S 4310 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL S 4310
`. I," 'BUIIAING PROJECT,IDRNTIFICATION-'A f
BUILDINGADDRESS: ' SANITARY NO. APDL ATION SUBMITTAL DATE
f}s7r-A_ Lo J 2 2
O NE AMPHONE, CO�(1'R/�j'\OR'S NAME: LIC NO:
EJ� ork) NIC CONTROL#ARCIII'I'E ENGINEER: LIC NO: ADDRESS:
A ^V r ❑
CONTACT: PHONE: JI�j/1�'t a-•�74� a leHUICDINGTERMIP INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT ,PLUMB MELD
re / ❑ ❑ ❑
' IFFYINhFLE
1 hereby afirm that I licensed d previsions f Chapter (commending LECTRICPERMIT '
JOB DESCRIPTION
OW CZ ithSection700(b.1D o3cftheSt dP boodon Gxle, ryLu i
WHO with PERMIT ISSUANCE RESIDENTIAL:
Fa in full force mJ effect
d CWJ U Liecnce Cl...II Liu# ❑SPDWL ❑KITCHEN REMODEL
mQ WW Dam Contractor APPLIANCES-RESIDENTIAL ❑ADDITION 0PIAMe1NG R&PIPE
RCHITEC•PS DECL R T ❑MULTI-UNIT ❑STRUCTURAL
PANELS
Z O w ZW I unded m
awny plans shall bed... asbli
puc record, - MODIFICATION
O Z�`"'Q UP TO 200 AMPS
El INTERIOR El CHIMNEY REPAIR
Fri WW Licensed Probessiomel 201-1000 AMPS IMPROVEMENT �SWIMMING POOLS
�COWNER-exemptRDECLARATION OVER UROAMPS ❑BATH REMODEL/REPAIR El DEMOLITION
y I hereby aflinn[Lal 1 em exempt from the Contractor's License Lew for 1M1e
W C d O fallowing reason.(Section 1031,5,Btoinec,and Poor essiOx Code,Any city or county SIGNS ELECTRICAL. El OTHER
61+0.y which requires a permit to construct,alter,improve,demolish,or repair any structure
F�O� ,in to its issuance,also requires the opdicant for such Permit to file a signet statement SPECIAL CIRCULDMISC.
that he is licensed pursuant to the provisions of the Contractors License Law Chapter 9
W�qp (commencing with Section 7oi of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
dy oy that he is exempt therefrom and the basis for the alleged exemption.Any violation or El NEW BLDG/ADDITION El DEMOLITION
7e mem Section 90315 ry
by mapplicaut for a pcnnit.subjects the applicant to a civil penalty of POWER DEVICES ❑ ❑
TENANT FOODSERVICE
C6611 nothime than five hundred dollars($500) IMPROVEMENT
'Z�"Q ❑I,vs ownemftheproperty,or my unployeee with wages as theirsolecompensatioa, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended in uttered far sale(See,9f14q Business ❑OTHER
1 m and Professions Code:'The Character's Licence Low does not eplay to as owner of OUTLETS-SWITCIIRS-FIXTURES
property elm ro
builds or impves dareup and who dues such work himself or through
his own employees provided thud such unt revements are not Intended or offerad for NEW RESIDENTIAL ELECTR SQ ET.
sale.l[however,the building or improvement is sold within oneyeanaf completion the SQ.FP.FLOOR AREA $/SQ.Er.
wnerTailder will rose the burden of proving that he did not build or improve for pur-
pose f. ) ' - '
- IDI of the property, exclusivelycontracting ithl" d contractors t
wnstt thep jet(9 1141 B .: d Professions. C J )The Contractor t La-
cerise
L J t apply t fp P rtY h builds p s th rcid -PLU•MBINGPERMIT
who contracts t h projects with a ce tr t (s)licensed pursuant t theContractor's QY a .FEE
I �,
License PERMIT ISSUANCE .., JUN 2 2 1999
❑
w.
