S 4469APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL -
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
PERMITNO.
!{ ii ',BUILDING PROD CTIDENTIPICATION' «-iyss,
S 4469
BUILDING ADDRESS:
/a/r ,L
SANITARY NO.
APPLICATION SUBMITTAL UA
_
OWNE AME: PHONE:
''ARCHITF,CDENGINEER:
CONT ACFOR '$ NAME LIC NO
7G3lo�a/
N/C
❑
CONTROLh
LIC NO:
ADDRESS:
02s3/ 6",4_.,apt „ (�rj/c: 9P�
CONTACT: PHONE:
❑ Consultant FOPS Paid by Applicant (Initial)
- ;i; ;BUILDING PERMIT{INFOkti `
BLDG ELECT PLUMB MECH
El El G1 ❑
JOB DESCRIPTION
RESIDENTIAL '
❑ SFDWL [I KITCHEN REMODEL
LICENSED CONTRACTORS DECLARATION
I hereby affirm that t 1 licensed under previsions of Chanter 9 (chromene n g
with Section 9WlpafDivismn defile B sad PtMessium Code and my licensors
I Icer in antic t.
J License Cla Lie. p S I y
i `
QTY! ( ELECTRIC PERMIT, FEE,j',4 e
+ - ,• f. _s '-• r ' ` +?I ..,
PERMIT ISSUANCE
APPLIANCES-kESIDF,NTIAL
Oate�Commaur 1W
El ADDITION C1 PLUMBING RE -PIPE
ARCHITECT'S DECI, RAH
1 understand to, plans shut[ focused as public rewMs
El MULTI -UNIT ❑STRUCTURAL
MODIFICATION
LJ INTERIOR [D CHIMNEY REPAIR
IMPROVEMENT [I SWIMMING POOLS
PANELS
UP 200
Ltwnsed Rufusronvl
OWNER-BUILDERexemptmtheARA'f1ON
2111-1000 AMPS
-I OWAMPS
OVER IBA AMPS'
1 hereby affirm Ihe[ I am exempt from the Convenor's License Law Por the
following revs.... (Section 70315, Business and Professions Code: Any city or county
j which requires a permit ort construct, alter, improve, demolish, or repair tiny structure
D BATH REMODEL/REPAIR El DEMOLITION
❑ OTHER _
��'� i
SIGNS ELECTRICAL
prior its issuance, also requires the applicantfor suet permit to file a signer) statement
that he is licensed pursuant o the provisions of the Contractor's License Law (Chapter 9
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLE'INSt
COMMERCIAI,
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
(commencing with Section 9000) of Di vision 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9031.5 by any applicant for a Penn'[ subjects the applicant to u civil penalty of
not moreman Ove hundred dollar, ($500)
POWER DEVICES
SWIMMING POOL ELECTRIC
❑ 1, as owner of the property, or my employees with wages as their sole compensation.
will do work, and the structure is not intended oroRered for sale(Sec. 7044, Business
IMPROVEMENT
❑OTHER
_
3 tine Professions Code: The Contractors License Law does not apply ter an owner of
OUTLETS -SWITCHES -Fix ruRE$
property who builds or improves [hereon, and who does such work himself or through
his awn amp ldmos, provide(] that such improvements arc not intended or offered for
NEW RESIDENTIAL ELEC1'R SQ FT.
sale.If, however ,[lie building..r impfovemem is sold within one year of completion, the
owner -builder will have the burden of forcing that he did not build or improve for put -
SQ. F.. FLOOR AREA
$ISQ, Fft
pr [ le)
❑ I of the pf perry 1 ely mobactial with licensed [ to s to
1
TOTAL'
.... fruit the roject Sort. 7044 Business and Prof n' Coke.) Tho C tract L
c _ L d [ apply to fproperty h builds 'tip- [h e and
who t Lto. hprojects wthuwn[ emr(s)I'censedv pursuant to the Contractor's
License
ex
�Idm nemptutdcr Sex. ,R&PCfar [M1ia reason
16
JUL ����
t o! - -W,
QTY' t (p j PL M13 PERMIT
PERMIT ISSUANCE rD
ALTER - DRAIN & VENT - WATER (EM
Owner Dateq
VALUATION
By
WORKERS COMPENSATION DECLARATION
I hereby affirm ander Dmal[y..l' perjury ono of he following doclurati urc
❑ I have and will maintain a Certificate ofCunscn[it) self -insure for Worker's Compen-
station, as provided for by Section 3700 or the labor Code, fir the performance of the
BACK FLOW PROTECT DEVICE
DRAINS- FLOOR, ROOF, AREA, GOND.
