S 3927 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
(BUILDING DIVISION APPLICATIONITERMIT PLUMBING.-MECHANICAL S 3927
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLI TION SUBMITTAL DAII
11 4z. L /�I ( �11SOn �'P`( . Colt eY 1
OWS NCAEL' PHONE: CONTRA TOR'S NA '� 1 C NO,
(�L L6YGh�_ r N/C CONTROL p
�AI{CIIITECT/I'.NGI EBR: LIC NO: ADDRESS ❑
CO;M�PACT: PHONE: BUILDING PERMIT INFO
'GO�Jer`I- P kJ/,rd� ❑ Consultant Fetal Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
2, o ❑ �/
LICENSED CONTRACTORS DECLARATION QTY ELECfRIC PERMIT PEE
I mochy afire mat I all licensed under powi,kno of chapter 9(a normal.IT JOB DESCRIPTION
worm with Smomu7lNN)of Divi,km 3ofthe Business and l'rulc,nons Code,mil Illy Tiocam is
pIiN MITISSUANCE RESIDENTIAL:
FIu in full forceandencel. ❑STOWE ❑KITCHEN REMODEL.
t-u License Clave, Lica APPLIANCP_S-RESIDENfIAL ❑ADDITION [I PLUMBING RE-PIPE
hZ i Dec Controls
Fly ARCHIT17I':SDECLARA'rION PANELS
❑STRUCTURAL
Z O'^Z l undcmm�d my plans shall he ac&as puhlic accords MODIFICATION
]z4—= (III TO 201)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
-N1"'ty Licensed Pndessional 281.100DAMPS IMPROVEMENT CSWIMMINGPOOfS
OWNER-BUIhUER DECLARATION OVER IWMI AMPS ❑BATH REMODHIJREPAIR ❑DEMOLITION
C Q 1 hereby cif,-that I on.cocoon from the C.mecoth License Law for the
L 0 ClaW V following mann.(Section 1031.5.Business and Prnfasdons Cale Any city or county SIGNS ELECTRICAL ❑OTHLR
LLO y which requires a permit to construct,altar,improve,demolish,or repair any structure
6, print t I. ry thef hPermit l IIsignedstatement SPECIALCIRCUIT/MISC. _
that he I dp 'alt Ih p fth C t t '1 W (CM1 ptcr9 _�
yCO
(commencing 'm5 ion'700(p fD"' 3 nth H .' .. dPrf de)
.Cor TEMP.MpITTORPOLEINST.
C.,
r
>.y o that be is exempt th erefirmor ad he base,far The alleged esmoplican.A Y violation of W BLD /Atl1) ION I DEh1_Q1 Df�IPN
^,y Section 7031.5 by any appl sato fora pvmitsutpttts the applicant toaciv'I penalty of POWER DEVICES fQ ANT ❑FOOy(Ldt ICE
noontime than five hundred&111.($500), I(�ry ROVEIIENT
f SQO ❑Las owner of the progeny.or mycmpbyecs with wagesas their solecompcnsatinn, SWIMMING POOL ELECTRIC
P.. I HIM it
will do the work,and me structure is not intended or offered for mle(Sm.11114,Baioas ERI
3 m and Profen leas Code:The Connector's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES J
property who huilds or nttpmv-v thereon,and who docs such wink himself or through
his own employees,provided that such improvements are not inten&ed or mffcnaf for NEW RESIDENTIAL ELECTR SQ FP
sale.IT,however,the building or improvement is sold within one year of completion,the pSQ.FT.FLOOR AREA Q.FT.
wner-holder will have the burden of proving that he did not build or improve for pur- By
psis of sale.).
