S 3075 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PE rr NO.
BUILDING DIVISION APPLICATION/PF.RMIT PLUMBING-MECHANICAL 3075
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS SANITARY NO. APPLICATION SUBMITTA,DATE
los �
OWNWAM[: PHONii: CON'IRACIOR'S NAME: LIC NO:
k) ' G. C �: ^ �� NIC CONTROL R
ARCHITEC'DENGINEER: LIC No. ADDRESS: O` ❑
5 OVyi
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI❑DG ELECT PLUMB MECH
Lo lz_,e i+k os W 1g�Y bL�
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE1 hereby nlfion enm
that I am Ited under provisions of Chapmr 9(cutnmm�d^y JOB DESCRIPTION
WOO with Section 70r of Division 3 of the Business and Professions Code.and my license isRESIDENTIAL:
Fly., in full force nnd,ffr I, PERMIT ISSUANCE J
�UV License Cloa �-+ Lim.k WOp�Sa�V ❑SFDWL ❑KITCHEN REMODEL
yZW )are Conic APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
Fly ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT [I STRUCTURAL
Z 0 y z 1 modo mad rare plain shall Be used as public records MODIFICATION
O Z'+ IIP TO 200 AMPS
❑INT'EWOR ❑CHIMN17Y REPAIR
Fa-�,F..ly LsensW Pmfessus"°I 201-1100AMPS IMPROVEMENT SWIMMING POOLS
y.Sd j OWNE&BUILDER DECLARATION CoulmON OVER]"AMPS ❑BATH REM FLJRIiPAIR ❑DEM .ITION
pq,d'ty Q I hereby affirm thin 1 1S exempt from the Qnium,Cos License Law for The
X 3 LL wF following disputes
- (Section 711315,easiness and Ihofessians Code Any city tor county SIGNS ELECTRICAL ❑OTHER -A�QCNJ C Cj,�LYCM
F.�.O¢ whirM1 requires o permit re consume.0mr,improve,h fain t t ri repair any swcmre �Clc 1 �
yJ prior to issuance,afro requires the applicant for such Permiuo file usigned,gmemcm SPECIAL CIRCUITIMISC.
p$y�pr that he is licensed pucuant to the prwidonsnl'rhe Cammemr's Lin,ensOil w(Cbapmr9
y 1�'Qp (commencing subsection 7")of Division 3 ofthe Business and Profe,unds Code)or TEMP.MIHT.R OR POLP J0 1i COMMERCIAL:
6 y M that be is exempt fl crefmm and the basis for the alleged exemption.Any violation of El DEMOLH'ION
la%1^ Section 7131.5 by any applicant for a Damn,subjects rhe applivantlnacivil penalty ,I POWER DEV ❑NEW BLDG/ADDITION
F-ZN ant more than rive hundred dollars($500). ❑TENANT ❑FOOD SIiRVICF:
�^ Q ❑I,as ownerof the propere,or my cmPlayeev wif wages as Their to ema,mrution. SWI I )L tC IMPROVEMENT
04 will do the work.and the stmcture is not intended or offered for sale(Sec.7044.Business _ ❑OTHER
IN� end Pmfessians code The Comuacsors License Law Aces not apply to an owner or "1. S- F In
Property who builds or improves thereon,and who does such work himselfJ�md
his own employees,Provided Thar such improvements arc not
intended orNE F. L EL R SQ FT
sale If.howeveq the building or imprwemmu issnld wirhinone yearn, SQ.FT.FLOOR ARG $/SQ.I9'.er-builder will have the burden of proving that he did not but poseofrale.).I,ns owner arthe prnpcny,am caclnsively contracting with It sed coTOT L
onswer the project(Sec.NOD,Business and Potasium,Cede.,use Law does no.apply us an owner of propmy who builds m sinQ PLUMBING PERMIT FEE
whocamructs forsuch pmJccn withnanwmnr(s)limuctl pursmn o CLicense Law' PERMIT ISSUANCE wJ
❑I am exempt under Sm. ,B&PC Avon
ALTER-DRAIN&VENT-WAT17R(EA)
Owner Done ALTER
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE C /' `(,� �-
1 hereby uRirm under penalty of perjury,one of the following dedanaions: d�0 V
❑Ihnvwmd will mainminnCsnilicnteof Cnnsem resell-invum lis Worker's Coca DRAINS-FLOOR,R(N)P,ARE CONU. STORIES 'TYPE CONSTRUCTION
smion,as provided for by Section 311001 of the Labor Code,for The gerfommnce of the
work for which this Permit is issued. FIXTURES-PER TRAP
[7�1 have add will maintain Worker's Campenration Insurance,as required by Section
of the Labor Code.for the performance of the work for which this permit is issued, - 'A.SYSTEM-I INC.JOUTLETS OCC GROUP AI'N
My Wnrke[1 C�omJrypaationRwraric ya�rtL�r andyolicyyy ar��
Cruder. a1 `� �_\Igs •'I1 Slic Nn.aLb`k_� � GAS- STEM-O
CERTIFICATE OF HXHMPI'[ON FROM WORKERS'
COMPENSATION INSURANCE G110s,IN ;TEL 'TE IN' PIOR BUILDING DIVISION FEES
(Thissenion need not be completed tithe permit is Turing hundred dollars(SI00) FE-
nrleas) T p r PLANCHECK FEE?