_
STORIES
TYPE CONSTRUCTION
FIXTURES -PER TRAP
whrkfur i,mmitk mucd.
use and will maintain Worker's Compensation Insurance, as required by Section
3700 if the Labor Code, f or the pent o nonce hf Ore worktor whicbihe,crmltkissued.
My Work C mP. sa�j t I I.I., c ie nJ Poh, num
a rn pvv
GAS -EA. SYSTEM -]INC, 4OUTLETS
OCG GROUP
APN
Grier' Policy N¢: >O�
CERT ICCOMPE
GAS -EA. SYSTBMOVER4(P,A)
'
GREASEIINDUSTRL WASTE INTERCEPTOR
EXEMPTION PROM WORK RS'
COMPENSATION INSURANCE.
(This section need not be completed if the permit is for one hundred dollars ($100)
*AS* # B_D I I1*51ON F49.14
or less)
of [he work me which this permit ix Issued L shall
[ certify pmt m the any ma n manner
ninonemployLove any person
arro any manner so as to become subject the Workers'Compen-
of Cnlifomia. Dene
sation Applicant
em
GREASE'fRAP
PLANCHECK FEE
SEWER - SANITARY - STORM EA.2WFT-
ENF.RGYFEE
YDELECTR
.7
GRADING PEE
NOTICE Exemption, you should
NOTICE TO APPLICANT: It, after nuking this Ci,io s of the
bcwrne subject to the Worker's Compensation provisions o[ the tabor Code, you must
forthwith comply with such provision., or this permit shall he deemed revoked.
TING
SOILS FEE
ENEWRESIDEWIALPLMB,
MB, SQ. Fp
CONSTRUCTION LENDING AGENCY
fherebyaffrathnt Ormisue arration lendmgvgen, fomite perfnrmanceof
PAID
kweip[#
♦♦♦
the work fir which this permit Is kaued (Sen. 3097, Civ. C)
Lender's Name
TOTAL:
Lender's Acidic,,
T
I elfythat Ih read this application dolt that the b information
wiret I g t comply with all ityand [y ordinances and [tit I I i g t
building onsuudon and hereby authorize representatives offhs city to enter upon the
abate-nentlnned property far inspection proposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
} y ., s Nr•, f=
QTty, + MH¢HANICAG PERMIT s FEE',
t 1�= ^1 i •.'SEISMIC
BUILDINGFEE '
PGE
PERMIT ISSUANCE
ELECTRIC PEE
hahili[icojudgmcntk chits and expenses which mayutiny way accrue agtiousaid City
consequencein of the grunting of this permit.
ALTER ORADU TO MECH.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,00) CFM)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCT)
-SicmhfApplimmIC tmetor ,Ic
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEB
HEATING UNITCIO I00,000 BTU)
Will the applicant or future building..wupunLdore or handle hazardous ma[enal
as defined by the Cupertino Municipal Code, Chapter 9.12, and He Health and Safety
Code, Section 25532(x)7
HEATING UNIT (OVER 104000 BTU)
❑Yes ❑No
use equipment ordevices which
Will us air examinations
or future building by the
mi[ hazardous alt wnwminnnta as defined by the Buy Area Air Quality Management
Dome,
❑Yos E] No
PAID
Date Receipt
-
VENTILATION CAN (SINGLE RF,SID)
BOILER - COMP (3HP OR 100.000 BTU) '
TOT L
BOILER - COMP(OVER 100,000 BTU)
AIR CONDITIONER
I have reuldne hazardous mnterialsrequimmcma under, Chapter 6.95 of the Crvli-
human Health & Safety Code, Sommers 25545, 25533 and 25534. I understand that tithe
baddhrgd..eonotearoodlyhav a nuns,tbn[it limy responsibility w n tiny III cupant
ISSUANCE DATE
r�
/— /6� X
NEW RESIDENTIAL, MECH. SQ. FP.
rt t Fru l 11h o act prl( I Lan ve of a Ccripcat ' Oce a cy
l ((00
� K_
ISSUED BY:
in s tit ate I
TOTAL:
OFFICE