S 3919 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIOSUPF,RMIT PLUMBING-MECHANICAL. S 3919
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPPLICATION SUBMITTAL DATI
44
WNER'S NAM.: PII NE: CONTRACTOR'S NAME: LIC NO:
�D _ '17 _ x NIC /?CONTROL#
.R HITI:CT/LNGINI:I:H:O /1l'� LIC I NO.nt� ADDRES� `- _ T �� uA ❑ C// / J,'\ Y1
CONTAC'll PDUN1113tJJ '�{• CA' BUILDING PERMIT INFO C/
❑ Consultant Fe"Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
x,¢_ 6 MATTat Or23a &' GY ❑ Q-'
LICENSED CONfRAC'FOR:S DECLARA'I ION QTY ELECTRIC PERMIT FEE
1 mmby amen that 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
CCZ with Section II%lB)of Diskion 3ofine Bu,inm,madl Profession,Code,end my license is RESIDENTIAL
IAO PERMIT ISSUANCE
in full fo�rc�e��and eftec 2I1 DSFDWL D KITCHEN REMODEL
QUU License�Fn'uns.. �7?, Lic.p -�fN-�'•�5 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
y6 a Date ':1s - �: comrac,e.
FOy ARCHITECTS DECLARATION PANIi LS ❑MULTI-UNIT []STRUCTURAL
z 0 a,z I unJw
eand my plan,shall be used as puhlic records MODIFICATION
OZ-L, UPTO 200AMPS C:1 INTERIOR ❑CHIMNEY REPAIR
Mx
Lioensed Professional 201-1000AMPS IMPROVEMENT DSWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IINIOAMPS ❑BATH RF,MODEIJREPAIR DEMOLITION
C I hereby affirm mat 1 am exempt from the Counselors License Law for the
XCWU
�(3 d following rcamn.(Section]OJL?.Business and Professions Calc:Any rip or annlY SIGNS ELECTRICAL OTHER
W W H which requires a Tramal m construct,alter,improve,demolish,or repair any structure
E'LLOQ' priorw its issuance,alorequires the applicant forcuch permit To l ile a signed,lacment SPECIAL CIRCUIT'/MISC,
fly Nat he is licensed pursaau
no the provisions ofthe Contractor's License Law(Chapters) - ---�
Pic 7
1.00 (commencing with Section 7000)of Division J of the Business and Professions Codd or TEMP.METER OR POLE INST.
d q W that he is exempt mentown and the basis far the alleged exemption.Any violation of D NE 41 VA DITTO D D' IOhITI
k^LL
Section 7031S by any applicant for operand,.bjeanducapplwanl m.,Nd penallyof POWER DEVICES y71'TEl 01-001 SE I
F Z ac not room than five hundred dollars($50(1). IM VEM
Q D1,as owner of the propenyormyemployees with wages astheir sole compensation. SWIMMING POOL ELECTRIC J'GN
W Oe willdnthe wed,and thear....tactual intended or o(fared for sale(Sao.7044.Business J DO R
L 3 m and Profession Code:The Contractor',License Law does not apply m an owner of �3 OUT LETS-
SWI ICHES-19XTURES ` (%
property,who build.,or improves thereon,and who docs such weak himself lir[hough
his non employers,provided that such improvements arc not intended lir offered for NEW RESIDENTIAL ELEM SQ PT.
sale.If,however the building or impmvenent is sold within one yeurof'c"o Jinn,Ne - HARED EISA. rf.
ser-builder rill have the burden of pmving that he did not build or improve for par-
'we ofsae.).