I certify thin in the perfarmence o(rhe work for which this permit is issued. shall SEW13R-SANT AR R i all
nm m I.mv any penin iaany manner xu as m become suhjaun the Workers'Compere ENERGY IEE
Oz wfinn laws of CaGfnmia.Date WA'I ER 14EATER W/VEN'1'/EI.
Z Q Applicant GRADING FEE
fA NOTICE TO APPLICANT.If,after making this Cenificam of Exemption.you shout o EATING
become subject m the Worker's Compensation provisions of the Lubter Cale,you run SOILS FEE
W forthwith comply withsuch pnwixions or this permit shall be dectnWmirukW. WpTIik SERVICE
az CONSTRUCT ION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ. T, PAID
V 0 I herehyuflirm rhot hem iso cnnstmctian lendingmgeney for the parf^rmaaccof Receipt IT
OP the work Ior which this Tonna is Issued(Sec.3097,Civ.C.)
1••' benders Name TOTAL:
Wlender's Address TOTAL: OO
y 1 cenify that 1 have read This application and'nodded the shove imfomtam entis BUILDING FE
C)
to correct.I agree to comply withal]city and county ordinances and state laws rebating to QTY. MECHANICAL PERMIT FEC
2 building construction,and hereby omhorire representatives ofthis city toenmr upon the SEISMIC FEE
abovcn tendo Nd property firer inspection purposes. PERMIT'ISSUANCE
(We)agree to save,indemnify and keep harmless the City Of Cupertino against - ELECTRIC FEF.
liabi]iries.judgmenrs,cons and expenses which may in any way ammo against said City
in m,g9ucnce of rhe granting of this penult. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNI'1'(TO 10.00s)CENT q
SOURCE REGULATIONS. MECHANICAL ITE .0
AIR HANDLING UNIT(OVER 10.00h CFM) CONSTRUCTION TAX
Signature of Applicant'Cotnmaor Dam EXHA UST HOLD(W/DUCU HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will thenpp]ieamor lattice haltering acupam none or handle incautious radical BEAT[NO UNI'I'('TO 100,1110 TO TO)
as defined by rhe Cupeninn Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532M)T HEATING UNIT(OVER 100,000 BTU)
[D Via, VENT]IATION FANS I NGLE RESID) PAID
Will the applicant,inants a huildmg occupancy A tyui it Qu or devices which
Gate Receipt g
emit hazardous air contaminants as defined by the Bay Area Air Quality Muwgemenl BOILER-COMP THP OR 100.INXr BTU)
TO AL:
r pinrim?
C3 Yes BOILER-COMP(OVER Using)BTU)
I have read The hazafdu^smammals or uimnams trade,Chapter ml'Ne Cali. AIR CONDITIONER
4 p ISSUANCEDfAT$)
forma Health n gefery Cede,Sailors 25505,25533 and 25534.1 i ndcrsmnJ that if the NEW RESIDENTIAL MICH. SQ.FT. 1 U_o/
building dssesmmcurmuh mane a niant,mat it ismyme it a btlttytate to Oheoccugrm
r •ynire�ry whte�lt must be mm pdonn ixsonneO nl"u Cenilianeof Ofawp[a�n�cly.
Owner au' Nonzcd agent ��-, `� Gate TOTAL:
2• PSSUED BY:
OFFICE