1,as comer of the Titoism,am exclusively contracting with nimdn d commeton to TMAL:
wn
consumer,The project(Sec.1(100.Business and Professions Code:)The Contractor's Li-
meLaw does not apply manowner of properly who builds or improves thereon,and QTY. PLUMBING PERMIT FEE
wheel......is Ln such pajeds with a contra togs)((sensed pnrutumt nt the Cmoramnr's '
1
License Law. PERMIT ISSUANCE
am ancer n under Sec. .B&P C for this ream. r
Owner [)amFA
ALTER-DRAIN&VENT-WATER( ) VALUATION
,( _
WORnderP COM1'EN$ATION Dfthe allow ON BACK FLOW PROTECT DEVICE Y �p
have
and w affirm under Comifiy of ofCoy one of me fnllowior Worker's
C a: 1
❑I have unsidelfor,maintain, eC37mof Cessna.Cool,fo, for Worker'scempem DRAINS-FLWR.ROOF AREA,COND. STORIES TYPE,CONSTRUCTION
Naini, ,provided far,by Section,I.. ?]1X1 o'ths Lnhor Cala Iiia the perfnrmanw of the
work for ad sohispeamn La orke, IBX'IORES-PER TRAP
❑1 have and will ulde.h n is performance
Ca ce of The
w lk for e.,a required by Session - /v
11fN1ufineLaMn Codc.fnnhe performance of the wok f�rwhich do,
�permri/t�is�issued GAS-EA.SYSTEhf-I INC.4OUTLETS OCC.GROUP APN
My Wy rfiyFtpc}y.yml�urypce cnmierant)policyPolny No tt�[.-J'-r<6�= I GAS-EA.SYS'IEM-OVIiR 4(EA)
Carrie 079!!a 'G� 3
I CERTIFICATE OF EXEMPTION FROMN )RKERS' GREASFJINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION FE LS
('1ltivseetion aced n...hncmnplcted ifEcpermit is Too hundred dollars(SIU)) GREASETRAP
ar le".) .. PLANCHECK FEE
I mrtifythat mine,pnfommnre ofthe work for which this permit is issued lshill SEWER-SANITARY-STORM EA.2W FT
not employ any penin in any manner so,as m m
becoe mit lmt to the w'orkeri Compen. ENERGY FEE
Z, inion Luws of California.Dam WAFER HEATER WNENT/ELECTR
C) O Applicant GRADING FEE
z NOTICE TO N'PLICANE If:idea ndking this Cenificam of Exemption,you should WATER SYSTEMO-REATING SOILS F1313
? decree mhject to the Workcrs Compensate.provisions of the labor Code.you must
1,,nhwith comply with such provisions.,this permit shall be deemed revoked. WATER SERVICE
0
CONS'1'RUCI'[ON LENDING AGENCY NEW RESIUENTIAI.PLM B. SQ.FI'. PAID
U Ihemhy affnn thnuhere izettmstmetion feeling egencY En the perlomance of Dam Receipt
P the weak for which this ,.it is issued(Sec.3891,Civ.C.)
OU Lender's Nom, D TOTAL:
} RlI<ndcr's Addmvs T)T C
y I mnify aha rem minhr
I have ad mi,application and seat the above rmatime is BUILDING FEE
.F. N correct.l agree to comply with all city and county ordinances and state laws rending to QTY. MECHANICAL PERMIT FEE
U Z haddi.S a....omtime.and hereby aul n,iw repmeunmtives nfmis city nt entaupon theSEISMIC FEE
maws-mentioned gegen tnnnspeenal pampa-, PIIRMI'IISSUANCEELECTRIC FEE
("'a)agree to save,indemnify and keep harmpcnl
less the City of Cuno ast
gain
niabilities,judgmems,costs and expenses which may in any way teems against said City ALTERORADDTOMECH.
PLUMBING PF.E
in as w,ANT ofthe ramergof Sthispermit.
SOURC REUI,ATI NS AND WILL COMPLY WITH ALL MOM-POINT AIR HANDLING UNIT(TO IU.lN1U CPM) MSCI{ANICAL FPI?
SOURCE REGULATI NS
AIR HANDLING UNIT(OVER IU,WU CFM)
% 4J 9 � CONSTRUCTION TAX
Signature of pplicara Cnaractor Dae EXIIAUSI'1 IOOD(W/DUCT) HOUSING MITIGATION FEE
IIAZARDOUS MATERIALS DISCLOSURE
Will thezpplicanorfuture holding eccupamson,or handle harmdous material HEATING UNIT(TO 100.008 BTU)
as defired by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
CIde,Smi,on 25532(u)'I HEATING UNIT(OVER 180.000 TO U)
QYcs E]No VENTILATION FAN(SINGLE RFSID) O PAID
Dam Receipt 4
Will the applicant or future building occupant use equipment or devices which
ry
f emit ba,aMnua I,Innmminants ar dcfned by the Bay Area Ain Q.1111,Management BOILER-COMP(HIP OR Hol,OIN)BTU) TO 1L: {/
Dittre,?
C]Yes )�s Iqo BOILER-COMP(OVER IIXI,(NNI BTU)
1 have anal the haaar aos m:ucri:ds rc mneat,under Chapter 6 95of the Cali- AIR CONDITIONER ISSUANCE DATE
manna Health&Salary Code,Sections 25505.25533 and 25534.1 understand third the NEW RESIDENTIAL MECH. SQ.FT.
Ilulldla6 does no came sly pa nt.the if' my respnnsihllay to only the occupant
Hi
a ch mu and prim m eofaCmiO of Occupancy.
as
rawhonzial lie Data
IA ISSUIiU 1{P.
OFFICE