S 3877 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
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CITY OFC ER INO BUILDING-ELECTRICAL PERMIT NO,
RUII,UMG DIVISION APPLICATIONFPERMITPLUMBING-MECHANICAL S 3877
RUILDING PROJECT IDENTIFICATION
WILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
Z l O o ,v-_Sr5 ti U 2
WNER'SNAME: PHONE: CONII'RACTOR'S NAM : LIC NO:
® CA /C"• NIC CONTROL p
\RC T" 1ENG1NE13R: IC NO: T ADDRESS.) ❑ ��
ONTACT: Q�U a PHONE
A6 Q ❑,Consultant Fees Paid by Applicant(Initial) BIL-DGS ELECT PLUMB mLCx
/� la Qom_ Qom_
LICENSED CON'TRACTOR'S DECLARATION
Qd' QTy, ' ELECTRIC PERMIT FEE
hereby affirm that I am Beensed ander provisions of chapter v(commencing - JOB DESCRIPTION
with senlon70lN0 of Divieim13 of the Business and l'ndcsninrlsQrde,and lnY lianuis
Oz p PERMIT ISSUANCE RESIDENTIAL:
C, in full force and eODet. �fFDWL E)KITCHEN REMODEL
Q U�j -wen
Clan [.it.#
gzw Date Conlracmr APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING REPIPE
ARCHITECTS DECLARATION - [I MULTI-UNIT []STRUCTURAL
Z C AZ I understand my plans shall he used as public records PANELS MODIFICATION
Z
Ov2—CUPT0200AMPS [I INTERIOR El CHIMNEY REPAIR
F4 Ili Licensed Professinmd 201-1000AMPS IMPROVEMENT E]SWIMMINGPOOL.S
�+,�W OWNER-BUILDER DECLARATION OVER 100ty AMPS El BATH REMODEUBEPAIR [I DEMOLITION
K 1 hereby n0irm has I ren exempt from the Contractor's LicenseTaw for the
prow 3 6 F following mason.(Section]03 1.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
Is7 LL. which requires a permit to construct,alter,improve,demolish,or repair any swemre •-etf
I"'�yOy prior to its issuance,also equines the applicam for inch permit to File a signed statement SPECIAL CIRCUIT/MISC. �•�.a" N
that he is licensul Pursuant to the Pnrvisiomofthe Conuaetor's license Law(Chapter 9
g00 (commencing wish Section 701X0 of'Divisien3oflha Businessnnd Professions Chow)or 0HMP.ME'1'17R OR POLE INST. COMMERCIAL:
d 0.e�' that he is exempt Iherefmm end the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�m Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES 1 ❑TENANT ❑FOOD SERVICE
e more than five hundred dollars($500). IMPROVEMENT
01,as owner of the property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC
will do the work,lmd the structure is not intended or offered for sale(See.7GLL Business ❑OTHER
{r13 and Professions Cole:The Contmcmr's License Law Bros not apply In an owner of OUT LETS-SAI'PCIiliS-PIX'FURES
11 property who builds or improves Jerenn,and who does.such work himself or through
his ow employees,provided that such improvements anot intended or offered for NEW RESIDENTIAL ELECTN SQ FT.
sale.IC re however,the building or improvement is sold within one year ofcompledish,fle SQ.FT.FLOOR AREA ESQ.Fr.
uwver-lbvildcr will has use burden of proving that he did not build or improve for per-
"a
IC.).
as owner of the Property,a exclo,waly a irmoning with licensed culnrunors to a_ry• t Q, •� L s 0
mmmm me prejed(Sec.7044,Bu,nos,and Note ssiona CealeU The Contractor's Li-
ch,
i-
come hew Ales not apply to an ownerof property who Wild,or improve,theme,and QTY PLUMBING PERMIT • -FEE
whocntaruasfarsuch Projects with a contractor(s)licensed pursuant m the Contractor's
Lice ve PERMIT ISSUANCE S. s
am exempt under Sec. .B&P C for This arisen
r WI1G
((�� ALTER-DRAIN&VENT 02R(kA) VALUATION
I P�OnIC
WORKER'SCOhIPHNSATIONDECI,ANATION BACK PLOW PROTECT.DE
I hereby affirm underpeaddy of perjury oncordhe Mks wing ded----- x: ��
] I have and will maintain a Certificate of Consenno self insure for Worker's Compen- DRAINS-FLOOR,ROOF. A, STORIES TYPECONSTRUCTION
J, notion,as provided for by Section 3700 of me Labor Costs,for the perfomence er the
work for which this pemdt is issued. FIXTURES-PER TRAP S
I have and will maintain Anders Compensation lnsumnecs as required by Section
37M oflhe LnWr Code,for the perfnrmunce efthe work for which this permit is issued. GAS-EA.SYSI IiM-I INC.4UT1.1'.TS OCC.GROUP APN
My Worker's Compensation Insuntom carrier and Policy comber are:
Cartier: Policy No.: OAS-EA.SYSTEM-OVLR 4(EA) /� p
CERTIFICATE 017 EXEMPTION FROM WORKERS' 0/
COMPENSATION INSURANCE GREASEANDUS rRL WASTE INTERCEPTOR
(This amino need but be emoplercd if me permit is 00th hundred dollars($100) BUILDING DIVISION FEES
or less.) GREASETRAP P N KFEP.
