S 3960 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF Cy1PERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPWCATION/1"ERMIT PLUMB INO-MECHANICAL S 3960
IfU11.DING PROJECT IIIEN'TIFICATION
r1ur
IL'Il AIURESS: O�r SANITARY NO. APPLICATION SUBMITTAL.DATE
NG`///R'S NI/AMME: ��� \(/l•\)NI I'BgC- NnhE S ONS iiV Ipf�
LY�/41 N/C CO ROL»
ARC III ECIPENCINEER: 'I. -NO: ADDRESS: ❑
G .TAcr: PHONE: .� BUILDING PERMIT INFO
�� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
W6-S6&4\W1,2U1 ❑ C ❑ ❑
LICENSED CON'TRACTOR'S DECIARAI'ION QTY ELECTRIC PERMIT FEE
I chy alarm that[.to licensed under pmvisinns of Chaper 9 gm
omenclag JOB DESCRIPTION
OL'Z with Scamn 7UW)of Doto.sn3ofthe Bmirremitrd Pndanions Code.and my license is RESIDENTIAL:
WOO PERMIT'ISSUANCE O
in mil furca mid P4tccl, ❑SFDWL [I KITCHEN REMODEL
=UV Licclue Ca. ick �/��y T,� APPLIANCES-RESIDENTIAL ❑ADUIT'ION El PLUMBING RE-PIPE
Nina Dam Conneclor.MI l�mX3'
F'r� ARCHITECTS DECLARATION PANELS
❑STRUM URAL
Z O°s rsa
Z I undend my plans shall be used as public records MODIFICATION
OZN� UP TO 200 AMPS 0INTERIOR ❑CHIMNEY REPAIR
W hiccnsal Professional 201-10110AMPS IMPROVEMENT E]SWIMMING POOLS
a,K=,-.a1 OWNER-BUILDER DECLARATION OVER 1000 AMPS ❑BATH REMODEUREPAIR El DEMOLITION
SxW a a 1 hemhy ultlml tM1:u I am exempt fr.....We C....In r'a UtOnec Law for the
W 3 Ufollowing reason.(Section 7031.5.Business and Professioms Cade:Any city or county SIGNS ELECTRICAL [3OTHER
L Co which require.%a permit to con ural.alcor.improve,Jcm011sh,or repair any omemre
OQ prior m M1sissuanee,also requires the applicanl h,rsuch peu 11.file.signed Nammenn SPIiC1A1.0 C
'A_1 that he is licensed punuanuo are provisions of the Contractors License Lew(Cbapmr9
�ap0 (commencing with Sation 9l1IX)of Division3ofthc lfusincss and Pro(caxiunx Cndc)n ' TMERCIAL
E •.M F,R('R POLBs S�'
L a o CC Ihan M is exempt fhercfrmn and the basis for the alleged exemption.Any violation n '"y I7W BLDG/ADDITION DD
EMOLITION
�MN Section]031.5 by any applicant for a permit subjects the applicant m a civil penalty of OW ENANT El FOOD SERVICE
1 mnm.the.five haWrcd dollar,(85110),
1-Z Y IfyIPROVEMENT
e Q ❑bo th,eunerafthe proMny, r mYemployees or wages for their rolecomPR`:.tion, SWI PIX IiL[CTRI 'y
Wit:ct will Jo the work,and The structure is sol imendN or n116mJ for s..........WlTusiness O HER
Ya]'-'w_ and Proua,o ,Gxle:The Connector's Licence Law docs nw apply to an Owner of 5- iESa FI% RI
_ -
L 3 property who builds or improves themon,and who does such work himself or through
his own employees,provided that wch Impmvetncros are not intended or alfroad for NEW RESIDENTIAL ELECrR SQ FT.
sale,If,however,the building or impnn'ement is sold within one year ofeomplenon,the gU.FT.FLOOR AREA S/SQ.FT.