D I,a,,sumo at the mcf,er y,am exclusively es baaing with licensed contractor.,m T AL:
mstraa the project Sm.](VW.Business and Professions Calc:)The Contractor's Li- IJ//
use law does not apply to ch owner of property who builds or improves thrown.and QTY. PLUMBING PERMIT FEE /v(p
who contracts Tor such projects with a conwctod s)licensed purseanun the Contracmr s
I......a Law. PERM ITT ISSUANCE
D I am exempt under Sat. .B&P C Iia mis mann
ALTER-DRAIN&VENT-W G VALUATION
Date / l{�
caner firm and R'S Catty of SAT10N Hf dLA1tATION BACK FLOW 1'HOTECI'.DEVICIi O pN
1 hereby ammo under penalty of perjury one of me insum or declarations: ll IV
Dlhave andwillor by netion37e ofConsent toLabor
Cash,
mfe facrder',Ce if the DRAINS-FLWH,ROOEAREA,[OND. STORIES TYPE CONSTRUCTION
,aline,as hick this
or by Section d. of the Lnhar Coda Ibr the par!,nonce if the
work fiat and this maintain
issued. FIX'rUREs-PER TRAP ///A /
D E have and will ode,fon Workers Compensation work
for wTd h requited by Section �/
J](Ml of the Labor Cole,for perfn.nu of the wsak for hich that,permit is issued. GAS-EA.SYS'TEM-I INC.40lITLETS OCC.GROUP Zl
�� pPR,g
My Wodcr's Qom eximnb,urance ca"',and Policy
CarierA J�Ji'� �+� Policy Nob'fq `f(IPa4Y7yJ1 cqs-F:q.SvsrliM OVIIR 4(EA)
CERTIFICATE OF SAIION'IONFRAN WORKERS' GREASFANDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This section need not be completed if me permit is Boone hundred dollars($100) GREASE TRAY
or Ices) PLANCHECK FEE /S �
Immifythat inthe performance of[he work forwhiah thispermit isisseed,I shall SEWER-SANITARY-STORM 10,.200 F`L
not employ any person in any nenner so as a bras se subject to the Workers Compcn- ENER YFHE O
� Z .mist.Laws of California.Data WATER HEATER WNENf/ELEMR GRA n3viE
z O Applicant
NOTICE TO APPLICANT:If,atter making this Ccmfcmc of Exemption,You should WATIiR SYSTEM,TREATING
1-' become subject a he Workers,Compint m'en pn,,,iom mf Phu Labors Code.you must 501 ,E
Qforthwith comply with such provisions-this permit shall be deemed riveted. WATER SERVICE Q
z CONSIIWCTION LENDING AGENCY NEW RESIDENTIAL.PLMN. SQ.IT. PAID
V 0 1 hambyaflimuhat Inc.,,.construction lending agency for performance of Dee Receipt#
the work for which this permit is issued Xarc 3097.Civ.C.)
H. lender's Name A _
otcy-
O Lender's Address TOTAL:
} 1 BUILD GFEE
1 certify that I have read this application.lid stare that the same l sus relation is
F' rn correct, agreemcomply with all city and coumy oNinanecs and state law,minting to QTY. MECHANICAL PERMIT FEE y>
V Z huilJing omwrvctlon,and herehy:nnhuriee representative.of mis city menterupm the SEISMIN
V
aMwc-owntioned property for intimation purposes PERMIT ISSUANCE 2
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE
Iiabil...a,,iudgmrnls.antsand expense which may inany way acerae against said City ALTER OR ADD TO MECH Jr �� PLUMBING FEE
uclea.a of she Inum ng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNH'(TO I0.00D CFM) MECHANICAL FEED
SOURCE REGULATIONS. J
�i AIR HANDLING UNIT(OVER I tL000 CFM) CONSTRUCTION TAX
/
Signature dApplcanUContmetor + J Dae E%HAUST OL
EXHAUST HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicamn,Masora building occupant smrc lir handle hvardous material HEATING ON['1'(TO 100.000)ETC)
m defined by lie Cupcninn Municipal Cale.Chapter 9.12,and the Health and Safety
Cada,Section 255320)' HEATING UNIT(OVER 100.000 BTU)
D Yes CNo VENTILATION FAN(SINGLE RESID) PAID -
[)am Recall)[#
Will the applimi nt or future building oce....I sex equipment or devices which gO1LFR-cUMP(JHP OR 10L000 BTU)
sun harardous air contaminants as defined by the Bay Arca Air Quality Management
13
District! BOILER-COMP(OVER IBB.(KKI BTU)
D Yes F7 No
I have read the hazardous materials requirements under Chapter 6,95 of the Cali- AIH CONDITIONER ISSUANCE DATE
tomiu Ilculm&Safey Crtle,S,oions 25505,25533 and 25534.1.ndmmand sun[ifthc NEW RESIDEN'FIAT,MECH. SQ.FT.
buildingdor,nsilemmntly havcatenan[,Ota ii ism re tmibiloy m notify the occupant J/ /
of me require- b whi poor m isuunce of a Certificate of 0dapentry.
Owncro amhorived.,cut Date ISSUED BY: 74 Z;i
OFFICE