I verify the in the any mmelm of the work for which this dmEnron,We ie is,Cm shall
neem In mhecenm suhLct molts Wnrkcrk Com SEWER-SANT 1'ARY-STORM H.A.200 FT ' ^
O z sabon Laws of Culifomis uDate:Inncr set as I' Pen- E RG FEE - l�Cl
WATER HEA'I'F.R W/VF.NT/EL[CTR
Z Q Applicata NO FEE
rjI
NOTICE TOct,offAPPLICANT.e,ottermaking this vision,, of Labor iodyoushould WATER SYSTEM?kGATING
become subjecnn irks Warksrs Compensation provisions of the Labor Calc,you must O SHE
LLI fnnhwilh comply wish such provision nr this permit shall he deemed rtvnked, WATER SERVICE
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. P ID
U Iherchyul0rm that there is a construction lending agency for the performance of Date Receipt#
[4 a work for which m'i5 pepn't i.
a.
1.
Lendels AAJmsT— TOT
4 I cenily mut Three read this application and slide that the above infnrmmi .is J 1 11, 1 1 BUILDING FEE
In cvocia.l agree m cool I with ell cit d count linances and sunc laws rclatin m
g py yen ynnl g 'QTY. MECHANICAL PERMIT -1 FEE
C.) ,z adhosingmnsmdogandherebyam,i.m menses. tivcsolmiscirynsenderupnnthe +' t SEISMIC FEE
"-' (clove-me e)agrd to citysave for emnif an keep hs.
(We)agree m save,indemnify and keep harmless the City of Cupertino against PERMIT ISSUANCE s SZ ELECTRIC FEE -
Iiabili0es,judgments,costs and expenses which may in any way(cosine against saiA City ALTER OR ADD TO MECH.
in consequence of the granting of this penrit. PLUMBING FEES aii
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM)
SOUR IREG�UTJAT0NS. `� // MECHANICALFBE r23
VGz (5p-
/ - RI•,a er, � Od AIR HANDLING UNIT(OVER IBgq CEM) CONSTRUCTION TAX
�+��+ppfi vl at.U- 2 r
Ignature fAppliceHAZAR O Dote IiXHAUST HOOD(WMUCP)
HAZARDOUS MATF.RIAIS DISCLOSURE. HOUSING MITIGATION FEE g2
Will meapplicam or future Wildingacct,ant Marc or handle baznNous material HEATING ON]]'(TO Iffl."BTU)
as defined by the Cupertino Municipcl Code,Chuptcr,912,and the Hcahh and Safety
Co,k.Stedon 25532(r)1 IIEA'FING UNI'I'(OVER 110,000 B'FU)
E]Yet VENTILATION FAN(SINGLE.RFSIU) PAIDI ��
Date Receipt#I
Will mm ro
e applicant future building use equipment or devices wNdh BOILER-COMP(3HP OR 10400(1 BTU)
fit hazardous sir contaminants as defnW by by the the Bay Area Air Quality Management TOTAL:
I vic17 BOILER-COM 11(OVER 100,0(X)RTU)
• ❑Yes
I have real the hazardous materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
mein Health&Safety Code Sections 225505.8533 and 25534.1 understand but if me NEW RESIDENTIAL MECH. SQ.ET.
building does not currently have a tenant,that it is my responsibility m notify the occupied
of the uircmen wt ch mus �m �d�u Cenifevteu fkc ncy. �J
0
Owner or mhmized agent Ise TOTAIg ISSUED BY:
OFFICE