S 3119 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.-ELEC'IAICAL PF.RMI'F NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 3119
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SU13MI'ITAL DATE,
o savG /•-�-9g
OWNI' "NAME: PHONE: CO ' CTOR'S NAME: LIC NO:
je� 3—/7 p %Lp V v NIC CGNTROI.«
CHITT:CIYENGINEER: LIC NO: AUDRISlJ ❑
JM
0 1 � S. 1U.On2! VIWI f
CONTACT, PHONE: BUILDING PERMIT INFO
/ ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
S3_p� 8 ❑ ❑ Ga-- ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERM IT FEE
I hereby affirm that 1 um licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
{O�'Z with Seen,,.7fXXn fDi1Wcu3nfthe Busine,sand Professions Cale,undm,hetaiels RESIDENTIAL,
FOO in full tone unJ ellen. PERMIT ISSUANCE
uI-� OSFDWL ❑KITCHEN REMODEh
�UV License Class Lic.« APPLIANCES-RESIDENTIAL. El ADDITION 9LIA.6 MING RH PIPE
y 6 L Date Conlmmor
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑S9RUCTURAI•
Z O n 3 PANELS
I understand my plans hull E used m public ATION MODIFICATION
O Z.-O UPTO20JAMPS Ll INTERIOR El CHIMNEY RFPAIR
2:1 1.1moved Pone'sinnal 201-1000AMPS IMPROVEMENT SWIMMING POOLS
KGs+W OWNHR-BUILDER DECLARATION OVER I(I(IIIAMPS ❑BATH RF.MODEVREPAIR El DEMOLITION
+1' I haffim
ereby r that 1 am cxempl from the Comment',License Law for the
s2x O L U following mason.(Siena.70315,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
1+131+•h which requires a perno..re construct,alter,improve,demolish,or repair ony structure
F�OQ primmin.it...am.al.c.myuires the applicant for such Permit o Do.signedsmunrum SPECIAL CIRCUITIMISC.
'hat he n limmsed pumuum m the previsions of the Contractor's License Law(Chapter 4
W�00 (commencing with Section 9fplWDivision3.Dhe Fixeme,and Profession,fessn,Cotte)o TEMP.METER OR POLE INST. COMMERCIAL:
6 L eC that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑ivIdo (TION
W m.N Section 1031.5 by ony applicam Cara permit subjeets the applicant re a civil penalty of POWER DEVICES
tel not marc than rive hundred dollars($500). TEN EMENT
❑FOODSERVICE
90 C] Las owner ofthe property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IM V
E- wdldn Nework,und Nestmcture is not intended mu0ered mrsao(Sm.1044,Business R
3 and Professions Code:The Coutmmr,
c ',License Law does m se
not apply an wner of OUTI.TTS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided Thal such improvements art no,imended or offered lar NEW RESIDENTIAL ELECTR SQ 19'.
sola If however,the huildingon improvement issold withinoneyeur ob co.ia, l..n,the SQ.FT.FLOOR AREA $ISQ.IT,
owourhudder will have the burden of proving that he did not build or improve for pun-
t pleat sine).
