S 4340 APPLICANTTO FILL IN INFORMATION.WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPFRTINO BUILDING-ELECTRICAL PERSH I NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING..MECHANICAL S 4340
,`W' C.j 'P;BUILDINPROJECT IDENTTkICATIONji hlf,r'••-i:
BUII.DINGADDRF,SS. SANITARY NO. APPLICATION SUBMITTAL DATE
ER'S NAM ONE: CO RACTOR" ,e LIC NO:
NIC CONTROL#
CHIT C /ENGINEER: LIC NO. ADDRESS J V !U ❑
�bvg
a,&11,-,4e R
oINTACT:/// / PHONP,: �t,�•i.t$.- ;,BUILDIN0 P8RMITdNFO-
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MEC
❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION 'I{ t i "! , t
It
QTY t,- I ELECfTRIG PERMIT, 1 `tFE�, ' �.
1 hereby strain that I licensed d provisions f Chapter (commencing ,.�: ,- ,- t ..a .. t . Li *'. ]OB DESCRIPTION
uppu77 tXZ with Section]WO)ofD"stop 3 ofthe Buil Business and preassintc C de,antl my lice seta RESIDENTIAL:
FWB in full force ml �• PERMIT ISSUANCE ❑SFDWL El KITCHEN REMODEL
h�UF Lic�Lic.# ✓ APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
G Dv Contmc
ARCHITECT'SD I ❑MULTI-UNIT ❑STRUCTURAL
Z O r/Z 1 understand my plans shall be used as public records - PANELS - MODIFICATION
OZ`4Q UPT0200AMPS ❑INTERIOR [I CHIMNEY REPAIR
C4�.0 LicensedPro@rslnnal '201-1000AMPS IMPROVEMENT [DSWIMMING POOLS
.4 OWNER-BUILDER DECLARATION OVER IUUf1AMP$ BATH REM VEEP t ❑DEMOLITION
U I hereby affirm that 1 am exempt from the Contractors License Law for the
W follnwin
C,
W F g reason(excitor 7031.5,Business and Pro@emoli Code:Any city os eovure SIGNS ELECTRICAL ❑OTHER
F❑to sr/o� which la]hula n permit to consuuel.ober improve,IF permit T or repair any nmerore
2 thathesficaread prlcconto as lheapplly,ofthe IF permit toicense Law
statement SPECIALCIRCUIT/MISC.
�y (commscingwith
iit pSrstion 70he pmvlslocofthe Contractor's License Loons Codter9
1ymj�l p 0 (wt he is
(commencing it therefrom
of basic
the al eg Business and on.Any
Gtion or TEMP.METER OR POLE INST. COMMERCIAL'
that im is exempt Ihererom and the pais for object,
alleged exemption.Any vlolatiov of El NEW BLDG/ADDITION El DEMOLITION
ul^h Seceore thea 7031 five any hundrelicantfee a.($50 rmit subjects the applicant too civil penalty of POWER DEVICES [-]TENANT ❑FOODSERVICE
F�Gnot more than five hundred dollars($Sa).
EJ1,as owner of the propeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVBME
will do the work,and the structure is not intended proffered forsole(Sea.]W4.Basilicas ❑OTHER (
ul m and Professions Cade:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
Y
property who builds or improves thereon,and who does such work himself or through -
his own employee.,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELEC'IR SQ ET.
aide.If,hswevu,marmilding lir improvement is sold within one yearofcmm Anumade, SQ.IT,FLOOR AREA $/SQ.ET.
