S 3956 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY \
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO. \
BUILDING DIVISION APPLICATIONlPF,RMIT PLUMBIN'O-MECHANICAL S 3956
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICNIIONSUBMITTAL DAI'
2 (13
OWNER'S NAME: /r �'f;4NiJw 3'/ CONTRACTOR'S�MI:: ^ LIC n:
er
J �/-C•//1 l G N/C CONTROL
//a----��
ARCHITECT/ENGINEER: LIC NO: AU RE55: /� ��� �� PP ❑ Q r/�
CONTACT: PHONE: BUILDING PERRMPI'(INFO
❑ Consultant Fees Paid by Applicant(Initial) , BLDG/ E9Z-0 ,PLUMB ME❑CH
LICENSED CONTRACTORS D rCLARATION QTY ELECTRIC PERMIT FEE �/
1 frothy affirm that 1 am licensed under president,of Chapmr 9 mammendmg JOB DESCRIPTION
C a'z with Section 7000)of Division 3 uOhe Intocc.a and Professions Cale yd my license is RESIDENTIAL:
W O p "s PERMIT ISSUANCE
Iilll limes and�Otero, � ❑SFDWL � ❑KITCHEN REMODEL
Q_u License— " /=�^ Lic.a APPLIANCES-RESIDENTIAL ❑AUDITION 0 PLUMBING RF PIPE
F•zM D:uc '}L/ ;�Ei.'.',L"�+0—Commcror -
ZN c. ABCHITGCTSDECLARAUON PANELS El MULTI-UNIT ❑STRUCTURAL
z C m L I undersurd my plana shall be used as Public records - MODIFICATION
Cz-O UPT02MAMPS 0INTERIOR 11 CHIMNEY REPAIR
W Licensed Is liewashal 201.1000AMPS IMPROVEMENT SWIMMING POOLS
C Q I hereby:dernn
OWNEthat IR-BUILDER DECLARATION,Contractor's License law barite OVER INX)AMPS BATH REMODEUREPAIft DEMOLITION
k 3 d U
following reason.(Section 71315,Business and Prolessams Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
W ti O y
which requires a permit to construct,alter,improve,demolish.or repair any structure r
prinnulto lxammac,alsoryei res theopphcam for.al ch perano m file usignolsmremcm SPECIAL CIRCUIT'/MISC.
SW} that he is licensed pursuant In the provisions of the Contractor's License law Chapter
(commencing with Section 711(10)of Division 3 ofthe Business and Professions Celli TF.MP.METERORPOLEINST.
d a e that be is exempt therefrom and the basis for the nllegW cocn:ptlno.Any oolminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section)031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES C1TENANT ❑FOODSERVICE,
t more then eve hundred dollen(S500).• coIMPROVEMENT
F=< D I,asrwnr,.f the poproy,or try cmployccs with wages as theirsnle r,on,asmlon, SWIMMING POOL EL IC /
f F-C will do the work,and the swaure is not intended orolTcred for sale(See7044.Busio
ness - ❑OTHER
d 3 m and Profession,Code:The Comructm's License Law docs not apply m an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,presided]that such improvements arc not intended or offered for NEW RESIDENTIAL F.LECTR SQ F1'.
