S 3854 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMITPLUMBING-MECHANICAL S 3854
BUILDING.PRLUII.T IDENTIFICATION
BUILDINGADDRE3S'. ' I i ^ t �1 �j_ p(Q SANITARYNO. APPLI ION
ATSUBMIITT%TA7LL DDATE
Z �/f_I 'jrlll 11•\O\V/" (1� kJJtbOf�$ ��
NBH'.Si ME: �g O ^ (Sr'HONE'..z��-�^.x CONTIt�Z4NAXat�N -W LIC NO:
' T OL z 1 { (S NIC ^ CONTROL,
CT/ENGIN :R' C _IL)[' ADDRESS: A I E] �/� ,� O
CONTRA/�f PHONE: L 1's BUILUINI/G P1 IFFINFO
/ ^) I Fox k.g��(� O ❑ Consultant Fees Paid by Applicant(Initial) ELECT PLUMB MECH
7 I \ l / lll••VVV ❑ ❑ ❑
I.ICF.NSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm m Thal 1 an licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WoZ with Section 7"amf Division 3 of Ne Businessand Professions Code,and my license is D
(-�� in full form andwlreta. nG PERMIT ISSUANCE ❑KRCHFiN REMODEL
RUL) License Class P Liex �aO��O" 1 �' gppL1ANCES-RLSIUIiNT1AL �pD El PLUMBING RE-PIPE
F-Z W Ome /D_ �- Contmc DLJ�t,Q'u:' 8A LL
ARCHITECTS DECLARATION ❑MULTI-UNIT El STRUCTURAL
Z p N Z 1 understand my,Imu shall be used us public records PANELS MODIFICATION
p Z.-� IIP TO 200 AMPS C:1 INTERIOR C1 CHIMNEY REPAIR
F¢�L j Licensed Professional 201-1000AMPS IMPROVEMENT C]SWIMMING POOLS
C kd f.-4 OWNER-BUILDER DECLARATION OVER Ig10 AMPS C1 BATH RFMODEUREPAIR ❑DEMOLTIION
M M sc L hereby alarm that 1 am exempt from the C.nwcm,'s Liecnve Law for the
3 a F following reason.(Section 7031.5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL. ❑OTHER
p which requires a permit to construct,alter,improve,demolish,or repair any structure
�B:0 prion.its iommue,ob'nrmmires the applicant ler,ach pennitm fle.mleard,Wmarint SPECIAL CIRCUIT/MISC.
f y that he is licensed pumu,nl to the provisional'the Conan.,',l.icnnse Law(Chapte9
6F. (mntlnencingwin+Secenn7OM)of Divislnn3nOhc Baxinc.ssod Pndbnl.n,Cnde).r TEMP.METER OR POLE INSTQX
COMMERCIAL:
apo C that he is exempt therefrom and Ihe basis for Ihe alleged exemption,Any violation of NEW BLDG/ADDITION ❑DEMOLITION
W to Section 7031.5 by any applicant fora permit subjects the applicant m a civil penalty of POWER DEVICES
not mom than five hundred dollams($5o0). ❑TENANT ❑FOODSERVICE
F=< I,as owner of the ® it IMPROVEMENT
G ❑ property,or my employees with wagesasdmirsole erneximatinn. SWIMMING POOL ELECTRIC ❑OTHER
F will do the work,,nd the structure is not intended or offered for sale(Sec.7000,Business
L3 and Professions Code The Cmaraern',License Law does not apply in an mune,of OUTLETS-SWITCHES-FIXTURES
property who build,or improves thereon,and no does such work larawlror through
hex own em,lnyem,provided that such improvements area.,emended or mTemd for NEW RESIDENTIAL ELFCTR SQ FT. J
sale.If,however the building or improvement is.sold within one year of completion.the ` __SQ,FT.FLOOR AREA S/SQ.FT.
wrier-builder will have the burden of proving that he did not build or improve for pur-
poV T I
se of sale.). T I R ,/
1,as owner of the propcny,am exclusively contracting wish licensed contractors to ll/t (((����
construct the project(Sec.7044,Business and Professions CWetl The Contractors Li-
eonse Law doe.,but apply In an owner of pmpeny who builds.,impmvct thereon.and QTY PLUMBING PERMIT FEE _
who contracts for such projects with a comractuni)licensed pursuant to the C.ntrcdors OCT 2 1999 D
License Law. PERMIT ISSUANCE
❑ l am exempt under Sm ,B&1'C lis,this reason
ALTER-DRAIN&VEN
r Date ER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.m nsv
EVI -.