❑ 1,as owner of the notroy, no oxelusively contmcfing with licensed esmtrun.rs to T(YIAL:
m,unat the project(Sec.9(94,Bounmes,and Professions Code:)"1'he Conlmdor's 1.'r
most,law does not apply to an owner of property who builds or improves demon,and Q"I'Y. PLUMBING PERMIT FEE
who contracts for such projects with n contractors)licensed pamuanuo the Contractor's
License Low. PERMIT ISSUANCE
I um exempt under See ,B&PC for this moron
Owner Date AITER-DRAIN&VENT-WATER IRA) VALUATION
WORKF..R;SCOMPENSATIONDECLARATION BACK FLOW PROTECT
1 hereby aRimt under penally of perjury one of the following declarations:
❑(have onJ wilDnaimwn oCenificme.f Conserv 1.ulf-i...refet Worlds Compen- FLOOR. F.AR SIR STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3100 of the hbm Code,for the performance of N
work for which this panni.is issued FI ERTRAP
❑I have and will maintain Worker's Compensation Insurance,as reyuireJ by Scelion
3100of1hel GNc.fanhe pedonnanre of the work for which this permit is isueJ, GAS-EA.S 5 M O 1 S OCC,CROUP APN
MY Workrmp •retro •urpce caRicr.1d Policy num�r �+
My woo orp anal No.: "1`« .S ST.M-OVER 4IF
CF.RFIFI ATE Or EXE "TION FROM ORKIiRS'
COMPENSATION INSURANCE GREAStIDNDUSTRL WASTE IM'ERCI 9T)R
BUILDING DIVISION FEES _
(This ewdnn need not he cumplctedtithe permit is foranc hundaddnllur,($1(1)) GRHASP.TRAP
or let,.) PLANCHECK FEE
I mnify thin in theped'oreaneeaflhe wank for whichthispermit is issued,l shall _SANITARY-STORM EA,2191 F.
not entpiny any pets,,in onymmnnerso us as becomesubject to the Workers'Cnngmo. - ENERGY FEE
O z smion Lows of CaliHmtia.Date WAI ER HEATER WNEN UELECTR*T(YrAl.
GRADING FEE
7 Appliconl
r'7 NOTICE?TO APPLICAM':It,after making this Certificate of Exemption,you should WATER SYSTEM,TREATING
F become subject to the Worker's Compensation provisions of the Labor Calc,you must SOILS FEE
Ww-t forthwith comply with such provisions or this permit shall be deemed revoked, WATER SERVICE
a. Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. PAID Date Receipt«
1hor which
thermic i iss issued
lending agency for the perfnnnancc of
the work for which this parotin is issued(Sec.3119],Civ.C.) 23
fr Linder',Name l'OTAL:
O U Lender',Address 1 mnifNm 1 have read Nis applicalion and state Nat Ne above immolation i, BUILDING FEE
W coat l agree m connply with all city and county ordinances and nate laws elating to QTY. MECHANICAL PERM
U Z building construction,and hereby announce representativesofnhis city noenmr upon the SEISMIC FEE
alasve-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m nme,indemnify and keep homeless he City of Cupenin.against ELECTRIC FEE
liabil'aicapdgmcces,costs and expense which may in anywayaccme against xmd City AITER OR ADD TO MECH.
in consequence ofihe gmmimgof nail. PLUMBING FEE
APPLICANTUNDERSTA ILL COMPLY WITH ALL.NDN-POINT AIR HANDLINGUNTT(1'0 IgmOCPM)
I. Q MECHANICAL FEE
SOURCE REGU
9--79 AIR HANDLING UNIT(OVER 10.(X9)CFM) CONSTRUCTION TAX
Signa phcam/ I or Date EXHAUST HOOD OVDUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the uppllcunl or boom huildna,umupmamore or handle hmardn i,aamnm HEATING UNIT('I'O Iffl Ax)HTU)
ns dcgned by he Cupanin.Municipal Code,Chapter 9.12,and the Health and Sully
Calc,Section 25532(u)? HEATING UNIT(OVER I00,0M BTU)
❑Yes ❑N. V ENTILATION FAN(SINGLE RES]D) PAID
Dam Receipt«
Will the at,minntimants aortunum building by ave Bay Aem Air
vices which BOILER-COMP(TUTOR 100,00 RTU)
emir hamNous air comeminemx as AefnW by Ne Bay Arca Air Quality Managnnem
District? BOILER-COMP(OVER 1 WpW BTU)
Cl Yes F-1 No
I have read the havardou,namenal,requirements under Chapter 6.95.fthe Cali. AIRCONDITIONER ISSUANCE DATE
(.rote Health&Safety Code,Sections 25505,25533 and 25534.1 understood Nat if the NEW RESIDENTIAL MECH. SQ.ET. t—J Q
d.building dren moremly have a Iemmt,Nal it is my rosponsibititym moify Ne ore.pam
of Bae"comments which most M mel in,to issuance of.CeniHeme of Occupancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE