S 4372APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
OFFICE
CITY OF CUPERTINO BUILDING - ELECPRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
IDEIFICATION
, BUILDING PROJECT NT
PERMITNO.
S 4372
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMIT'FALDATE
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' 'i! :;; BUILDING PERMIT INFO -
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❑ Consultaln Fees Paid by Appiicent (Initial)
BLDG ELECT PLumle MECH
❑ ❑ ❑
LICENSED CONTR ORS DECLARATION
hereby affirm Nal 1 am licensed underprovisions of Chapter 9 (comma ring
with 5«tion ]OM)of Divxon 3.ftheBmn rod Profess ons code. ane my teen. is
in full force and IT 2 j�
Liceme Cb.ss - Lie.a -*1
Date O'nountor
'QTY ELCLUZJBPERMITt� r „ F'E'E'1
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL C1 KITCHEN REMODEL
El ADDITION ❑ PLUMBING RE PIPE.
❑MULTI -UNIT C1 STRUCTURAL
MODIFICATION
PERMIT ISSUANCE:
APPLIANCIiS-RGSIDEN'flAl.
ARCHITECTS DECLARATION
I understand my plans shall he used as public records
PANELS
UPT02M AMT'S
❑INTERIOR ❑CHIMNEY REPAIR
j
'Oil!
WU
C J tia
License) Pruressional
OWNER -BUILDER DECLARATIONOVER
I hereby affirm .ha( I am exempt Gam the Cramer...x Licenve Las, far the
following reason. (Section 7131.5, Buviness and Profession. Crile: Any city or county
which requires a permit to commi ahma improve, demolish, or repair any sm.aure
pdono its inomet..k. reruns the applicam(.,suck permit.. fileasigncdstatemem
201-1000 AMPS
IMPROVEMENT C] SWIMMING POOLS
Cl BATH REMODEUREPAIR C1 DEMOLITION
❑ OTHER
If
SIGNS EL
SPEC14 CIRCUIT/
}
OQ
o e'
that he is licensed pursuant to the provisions of the Contractor's license Law Whapmr 9
(commencing with S«tion 70M) of Division 3 of the Bisinevsumd Profess ions Qda) or
that he Ix exempt threat n and the free, For the allegul exexnptian. Any vinlmion of
T .T R( POLE, INS'C
COMMERCIAL:
❑ NEW BLDG/ADDITION Cl DEMOLITION
POWER DP CR
ZY
�M
1..�
Section 7031.5 by any aa
pplicam fora permit suhjes Ne applicant.. a civil penult, of
net mom than live hundred dollars ($500).
L)1. as owner of rhe property, or my employees with wages as their sole compensation,
will do work,andthestrvcrme is not intended. tottered minic(S«.]044. Itusiness
and Professions Code: The Contractor's Liceuuse Law flows nn, apply to un owner of
❑❑
TENANT FOODSERVICE
IMPROVEMENT
DOTTER
SWIMMING POOL L RIIF
OUTLETS - SWITCHES - FI RES
ICS
property who builds or itn emao.heron, and won does such work himself of through
his own employees, provided that such improvements arc not intended or offered far
NEW RESIDENTIAL ELECTR SQ FT.
SQ. FT. FLOOR AREA
$/SQ. FT.
safe. If. however, the building or improvement issold within one yearafconsplmlon,.he
ousear-lailde, will have he burden of proving that he did nm build or improve far pun -
pose mad"),
TOTAL:
❑ 1, as owner of the property, am exclusively contracting with licensed carime rs m
construct the protect (See 7044 B :,, and I r r Cm Ir,) The Contaemr s Li-
t , -1 r I. .. - -
se Lax does not apply. a of property h builds or improves thereon and
QTY, PLUMBING PERMIT. 11 FEE
who contracts forsuch Projects with a arrestors) licensed pursuam m He Contractors
PERMIT ISSUANCE
License Law.
❑ Lam exempt under Sec. ,B& P C for this reason
ALTER - DRAIN & VENT- WAI'E
Owner Date
VALUATION
to
WORKERS COMPENSATION DECLARATION
Ihereby afBmr under pemrlty of perjury one of the following declarations
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR, ROOF, AREA. COND.
I have it will maintain a CeruficateofCament to sef-insure for Worker's Compete
prion, as provided for by Section 377 of Latin, Lar Cade, far the perfomxunee of the
work for whith this permit is jawed.
STORIES TYPE CONSTRUCTION
/
FIXTURES - PER'TRAP
❑ I have and will maintain Worker's Compensation Insurance, as required by Sceim,
or
37M of the � for �the Owe ccarrieraad Poliy(nrwhiiarei rmi'.i^issuey
work
ch
My ofth . In JPolicyn rr whiI —V Jr'
Canter. Policy NA:
CERTIFICATE OF EXEMPTION FROM WORKERS'
GAS- EA. SySr FEM-I INC. 4 OUT ETS
OCC. GROUP N
�- �
jq
GAS-EA.SYSTF.M-OVFR4(E
COMPENSATION INSURANCE
(This section need not Imcomple.ed it hcpemuit ixfmone hundred dollars (SIM)
or less.)
GREASEANDUSTRI. WASTE INTERCEPTOR
$'a -u r ,I a BUILUINGD�VI LANs h'Ixli.t ,F s,St
GREASE TRAP
PLM,CHECK FEE
SEWER - SANITARY - STORM EA. 200 FT.
,Z
� �
ythatPer in in mydrmanceo as t becomeork this teem.is issued.ishall
Toy any
not employ any person in any manner so m to become subject m the Workers' Cnmpen-
AppdILaws of California. Dam
Applicant �
J V
ENERGY FEL /f �"� Q
GRADING I>LE
ER
WATER HEATER WNENI/ELCT
NOTICE '10 APPLICANT: If, her making this Cenificam of Exemption, you should
became subject to the Worker's Compensation provision of the Labor Code, you mut
forthwith Comply with such provisions onhis Permit hall be deemed revoked.
WATER SYSTEMTREATING
WATER SERVICE
(01
0
SOILS FEE
NEW RESIDENT IAL PLMB. SQ.fT
Z
CONSTRUCTION [.ENDING AGENCY
PAID
Fthe
U
W
I M1orwhichinn thanhcrc issued( itesi.n len die. agenc, for the perfnrmnncoaF
work for which this pernJ. is issued (Sec.3M]. Civ. C.)
Lenders Name
re Receipt
TOTAL:
Inde I AJdreas
c 1 have and stain that the above information is
1 agree
this ci
TOTAL.:
3t
BUILDING FEE J
-
Z)
Z)
o with y and
coil«.J agree m comply with rill city one county ntativ eees and smte laws relining a
huildingaondnm.iomund horchyonmon this city to enter upon thin
'QTY. , (, MF.CHAMCAL PERMIT,. FEP,
t" i'I)
SEISMIC IEE
pmpmexamatiwa'oF
above -.(Way arepropmve for inspection keephs.
(Way agree m save, indemnify and keep bamticss the City of Cupertino against
PERMIT ISSUANCE
ELECTRIC FEE ,
Iiabili.ies.judgmens, costs and expenses which may in any way accrue against said City
1. consequence of the grunting o I I it.
ALTER OR ADD TO MECH.
PLUMBING FEE
APPLICANT eRSTA SAN OMPLY WITH ALL NON -POINT
SOURCE RF L
keqN.'
AIR HANDLING UNIT (TO (1,M) CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER ULM0 CEM)
CONSTRUCTION TAX
rgoamrc Zpfanff&abmtrr Dam
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCD
HOUSING MITIGATION FEE
HEATING UNIT 00 IM,M) ID U)
Will the upplimnt or future building (arrual store or handle hazardmsv material
as defined by the Cupertino Munkipal Code. Chance 9.12, .,,it the Health and Safely
Coda Seaton 25532hoi
HEATING UNIT (OVER IMMKI011'1'U)
_
C] Yea ❑N.
WiII the applicant or furore building «cupant use equipment or devices which
:mit hazordnus all lema limen as defined by the Boy Ater Air Quality Mnnugem.nt
PAID -
Date Receipt#
VENTILATION FAN (SINGLE RESID) -
BOILER -COMP (31IP OR I00AW BTU)
ticYl
Fl yes No
BOILER - COMP (OVER 1W,11(I()DN)
AIR CONDITIONER
"am ma¢rials ireme wonder Chppmr 695 of @e Culi-
ISSUANCE DATE
NEW RESIDENTIAL. MECH. 5 FT.
411ve
fC e. S coons 5 2553 pod 255311 understand thin if the
rod have a to. resporedilily to notify. c ecu, .id
mixsu ceol'a CeniGeme�F vv rc
(O
ISSUED NY:
caner are zed agent Doc
TOTAL:
OFFICE