S 3809 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL S 3809
BUILDING PROJECT IDENTIFICATION
BUILDING ADRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
X / S-96 M 0,1 RQ vl"'i _S- 2,5 -9 9
OWNER'S NAME: PHON / CONTRACTOR'S NAMENIC COMOL#
: LICNO:
ARCHITECUENGINEER: LIC NO: ADDR 5: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG ELECT/ PLUMB MECH
0 7 0' ❑ ❑
LICENSED CONTRACTORS DECLARATION QTY, ELECTRIC PERMIT FEE u
Z 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
EO withSmian]d(1fi)ofDivisionJofthe Business and PmfessionsCMe,and mylicenm is R SIF�DENTIAL_
FSO in full force sod yr g- �r PERMIT ISSUANCE. (ISFDWL ❑KITCHEN REMODEL
�FUZ License Class Lica : APPLIANCES-RESIDENTIAL []ADDITION C1 PLUMBING RF.-PIPE
N M p, Date GmnlDECL
i001be.sta DECLARATION ❑MULTI-UNIT [],STRUCTURAL
H�y PANELS
Zp G Iuwemand my plans shall he used as public records MODIFICATION
OZ O UP TO 200 AMPS [I INTERIOR [I CHIMNEY REPAIR
F-LIt; Licensed Professional 201-1000AMPS __,,�IMPROVEMENT C]SWIMMING POOLS
�%Mf OWNER-BUILDER exempt
mDECLARATION OVER IT00AMPS C10ATH REMODEMEPAIR ❑DEMOLITION
1 herehy (Sect that 1 am exempt from the Contractors License Low fm the
ip5�O y U following rcamn.(Section 7031.5.Business unit Ihnfesninns Code:Any city or county SIGNS EhF.CfRICAI. �OTHER
FO which requires a permit to construct,alter,improv demobs nr repair any structure
J poor to its issuance,also requires Nc applicant fon panni o rile s signed statement SPECIAL CIRCUIT/MISC.
f'yy thatheislieensedpursuannotheprovisions of the Co s License Law(Chapter 9
W8a�p0 (commencing with Section 7")of Division 3 q[Iha usiness and Professions Code)or TEMP.MUTER OR POLE INST. COMMERCIAL:
el, M y that he is exempt therefrom and the basis for a"t��,��I exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
U-+m Section]011.S hya plicvm fora perm h is the epplicam mucivil penalty of POWER DEVICES
not more Chun live ndred dollars(SS ❑TENANT [_1 FOOD SERVICE
C Q ❑ Las owner of pmpeny,mrayem o�y es with wages es their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
22 willdothasookadthemunt.r 's notim Jed nroffertd for evle(Sec.]044,Busineu ❑OTHER
3 and Patriotism., :The Con ohs License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES O
progeny who hui s improv the end who does such work himself or through
his awn employ s,provide) m such tmpnwanems arc not amended or offered for NEW RESIDENTIAL BLECTR SQ FT.
sale.IT however, ebuildin r improvement is said within one year ofcompletion,the SQ.FT.FLOOR AREA $/SQ.IT.
ter-builder wit unden of proving that he did not build or improve for put.
pose of sale.). e
1,as owner of the property, m exclusively conducting with Eventual contractors to AL:
construct the project(Sec.7044 Business and Professions Cods:)The Co urnowt s Li.
erose Law do,ma apply man ownerofpmpeny who bmildsor improves theteon,und QTY. PLUMBING PERMIT FEE
who rmwet for tach project with a ccandomr(s)I Icensed pursuant tithe Convnnnr's
License Low. PERMIT ISSUANCE
❑I am exempt under Sec. ,B&P C for this reason
Owner ]).atALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE OOQ
I herehy inform under penalty of perjury one M the following declarations:
0 l have and will maintain aCenifcateof Canxem toself-insure for Worker's Compete DRAINS-FLOOR,ROOT,AREA,GOND. STORIES TYPE CONSTRUCTION
sodium,as provided for by Section 3700 of the Labor Cade,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
I have and will araimdn Workers Compensation Insurance,es requited by Section v
37M of the Labor Code,for the performance of the work for which this permit is issued. GAS-PA.SYSTEM-I INC.4OTfLETS OCCGROUP � lA2
My Workcr's pphpcns ion Insurance carrier and Policy a'� a•g ,,,///��� (� L.
Comer: &NazeR Policy N., TI137I I/II GAS-EA.SYSTEM-OVER 4(EA) // /6
CERTIFICATE OF EXEMPTION FROM WORKERS' /<
COMPENSATION INSURANCE GREASMNDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FCFS
(This section need but be rntrM
completed i(thepnit is forone huntlollars(51110) GREASETRAP
caless) PLANCHECK FEE
I cenify that in the performance ofthe work for which this permit is issued,l shall SBWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner so as n become subject o the Workers'Common. ENERGY FEE
Oz satimn Laws of California.Dam WAT17R HEATER W/VIiNT/ELECTR
Z Applicant - GRADING FEE
y NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEM?REATING SOILS FEE
ai become mbject n the WmmA Compensation provisions of the Labor Code,you most
Lkl forthwith comply with such provisions or this permit mail be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ,FT. PAID
V O l far which
that is..cal( ea.30 leading agency for the performance of ¢ Rtteipt«
� r @e work for which this permit is isauM(Sea.3107,Civ.CJ
O I-'ULenders Name TOTAL:
{Ll Lenders Address TOTAL:
;r e9l
Or I cenify that 1 have read this application and state that the above information is BUILDING PEE
fA correct.1 agree to comply with 411 city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
L) z building construction,and hereby addition represeamovesofthis citymenterupon the SEISMIC FEE D
above-mentioned progeny for inspection purposes.
(We)agree to one,indemnify and keep hamdawds,City of Cupertino against PERMIT ISSUANCE ELECTRIC FEE 6 O
liabilities,jAgitators,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT G'010,1X)0 CFM) MECHANICAL FEE
SO EGULATIO a
S y/ AIR HANDLING UNIT(OVER In"CM) CONSTRUCTION TAX
Sign me of Appliean unmrnor Dole EXHAUST HOOD(W/DUC) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant m)wore building occupant store or handle hazardous material HEATING UNIT 90100,0110 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)' 1 HEATING UNIT(OVER 100,000 BTU)
E]Yet ❑No VENTILATION FAN(SINGLE RESID) PAID
Dem Receipt«
Will the applicantor future building occupant use equipment or devices which BOILER-COMP QHP OR 100.000 BTU)
emit hazardous air contaminunb ns defined by the Bay Arcaa Air r Quality Management
O
District?0 Yea ❑No BOILER-COMP(OVER 100,00)BTU)
I have mad the hamtdous nsmarmlx requirement under Chapter 6.95 of the Cali. AIR CONDITIONER ISSUANCE DATE
fumlu Health&Safety Code,Sections 255(15,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ.FT. a O Qj
sn Iturn d hove mount,thatitisnryrespnnsihilitymnotifythe cupaut
aft
.he
mat w m tet priortoissuancer vCcniIt -ofCC pant.
O
outhun agent Dam TOTAL ISSUED err,
OFFICE