S 3831 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ` BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL. S 3831
III;;., '•
BUILDING'PROJECITI)ENTIFICATION" "' '175
BUILDING APURF_SS: SANITARY NO. APPLICATION SUBMITTAL.DA'Z'E
aa�o / (�7-8 -,9
OWN
PRNAMfirE: PHONE: CON C1OB'S NAME: LIC NO:
NIC CONTROI.N
'9 WaS9
46
ARCI111 ECT'/ENGINI?ER: LIC NO:^ ADDRESS: ❑
S !/ell
CONTACT. PHONE, - .!I'L}r`t)ili;BUII.DINGPERMITINPO;
37 y_76-;fl ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELFCI' PLUMB MUCH
Dr ❑ ❑ ❑
LICENSTUCONIRACTORg DFCI ARATION QTY '• �Il tt FLECTRICPERMIT' ! 4S( 1 i ;�;,ITF II '
I herehy affirm that l d de p " fChupter9(cote na -g t�.) i C i .rrs„ s t ., t. ,:( t{} sift tt-1I'.i JOB DESCRIPTION
G8,Z wtlh Srd on71100)of D' 1nnp�[thu Bua ndFoR.aiots Code.ndnylee - RESIDENTIAL:
I'IiRMfI ISSUANCIi
W F ,full!arse and [ul y' ❑SFDWI. ❑RITCHL'N REMODEL
d V V License la_s Co.N APPLIANCES-RESIDEMFIAL []ADDITION ❑PLUMBING Ric PIPE
If i Dam — cnmmemr51 -
F 7,o, ARC[II'1 F.CI':S DECLARATION PANELS ❑MULTI-UNIT [_1 STRUCTURAL
p Zm Z I under mod my plans shall be used as public records MODIFICATION
=-0 UPTO200AMPS El INTERIOR ❑CHIMNEY REPAIR
F4t:w Licensed Professional 20140MAMPS IMPROVEMENT ❑SWIMMING POOLS
C Q 1 hereby off nn tOhmhlamER exempFhomEthc DECLARATION
Contractor's License Lew for the OVER 1000 AMPS C1 BATH REMODEUREPAIR 0 DEMOLITION
PpC.O y V following recon.(Section 9031.5.Business and Professfonx Ginn Any city or county SIGNS ELECTRICAL ❑OTHER
W W tL y which requires a Parent to enmtmcl,aIle!,improve,demolish,or repair any structure
F,.,Od prinrtn is issuance,also myulres the aplAcnmfor such lwnot(to file a signed statement. SPECIAL CIRCUTOMISC.
that he is licensed pursmtnt to the pe"kion.of the Contractors License law(Chaptu 9
W ! (eanumsntoing withslcda17h)(Bdf Division 3ofthe Baeonessand Professions Code)ar TEMP.METER OR POLE S'1'. COMMERCIAL:
a g.c that he is exempt themfrom and,he bmis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Section 7031.5 by any applicant fora permit subjects the applicant o a civil Penalty of POWER DEVICES
[]TENANT ❑FOOD SERVICE
act more than five hundred dollars t$5B(W
^Z Y IMPROVEMENT'
=d ❑Lcowner ek,the pmperlyonny employees with wages as their sole le cotnpcnsati0n, SWIMMING POOL F. RIC
WFO will do,hework,ands she Omisnot1 Lill."
oro,,boax rsalepply al not Business ❑OTHER
tail`� and Profusions Code:The Commctors License Law does nm apply m vn Owner of OUTLETS-SWITCHES-FIXTURE
6'3^ pmpeny who builds or improves thereon,and who does such work him a f or through
hie own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELECTR
sale.IL however,dichuil Inger iinprnvnmind les0ld wl0lnone your nl completion,lM1e SQ.FE FLOOR AREA $/SQ.IrI'.
n-wilder,will have the nutriment Pmving,hat he did not build or Itnprave for par-
Paxe of sole).