toner-M1 older will Towelled burden of proving that he did not build or improve for Fur-
pose of salaT
❑1,es owner of the propeny,nm exclusively cmnto ding with licensed coutmetors m AL:
construct
the project(Se 7044 ..B and Pudexacans Cade)The Contractor L
cense Law does not apply to e fproperty who builds or improves thereon d QTY, - •PLUMBING
who summers far such Projects with a contract orbit licensed pro en o,the Conmamtors
License Law. PERMIT ISSUANCE
❑1 em exempt under Sac. ,B&P C fur This reason
ALTERDRAIN&VENTWATEREA
wear Data E ATIO ')
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE 1�
I busby affirm under penalty of perjury one of the following declarations: It UN
(have and will far Certificatetain byei37 of the Labor
for Worker's Ce of the DRAINS-FLOOR.ROOF,AREA,GOND. ��II STORIES C UCTION
tion,as hick this
for ro Suction 37!10 of the LeM1nr Cade,for the performance of the 2.
sod for which Ibis maintain
is issued. FIXTURES-PRR'fRAP
❑ Ihvve and will mainoin Worker's Compensation Insurance,as required by Section
37W.fthe Labor Code,for the performance of,ha work roe which this permit is issued. GAS-EA.SYSTEM-I INCA OUTLETS
My We Cm pensa e�lnsurra career and Policy anneerwri
Cartier. Polley No, GAS-EA.SYSTFM-0VER 4(EA)
CERT EICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR 7 orK a
(Thus section need not be completed tFlhe permt-s forms,hundred dollars($100) -8a Ad4:N��1 SIN I l ]`g. FLH #a
lir
les") GREASE TRAP
PLANCHECK FEF.
1 oy any that in performance of as t work for which his permit Is issued,l Shull
not employ any person in any manner so Ism become subject tothe Workers'GtmpenSEWER-SANITARY-STORM EA.200 FT ENERGY FEE
Z swine laws of California.Data
Z Q Applicant WATER HEATER W/VENTILLEC'TR GRADING FEE
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEMITRIiATING
F become enbJmt to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
forthwith comply with such provisions or this peuail shall be deemed revoked. WATER SERVICE
Q
UZ CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMR. SQ FT PAID
U 0 l he
rebywhich rte that permit i isaeormweti30 lending agency for the of Dote Rweipl#
� P ;ha work for which this permit is issued(Sec.309],Civ.C)
0 benders Name TOTAL
W Lenders Address TOTAL.
1 certify that 1 have read this application and ewte that the h information BUILDING
:i4 correct l agree to comply with all city and county ordinances and state laws releTng to QTY• y. MECHANT1'5r% EMIT' ( ?*I,F-ELr ;i SErsMICFBR
V Z building construction,and hereby suthorze opre.eredwes offhsety to erterupom the
above-mentioned propeny for inspection purposes, r
in co PERMIT ISSUANCE J
(We)agree to save,indemnify and hkeepick harmless the City of Cupertino against ELECTRIC FE
insessiojudgments,cows and expenses which may in any way accme against said City ALTER ORADD TO MECH.
nsequ of the,taming of this permit PLUMBING E
APPL NT UNDERSTANDSA WILL OM .Y WI .NON-POINT AIR HANDLING IINIT(TO 10,000 CFM)
I S GULATIONS. MECHANICAL
AIR HANDLING UNIT(OVER 10,000CFM) CONSTRUCTION TAX
/ Si,1MTmj,ofApplicanl/Comr r Data EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PER
HAZA OUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store a handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Gale,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)P HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No
VENTILATION PAN(SINGLE RESID) PAID
Date Reecipt#'
Will the applicant or Powro building occupant use equipment or devices which
nil hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP OHP OR 100,000 BTU)
isIJet, TOTAL
❑Yes ❑Nn BOILER-COME(OVER 100,000 BTU)
I have mad the hazardous materials requirements under Chapter of the Cal i- AIR CONDITIONER
9 P IS ANCB DATE
for, He Ith&Safety Ced ,Sections 25505,25533 and 25534.1 nmdmtand Thal if the /^_ f
build] s not currently have n61 it po y yoccupantNEW RESIDENTIAL MPRH. SQ.Rf. lD w ��
> yrea 'ti to notify NeG f
moreems wines, rel if ejfNe,:upa
P
O er or amhmnzcd agent'p, I Data TO L: ISSUED BY:
OFFICE