S 4309 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 4309
BUILDING PROJECT IDEN DFICATION
BUILDING ADDRESS: SANITARY NU. APPLICATION SUBMITTALDATE
3 o cs Go, 2Z 9
OWNIiR'S NAME: PHONE: CONTRACT'OR'S NAME: IC NO
N :
F. -D3 �O R/O PIG L71 NIC CONTROL#
•ARCHITECT'/° CLN,INF.F:R: LIC NO: A13DRES5: ❑
o !,
CONTACT. PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BI_PG ELECT PLUMB MECH
V ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affir that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
,aZ wilh Section700apof Gas Num 3 of the Brione.s and Perfe,uns GMs.andmy license is
FOO In lull fare d L 9 PERMIT ISSUANCE RESIDENTIAL
aUU Lirenw CRI Lto, #72 • ;8SFDWL ❑KITCHEN REMODEL
tiQ1 Umc k C.ntmaor - APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
ARC TE I)ECI.ARAI[ON ❑MULTI-UNIT ❑STRUCTURAL
H h PANELS
ZOy s records MODIFICATION
CZ-0 UP TO NW AMPS
[-nn F-al Licensed Profen nal ❑INTERIOR ❑CHIMNEY REPAIR
201-IINW AMPS IMPROVEMENT
a c :- Oat I am
DECLARATION ❑SWIMMINGPOOLS
i Owl, I here y rllirm that 1 um,sent#[from the Contractor's License Law for the OVER IIkW AMPS ❑BA'TH REMO�DEIJ!RE�P�AIR (]DEMOLITION /
ykj F.3 Q.F lidlnuhng r s n.(Sean..91131.5,Busmess and Professions Care'.Any city or county SIGNS HLECfRICAL ❑OTHER -NEMS ase �6QQw
O y which requires a permit to construe[,alter,improve.demolish,or repair any structure
Prion.its issuance,also requires the applicant for such Penni[to file a signed statement
y SPECIAL CIRCUIT/MISC.
Eby that heisliwnnWpursuant mthe provisions.fthe Gmvaemr'slicenseLaw(Chupar9
Ig feuntmeming with Section 91XT)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL'
a 6 p Ic tbm he is exempt therefrom and din basis for the eliegcd exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
X m Section]031.5 by any applicant for a peril aublects the applicant m a civil penalty of POWER DEVICES
t more than five hundred rogues($1006 ❑TENANT ❑FOOD SERVICE
SSD ❑ I,as owner of the property,
1•No ormyentpluyees with wages
tcompenation SWIMMING POOL,ELECTRIC
IMPROVEMENT
willJnthe work,andthestrucwrcisvnl ncndWomffetcd foal(Sec.J(4
Business — THER _
a3 and Professions Code:The Centimeter's License law does not apply to an owner of OUTLETS-SWITCHES-FI%TURES
property who builds in improves thereon,and who does such work himself of through
his own employees,provided Out such improvemcntn Bre not intended or offered for NEW RESIDENTIAL HLECTR S PI'. 1—\ 1r�
sale.11 however the building p t is sold within one scar offromplerearden illJ FT.FLOORAREA EH FT.
covirer,budder willh are burden ofproving ttout he Jd notWild or improvefor Por JUN 2 2 199
po , )
❑ 1.n lit p pony ely t i' y dr licensed I rs, 'r L:
n tnsvua[heel not (Sec.]W4,Holowner
off and Profession,Codei moves thement Li-
c seLawdcesrrnapplyman with
aofproceny whored pursuant
tooth mercon,and QTY. PLUMBING PERMIT
xM1u contracts for such project wink a contractors)licensed pursuant[n the at,
�Y
License law. PF,RMI'ISSUANCE
0Imur.on tendo Sec. ,B&PCfm1U,r,rom
Owner Date ALTER-DRAIN&VENT'-WATER LEA) VALUATION
• WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hemby afilr under pen dly of licHary one mf the f(lowing d,dance e 7
❑ I have and will maintain aCciificateof Consent usclf-inure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA,CONU.