sale.ILhoseveT.the budding or in provcravat is sold within one year ofcomple ion.the SQ FT.FLOOR AREA
camer-lbuilder will have the banderol proving mat he dill not build]or improvefor put-
TOTAL /
E] as ) /
E] 1. of the pptexclusively t fig lhldo tit m '
1. T
rave L she p d] t p o an Businessd Professions d Code.) pr Contractor l' - - /
crave Law I t apply to fp pent' h builds p th n d QTY, PLUMBING PERMIT PEE
whac tnusfor xuch Pnl cwth soave t :OIurnxcJ pursuant Ic the Cnnven ns
License law. PERMIT ISSUANCE
ED I not eaetnpt under Sec. .B&P C Bemis reawn
ALTER-DRAIN&VENT-WATER(IiA) VALUATION
Owner Date Q
WOR K17 R'S COM PENSATION DECLA RATION HACK FLOW PROTECT.DEVICE /QQV
I herebyaflirm undo!prandtyofp jury nncofthe fallowing declaations:
[have and will maintain a Certificate of Conscnt mself-insure for Worker's Camper- DRAINS-FLUOR.ROOF AREA.GOND. STORIES TYPE CONSTRUCTION
,mints,as provided it,,by Section 3700 oT Ibc Lulea Code,to,the pelmarmnre of the
work for which this permit is issued. FIXTURES-PER TRAP
El 1 have and will nuintain Workers Compensation Insurance,us required by Section
37m)ofthe Lata(Code.forImperfenrance ofine work l'orwhich dais permit is issued GAS-EA.SYSIITsFI INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carver and Policy number am: (�
Carrier: Policy No.: GAS-EA.SYSTEM-OV17R4(CA)
CHKOFICATE OI'1!XEMPTION FROM WORKERS' GRCASF/INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING INVISION FEES
(Th'osmtinn...dont be connplemd iOhe warn is forene hundred dollars(MW) GItEASETRAP
or less.) VLANCHECK FEF. O r
leenifythat inthe performance ofthe work for which this permit is issued,Ishall SEWER-SANITARY-STORM EA.200FT.
nal cnnpiny vny perxon in any mannerso uxwhecumc suhjecnolhc Wn kou 'Compcn- ENERGY FEC 3�•��
O Z sntion laws of Culdoorm.Date WATER HEATER WNEW/ELECT) GRADING PGE
z O Applicant , _
IZ) NOTICE 10 APPLICANT.IL alter making this Ccnificum of Bramoun. on should WATER SYSTIiM/TREAI'ING
a ? become subject to the Workerb
Workers Compensation provisions of the Leer Cade,you must 501L5 FEE
fnrmwim comply with such provisions mind,permit shall be deemed invoked WATER SERVICE
a �
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.14. PAID
U I hercbyeffimnthmthem isocar,mtion lcndingageney for the performance of Receiptx
LL F the work lar which this penin Is owed(Sec.3097,Co..C.)
TOTAL:
U Lenders Name
C
TOTAL:
Lcndet,AEdm.as
S I cenifY thus I have read this apPlicmion and sue mat the ab ve information is 'P[E 2�•
L�. (A correct.I agree To comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z limiting ....cstruction,and hereby unthorLc reprewntmivcsof this city to cater.lam the SEI CFEG
alwve-meminned pmpcny forinspectionpmFor . PERMIT ISSUANCEn
(We)agree to.save,indemnify and keep harmless the City of Cupertino against EL RIC PER I P
Iiehilincs.judgmcnb,owl,and expenses whiebnwyln any way carve against said Chy ALTER OR ADD'TO!vWCH.
1' MBING FEE
in consequence of me gm N of suis pewit.
API'hICANT UNDER ANDS AND WILL COMPLY TII ALL NON-POINT AIR HANDLING UNIT(TO 10,"CFM) ECHANICAL FF.F. '
SOURC' LAT
AIR HANDLING UNIT(OVER 10.00g)CFM) CO RUCTION TAX
1 Si,mumendApPlihrulComrscmrIn EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE/
WIIIthe nppllamnr future building nceupmn sore rr handle harmduus remenul HEATING UNIT(TO 100.001 NTIJ)
as defined by the Cupertino Municipal Cole.Chapx,9.12,and the Health and Safety
Code,Section 25532(a)7 - HEATING UNIT(OVER 100.000 BTU)
0 Ye, - Fl No PAID
VENTILATION PAN(SINGLE RESIU) Date Receipt M Q
_ Will the applicant or future building occupant use equipment or dc,iees which I
emit haranlues air comaminams as defined by the Buy Area Air Quality Management BOILER-COMP QIIP OR IIM1,000 B'1 U) 101A1.
District? BOILER-COMP(OVER L00.00N BTU)
' ❑Yes El No
I have mad the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDU IONER ISSUANCE DATE
Inmie llculth&Safety ClJ,Sections 25505,25533 and 25534.1 u.deomnd tha'd mic NIiW RESIDEN'I'I Al.MECH. SQ.IT.
holding of not currt havcammant.the it ism rests bilitymnoofythe ecu ant
nl me ams 1 h et prior m' a of a Ccri f(kcu y.
x 44
\ Ow ro um n •d agcm 2 arc TOTAL: ISSUED BY:�J
OFFICE