L as owner of the properly,am exclusively contracting with licensed enmmanrs ns AL
onnwct the project(Sec.7014 BusinessdProfessions Code.)The Can ca
cmr
ame law does not apply to fpmpeny h build%or improves thereon d QTy�j',It� PLUMBING PFRMIT.r� yI 1 FEE,:1� ;
hnommuccitmicochpmjectswi,ho.muse t rO1 sed punuar,n the Conded,ii
License law. ' PERMIT ISSUANCE
Fl 1 am exotnpt under Site .B&to C tonhis reason
Owner Ilam AI:1'1tR-DRAIN A,VENT'-WAT'IiR H!A) VALUATION
WOR K17 R'S COM PFNSATION DECLA RA PION BACK FLOW PROTECT.DEVICE KIU /IO�IQD
I hereby afijrn,under penalty ol'crop,one of the following declarations:
❑ I have and will maintain a CertiEaua ofConsennn self-insum lite Workers Comped- DRAINS-FLOOR,ROOF,AREA,COND' STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3700 of the Labor Code,for the panto mance of the work for which this permit is:.sued FIXTURES-PER TRAP
�have and will maintain Worker's Compensation Insurance,m required by Section
nfthe Labor Codcfor the performancenf,he work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 DU1'LETS - OCC.GROUP APN
My W6r R pens: nbWl� 'er and Policy vr�
Currierllll FT7ct00lCr/�°7G'olicy IN g���/�� GAS-EA.SYSTEM-OVER 4(HA)
CERTIFICATE OF EXEMPTION FROM WORKERS"
COMPENSATION INSURANCE? GRHASFJINDUSTRI.WASTE IN'FERCISM OR
(This section need not hecotnpletW iflhepereit is fornne hundred dM tars($100) - ov.� ' `IfI11LDIN_O DIV16_ION FEES - :a
nr le"') CIt IiASH'1'RAP PLANCHECK PEI:
I sonifydmt in the perumnanceof,he work forwh,,h,hi,Permit......do.(shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become subject of flat WorkmS Cnmpen- ENERGY FEE
Z xdtion Laws of California, /
ia,Date WATI7R HEATER VENVELECfR
Z O Applicant GRADING FEE
rA NOTICE TO APPLICANT:If,afar moking,his Certificate of Exemption,you should WATER SYSTEM/ TING
a > became subject to the Workerp
Worker's Compensation mvisions of the laMu Code,you must SOILS FEE
L]J limhwith comply with such provieionsor this permit shall he deemed wont WATER SERVICE
a
CONSTRUC I,.I']ON LENDING AGENCY NEW RESIDENTIAL PUMP. SQ.PF. PAID
I harsh affirm lh,n there isucnnevuctlnn lendfn lite the rformance of Receipt If
thereby gagoncy, pe
V w-t Thu tuck for which his pcnnit is ivxunl(Sao.3(19],Civ.C.)
U Lender'..some 'TOTAL:
O W LeadersAddress TOTAL-
I certify thou l by read thisuppli,i d state that the b informations . - a, pa. .. .. , - BUILDING
y correct I agree to comply with all city and< my ordinances dart I ws relatngto QTY 'IMECHANICAI PERMITI s ,tJ 11l' 151`
' FEC'
V Z building construction,and hereby adamite repreweettives fit this city to was updn,he n.; r. t 'If F SEISMIC FEF,
Insse-mentioned property for inspeainn purymes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep handless the City of Cupertino against ELECTRIC FE
Iiahilines,judgmems,cnstsand expenecs which may in day wayaeemeagfor id City ALTER OR ADD TO MECH.
in consequence of the granting of this Petmir PLUMBING FEF.
APPLICANT UNDERSTANDS AND WILI. OMPLY WITH ALL NON-POINT AIR HANDLING UNI Fill)10,000 CPM)
SOURCE REGULATION MECHANICAL 1:17.17
AIR HANDLING ON[I(OVER 10,0011 CFM) CONSTRUCTION TAX
JI L (�
SMCo isle'nFac Appliea , Ume HXHAUSTHOOD(W/DUCT} HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO Hoeft BTU)
as defined by the Cupertino Municipal Code,Chapter 9,12,and the Health and Safety
Cale.Section 25532(x)? HEATING UNIT(OVER 100,001 BTU)
E3 You, E]N. VENTILATION PAN(SINGLE RESID) PAID
Date Becelptk
Will the n,coolntnr B k a building screamaseea A[,Quordwicerwhich BOILER-COMP(3HP OR I N0,000 BTU)
v if Toole'? nus air ammtniunntx m defined by the Bay Area Air Quality Management
all ❑Yes 0N BOILER-COMP(OVER❑k1.(HM1 ETU)
AIR CONDITIONER
1 have real,he hazardous materials requirements under Chapter fi 95 of the Cali- /N ti DATE
Amain Health&Safety Code,Sections 25505,25533 and 25534,1 umkrsmnd that nth. NEW RESIDENTIAL MECH. SQ.FE /l/Yie' S
building does not currently have a arced.that h is my responsibility to notify the occupant
ofthc qui mems wNch must be, rionoissuance ofa Cenificam of Qcu an
6 —
Ow ruuthonead agent Date TOTAL: ISSUED BY:
OFFICE