anon,as provided for by Section 37W of the labor CWe,fm the ferforancc of the STORIES TYPE CONSTRUCTION
work for which this pent is issued. FIXTURP_S-PER TRAP // l
❑I hove and will mainmin Worker,C.Iru emal on Insurance os required by Section
39110o1[te Labor Code,far he porfnrmanaeofthe work f'orwhict thlsperit is issued. GAS-EA.SYSIEM-1 INC 4 OUTLETS OCCG OUP
My Worker,C an ywlapnI Insurance artier and l'nlicy 9p
Camcc�Tnxi.JArp Policy No.:7iti5�. � OCYb72 GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 3 b,4
COMPENSAION INSURANCE. GREASIVINDUSTRL,WASTE INTERCEPTOR
('this section need Bat be completed if the peril is fore hundred doll.(510) BUILDING DIVISION FEES
or lost GREASETRAP PLANCHECK FEE
I"Y my Per
intone ,flmyreaanceolthe ltotroere.k for,aicttisper orke.s'Comate SEWER-SANITARY-
not mnLaws ofCasmoix.Dy manner so rte In heconu.aitjed 1.Na Workers'Compete STORM EA.200 FT.
'Z mdnn Lows of C0ldornia.Dam
ENERGY FEE
z WATER HEATER N'/VENT/ELECTR
Applicant
Z E NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should KME
G FEE
? become subject to the Worker,Corepesmion f the Labor Code,you must WATER SYSTHM?REATING
fonhwllh com with suet provisions. E
� Q p y wi pnrvisi.re.nhia porn shat be tleemcd rtvokW. WATER SERVICE
a
7z CONSIhante iso c10NLENDIPGAGENCY NEW RFSIDEM1TIAL PLMB. SQ.FT
U. I� ]bore ehidi e,EVmrert isac.nstee 3097.Or.
for the performance of Receipt#
U. F:, the wmk for which Ihm permit iv issued(Seco 3.9"1.civ.CJ
Lender's Name V Icnde/s Address TOTAL:
FL 1 sonify that 1 have read this application and state[tat[he above,inf9ra[ion is TOTAL: ,P
LA c.rcl.1 agree w comply with all city and cony me manes and aune laws relining m QTY. MECHANICAL PERMIT FEE
U Z bulldingconstrucron,andherchy authorize representatives ofthis city menter uponthe FEE Qabove,mentioned property for inspection purposes. PERMIT ISSUANCE(we)agree to save,indemnity and keep harless the City of Cupertino against IC MEIiabilitiesjudgmets.costs and expenses which may in any way seeme agmen xuid Cip ALTF:k OR ADD'IO MECH. G FEEJAPPL I E -UNI)TIO TANUS AND ILL PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) ICAL FEEAIR HANDLING UNI'T(OVER I41W0 CFM) UCTION TA%Signature of Applica Contractor Date EXHAUST HOOD(W/DUCT)AZARDOUS MATERIALS DISCLOSURE MITIGATION FEE
Wlllthe #[Ecom or furore building wcupant port or handle hueardous mamrial HEATING UNIT(TO I IW,(WO B'IL)
as defined by[be Colm n Mon lipel Code Chaptcr 9.12,and the Health and Salcey
Code,Section 25532(0)^ HEATING UNIT(OVER 100.000 BTU]
[�(Pes ON.
VENTILATION FAN(SINGLE REM.) PAID
Will the applicant or return holding ce,.L rat uso,yuipmat or devices which Date Receipt p
Ianit I does air conmmina.0 as defined by the Bay Area Air Quality Mawgemmut BOILER-COMP(311P OR I RJ W BTU)
District`, TOTAL:
)Y,s 0N BOILER-COMP(OVER 1041](111 BTU)
Ihlrve recall he havrdmrslloulerwls tryuirenmme under Chaptcr 6,95 of'he Cali- AIR CONDITIONER
fomm Berlin&Safely Code,Stoics 25505.25533 and 25534.L understand that if theISSUANC DATE
buildi Jces nmcurtentlyha ten .ralitismymes )n%ibilitytonmifythececupant NEWRESIDENTIALMECH. SQ.FT. /
enfa Ccnifimteof Occupancy. /& V !i 111
Owneloriet r,ndagcm Dam TOTAL: O
. ISSUED BY:
OFFICE /