I hereby affirunder penalty of Perjury one of the foiling declarations:
I have and will maintain a Cenificme of Comennn self-insure for Worker's Compen- DRAINS-FLOOR,ROOF.AREA.0 STORIES TYPE CONSTRUCTION
.mtlon,as Provided for by Section 3700 of the Lahor Cade,for the Pcdtrmance of the
'GIfor which this perm,is issued. FIXTURES-PER TRAP
have end w111 ntalmnie Workers Compensation Insurance,as required by Section
)of the Labor Code,for the performance d the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My W., es Clm(npensmion Insurance banneryyad Policy a arc: w .. 2
Carsiee C( '1T2CA b4' Z'NbSvNS.he,N., 5� SG,�J Det GAS-FA.SYSTEM-OVER 4TA) �br
CERTIFICATE OF EXEMPTION FROM WORKERS' O( O
COMPENSATION INSURANCE GRE iSEANDUSTRL WASTE INTERCEPTOR
(This semina need not be completed iflhe peons is foroue hundred dollars($100) BUILDING DIVISION PEES
GREASE TRAP O
or lees.) PLAN EC FEE Iccnilylhw in lin inrf,nnanceof the work l'nr which this In.onal Wi.kb,,'C,lshan SIiWER-SANITARY-S H)RM EA.21k1 FT.
nal employ any n n any roan., o u m been�9C xub7wt to IM1e Wnrk,rs'Gnnpen- IiNE Y PEE
z ,� onion Laws. Lfaniu.D JJ WATER NEATER W/VENT/ELECIR
f� APPlicant U DI FEE
r~N. NOTICE TO PPL m afar making this Certificate of Exemption,you should WATER SYSTR,MORFATING
� ' become subjca m the Wink r Cooreci satin.provision of the Labor Cale,you most SOI FEE
l[7 fonhwith comply with such ns or this actual shall Wdeemed revoked WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ,FT. PA
V u I hereby allina thin then,is a conuudlon lending agency fmthelwrf.naim,c of Date Re,elplx
the work for which this fairlml m'swed(See.3097,Civ.C.) loq6
,dell Name ' )( ,07-- O
0 U lenders Address AJ' � TOTAL: / z
I cenify that 1 have read this application and state that the above information is BUILDING FEE
FLiII corexn.l agree to comply with all city and county ordinances and state laws minting to QTY. MECHANICAL PERMIT FEE ! O
U ,Z, building construction,anal authorize representatives ofthis city menterupon the SEISMIC FEE
chose-mentioned prn,cny for inspection purouses. PERMIT ISSUANCE
(We)agree msevc,'ua1.odfy and keep Iamdess the C'dy of Cupertino against ELECTRIC FEE
bidadides,judgmems.en.Oran expenses which may in any way accmmlgainslsaid City ALTER OR ADD In MECH.
onxqu�nce of the 6rami poi Nis permit. PLUMBING FEE
APPLIC+ UNDERST(IDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CPM) MECHANICAL FEE
SOU F REGUfAT1ON n
C-ZC,�QQ AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
Snamrc ofan C meemr Date 1 17XHAUST HOLD(W/DUCT)
II RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theappllcaanr rumre b,ildnilo,ritinnl I, car handle hocenntoi,material HI7A'I'ING UNIT(In IIth,0(10 BTU)
as defined by the Cu porion Munlcgpm Coda Chapter 932,sad Ihe Hmllh and Svfety
Code,Section 25532(x)? HEATING UNIT(OVER 100.000 BTU)
❑Yea XNo VENTILATION FAN(SINGLE RESID) PAID
!l/��� Data Receipt x
Will the applicant orn furore building occupant use equipment.,devices which l
covet hazaNcontaminants air mmiwms as defined by the Bay Arca Air Quality Management BOILER-COMP CHIP OR 100,000 BTU)
TOT
District^. Yes / BOILER-COMP(OVER 1(10,0(10 BTU)
❑ �J Nn
I 4ed the haeandous me riuhro armaents unde Chapter 6,95u1 The Cali- AIRCONDITIONER ISSUANCE DATE
forms H &Safely Cale,Sectio 255115.25533 and 25534.1 understand than if the NEW RESIDENTIAL MECH. SQ.FT. O 0
buildi d samctionce have arc runt,Ihm it i....mspootal ihly mnndfy the occupant A ( 2— T /'
nfN menu, 0ich musnbe en bnoiseuancenfa CenihcatenfOm�an V
D-Z �.�
uNori Date TOTAL ISSUED BY:
OFFICE