I exempt
x exe mpinnders B&Prror tmat as.n
Owner Date ALTER-DRAIN&VL'Nf-WATER(BA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PRITTF,CI'.DEVICE
Th...by vflinn under penalty of of perj.0fa
ry one of the llowing de.lamtions: B
I have and will martian a Certificate of Consent o self-ireame for Workers Cumpen- DRAINS-FLOOR,ROOF.AREA,COND. '— "ITCOft;I RUCTION
,.tion,as prof the vided for by Section 39W oLabor Code,for the Performance of the '
IUKFS
work for which this permit is issued FIXTURES-PER TRAP
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 or the Labor Gale,for the performance of the work for which ibis permit is issued. GAS-EA.SYSTEM-1 INC 4OUTLIII S OCC.GROUP APN
My Worker',Competmmion Inwmtce carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(RATt.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINUUS'1'RL WASTE INFERCEPTOR ,#&Ca 1}U,LQI'
(Thissectlnn need not buchor �ed if the Permit is forme rimmed dollars($10B GRP,ASE'CRAP
car r,".) ,HEK FEE
I certify thatin d e the work fm whldi this permitici,csued.I sM1ull SEWER-SANITARY-STORM EA.2W FT.
',� scion Luw cnfy Pers t u I u a s m become veh ee m the Wokers'Cumpen- ENERGY FEE
er WATER HEATER WNENT/ELECTR
z O AFlplicanl• GRADING FEE
In NOTICE P 1 ,otter making Ois Cenificme Of Exemption,you should WATER SYSTEMITREATING
f"1 7 became subject o the Worker's Comensa
ption provisions of Labor Code,you pard SOILS PEE
Qforthwith comply with such provisions or this permit shut l he decided revoked. WATER SERVICE
ULL CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ph. PAID
'z I hereby affirm that there is a conduction raimagageicy for the performance of ate accept
the work fur which this permit is issued(So,.3091,Civ.C.)
W L~ Lenders Name TOTAL,.
WLender's Address TOTAL:
04 1 seri fy than 1 h d this application t' d state that
V ' the Morientation . .
BUILDING FE
h correct i agree or comply 'm II city d county rdd state lrelating t QT Y" .MECHANICALPRMIT
4 btd ng eonctrueion add by p rinds of this clyrocolor upon M1e
SEISMIC FE
above neniened popety for'ncpecion puRrscc PERMIT ISSUANCE
(We)agree to save.indemnify and keep harndesd the City of Capenino against ELECTRIC
liabilltics,judgments,costs and expenses which may In any way accrue against said City ALTER OR ADD TO MECH.
in asequence of the grouting d this pemit. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH
HHJJALL NON-POINT AIR HANDLING UNIT pro 10,000 CFM) MECHANICALFEE
SOURCEREG� /At-Z/-r /S
AIR HANDLING UNI'1'(OVP.R 10,000 CFM) CONSTRUCTION TAX
Signature of pp V dmr&- Date EXHAUST HOOD(W/DUC'U
HAZARDOUS MATERIALS DISCLOSURE HOUSING MD'IGATION FEE
Will the applicant or luturebudding occupant stnmarhandle hazardous material MATING UNIT IT 0100,000 BTU)
as defined by the Capenme Mnnio,el Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)IJJ eip
HEATING UNIT(OVER'100,000100,000BRE
0 Yes IIFNo VENTILATION FAN(SINGLE RESID) PAID -Dole RectA Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP CILEP OR 100,000 BTU) d 0
Distrldt?
L]Yes �{Akr BOILER-COME(OVER 100,000 BTU) OL,
I have reed We hazardous amounts requirements under Chapter 6,950r the Cali- AIR CONDI'I'IOKER ISSUANCE DATE
Input Ilealth&Soret ford Section,25501 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.ET. /
building does nom Iatenant,th is my responsibility m notify the occupant /art Y /
oft rcquimn h' (A
st be missuance of american,of Occupancy,
cOupinamoo z Dale 'TOTAL: ISSUED BY; ^�
OFFICE