Ips,w sale.).
❑ I,u,ownerof the propimy,vit,exelrokely nnimear,w,,It licensed contract m TOTAL:
can...net the project(Sec 9041,Badness and Profea,ions Code.) he Contractor's Li
cense Low does nm apply it)an owner of pmpcnY who build,,,,improves mernm,and QTY. PLUMBING PERMIT FEE
xho conuans for such projects with a commeior(s)licamod pursuant to the Comracmr s
License Law. PERMIT ISSUANCE
1 am exempt under Sec. .B d:P C for this reason
Owner Done, ACFER-DRAIN k VENT-WATER(EA) VALUATION
WORKER nderPCOMPENSATION DE CLARAIJON BACK 11004 PROTECT DEVICE
1 hanillri
thereby rtn under Penalty neperjury one of the insum for Wwker''%Co
Ihave and will maintainectioiftcare ofConcent to
bor Care.
riot Worker'sce of h- DRAINS-FLOOR,RWEARF.A.COND. STORIES TYPE CONSTRUCTION
work,as provide)for by Section J]W of the Labor Cider for the performance of the
work avearie ill mennii i.,issued. FIXTURES-PER TRAP
❑ 1 hove and will mainmin Worker,C,,mp,m,:nion Insurance,u,Teyuircd by Sceaion
JlW of the LaWr Code,for the performance of Ne work for which�lhi�,L lis isucd. GAS-EA.SYSTEM1f-I 1NC.40UTLLTS OCC GROUP ANN
Clameorlt/1f;um18nsayyn lefPanec carne Pai`Y oNocy.Aurd�o!re\ ��0f GAS-EA.SYSTEM.OVER 4(EA)
T7 CCERRTI,FIC`ATE OF EXEMPT ION FROM JWORKERS GkEASFIINDUSTHL WASTE IN'1'IikCEPTOR
COMPENSATION INSURANCEl)UILDING DIVISION FEES
(Thi„cetian neeA nm hcmmplel.J ifthe pnmiit isf r„rte hundral Jollvrslsl W) GRBASG P
or less) 1-'� PLANCHECK FEE
learayahwirmoperfnmunceofthewnrk for which thispermit is issued,lxhall SA SANT Y-� RME 00 FT.
not employ any Pinson in any manner so a,to become subject to the sembe,x Compen- ENERGY FEE
Q Z saaion Laws of Califemia,Ila, WA E EATER W/VENT/E ECTR GRADING FEE
Z2 Applic et
.Na NOTICE TD APPLICANT:If,after mukin6 this Certificate of Exemption,you shoulJ WAI -'SYST ?A
F > become,subject to the W'orker's Compensation prov,ions of the Labor Code,you must SOILS FEE
forthwith comply withmch provi,am,.,,his .it shall W Deemed revoked. WA : SERVICE.
Q
= Z CONSTRUCTION LENDING AGENCY NEW REQ F:NTIAI.YLMB. - PAID U' Receipak
1 herchy tiff rte that there is nutearalion lending agency farth Performance n(
LL P the work ter which this permit is issued(See.JIM)].Ci,C.)
Lender's Name TOTAL:
�UJ Landers Address _ TOTAL BUILD rPEF.
F' G I certify that 1 have read this application and state that the above information is
h mtmm.l agree mcomply with alldry and county,Minae«s and sante laws rcmung ao QTY. MECHANICAL PERMIT FEE
building comhuction,and hereby authorize representatives ufmis city to enter uponihe SEISM FEE
aho-a-an boned PropenY fur Inspection purees,,.
(We)agree 1.,ave,indwnnify and keep harmless the City of Cupertino against PERMIT ISSUANCE ELE C FEE y O
liobilniecjadgmenm,corm and exproo-which may in am way accme agaima said City ALTER OR ADD TO MECO
in nuquence of Ne germing of this permit. PLUMBIN WIG
APPLICANT UNDERSTANDS AND W .L COMPLY WITH ALL
NO/N.POINT AIR HANDLING UNIT(TO 10'”CPSH MECHANICAL FEE
SOURCE REGUJ.a�I'IONS. /� � � p/ ABR HANDLING UNI'P(OVER Wool)CFM)
(\)eft'` CONSTRUCTION TAX
Signature of AppIicam/Cwt? m, Data EXHAUST HOOD(W/DUC) HOUSING MITIGATION HE
HAZNRDOUS MATERIALS DISCLOSURE
Wilithe applicant orfuture buildingoccupamstole or handle hazaNnm mae,ial HEATING UNIT TT O 100.000 WITH
as defncd by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
�
Code,Section 25532(a)1 _ HEATING UNI'I'(OVER 100,W0 11TU)
❑Yes ❑Nn PAID --
VIiN'TILATIONPAN(SINGLE H6SID) Uate ReceiptM
Will the applicant or furore building accupam use equipment or devices which
,.it heIDNnas an ceremonious as defined by the Bay Arca Aa Quality Nanagemwt BOILER-COMP CHP OR I00,000BTU)
Dome,' H(IILER-COMP(OVER 100,1010 BTU)
❑Yes ❑No
I have marlthe hhazardousmaterials requirements under Chapter hAIR CONDITIONER95 of the Cali- ISSUANCE DATE
fomia Health B Safety Code.Sections 2550 .255JJ and 2553,1 understand abs if the NEW RESIDENTIAL MUCH. SQ.ET.
building lr��wnD wool to nl� it is my responsibility to notify the mcupam
of the rcgt at,which which t n aiyµv''uTn ICmIC nf$kcufi boy,%
Owner or Ma on ed agent ,/ D�cjG/Gp TOTAL: ISSUED BY:
OFFICE