owner-builder will have the burden of proving that he did not build or improve for pur-
pnse of sale.). T Q
❑I,., r of rhe property,nm escic,ively contracting with licensed enntrmars to L:
,,asoma the project(sec.7614,Business and Professions Codep'ILe Comarctnr's canoc does nm apply In anownerofproperty woo builds,,,improves,lice'n,and QTY, PLUMBING PERMIT FEE
who contracts for such project with a cnntfacmgs)licensed punuanuo the Cmtranors
License law. PERMITISSUANCE
I atm exempt under Sec. .B TO,P C far flus reason
ALTER-DRAINA,V- - R(EA) VALUATION
Owner Date
WOR KER'S COM P17NSNI-ION DECLARATION BACK ROW PR OTF ICE
1hereby alarm under penalty0fperjamaneofthe li,awingderker's m:
Inavn and will far
etio it icac of the Laor sol,to. for Workers G,mp<n- DRAINS-R(IOR.RWF.AR.,. ND, STORIES TYPE CONS'IRUCI'ION
smirk,ns pmvWff&rt by Section 3781 of the Labor CWe,for fie performance of Inc
work for z I Ibis p umin is issued. 10%Tl1RF.S-I'ER TRAP
❑I have and will ode,for Workeos Compcfthew Inwmnea,as required by Section
P(X)of the laMrCWe.for he perlommame of the work for which this permit is issued. GAS-GA.SYSTEM-]IN .4 S .r OCC GHUl1V APN
My Wu,r,kFFr'v��Co��m-_pen�sa--linlhhl�ns�ur,n,n.ec�carr ¢ gt17,1icy numhpr.t
Carticr:l,dgSfi/jpy6i(Yq o¢y No.: Al SA-- —/5i� GAS-EA.SYSTEM-OVER
CERTIFICATE bbF EX AITION FROM WORK(?RS' OREASEINDUSTRL WASTE INT[RC r R
COMPENSATION INSURANCE BUILDING DIVISION FEES
(lbissecninnneednot he completed lithe permit ix fortune hundred dollars(Sl W)
GREASETRAP
trless.)
Iccelfy than in the veri,manrufthe work finwhichthis permit is omed.[shall SEWER-SANITARY-STORM EA.AM FT.
nun employ any pcnon in any manner or as to became s.h O,t to the Workers'Camped- ENER
O Z adins laws of L'alifnrOre.Data WATER HEATER WNENIVELECfR GRADING FEE O Applic:mt
NOTICE 10 APPLICANT:If,Offer making this Cenifieam of Eseepnion,you should WAIBR SYSTEW REATING
Mcomc wiled tame W„,kers Compensation pmvis ons of the Lanm Code.rain must S
rte.. 6,ehwinh comply with such poviosim;.,,his permit shall be deemed revoked. WATIiR SERVICE
aQ
CONS'I'RUCfION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fir PAID
UC) I hereby affirm that there is a construction lending agency for the performance of Date Receiptk
H the wad ax which Ibis permit u ixaueJ(Sec.JOY].Civ.CJ
Q U Lender's Name I”
r benders AJJress TOTAL:
y 1 certify than I have read Ibis appl cation and dale than the aMrve information is BUILDING FEE
to comma.l agree to comply with all city and county ordinances and sum laws relining to QTY, MECHANICAL PERMIT FEE
U Z huildingmnstrucfim.andhercby truthnriec representatives of this city eta endo upon he SEISMIC FEE
above-mentioned p,,,,,Iy fur Inspection p.,,,a'. PERMIT ISSUANCE
(We)agree w wve,indemnify an ann isrS n p,[�y mCu vino again ELECTRIC TLE 0
liahilitics.lodgments,costs and ex, Yuc upnin.a s,id C'nY Al.l'IiR OR AUDIO MLCH,
PLUMBING FEIi
in mscquonm of the groat
APPLICANT It ,TA sU WILL YWITH ALL NON-POINT AIR HANDLING UNI'1'(TO IILW)CFM)
MECHANICAL PCI!
SOURC ULATIO
AIR HANDLING UNIT(OVER IO.WO CFM) CONS]RUCTION TAX
comm Omar �C' D c EXI IAUST HOOD(WMUCT) HOUSING MITIGATION Ill.
LAROOUS MATERIALS DISCLOSURE
Will Ppbcadremme mildingmreupamaorc ur handle hironvoos material HEATING UNIT(TO UYON0 BTU)
nv defined y the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
CWe,Se Jon 25532nd? I(EATING UNH'(OVER I(K,000 BTU)
❑Yes PAID
�� VENI'ILAI'ION FAN(SINGLE RI3SID) Date R,rai"Or
Will as applicant or furore building occupant use equipment or devices which
min bamrdous air caemnnern l as dcfitmd b the Ba Are,Air IJ Management BOILER-COM('LIMP OR 1 WH10 BT'U)
• 5 Y Q.,day �gcmcn TOTAL:
Diuia? •, BOILER-COMP(OVER ItNQW BTU)
❑yes '
(nave read he na am aedaBm orals Orme it he AIR CONDI'f IONER ( .DANCE DATE ,a
lomia Health SO Salary C .Sm' ., ..3 and .I unJcnnxnJ II Ih:n the NEW RIi51DIiN1'IAh MITH. SQ.IT ,k Y
huild'mgdoes not carte nam that h' s,,a,ibility m notif the ocupot
"Ohs inquire tch mu pet (can of kxu
Uwncr nr awhorie.,
bide TOTAL: ISSUED BY: _••(ft/�'J
OFFICE