S 4319APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING -ELECTRICAL
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING -MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
S 4319
dU1LDING ADD :
8o5Q �vU,)Wd �°v t414o ct ilt4
O NOF$',S NAtrJE: \ 1 1 ' �iONF.� CONT ACTOR'S NAME: LIC HIT
NN Y J 4* hJy`
SANITARY NO.
APPLICATION SUBMITTAL DALE
23-9j
NIC
❑
CONTROL#
ARCHITECT/ENGINEER: LICNO:
ADDRESS:
CONTACT
J1��_V
TVJK
PxDNE:
o(„ L �(
qS
❑ Con3ultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
f� ❑ ❑ ❑
LICENSED CONnsed under provisions DECLARATION
I hereby (farm Nm 1 a3t R,neBi ander ndPoof chapter 9 (commencing
Zwith ilfor nm00ffechof Division.3 afNe Business and Professions Code, and my license is
in PoII tome and effect.
U License Class Lica
WM Date Co nsider
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
,PIAL
RRNIIIAN __ _
CSFDWL ❑KITCHEN REMODEL
❑ADDITION ❑PLUMBING REPIPEN
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
C1 INTERIOR C CHIMNEY REPAIR
IMPROVEMENT CDEMOLSWIMMING
TIONPOOLS
El BATH REMODELREPAIR � DEMOLITION
❑OTHER
PERMIT ISSUANCE
APPLIANCES—RESIDENTIAL
ARCHITECT'S DECLARATION
Z I understand my plans shall be used as public records
PANELS
UP T02W AMPS
L¢enud Pmfessoaal
..t
„I OWNER -BUILDER DECLARATION
Q 1 hereby efllrtn that 1 am exempt from the Contractors License Law for the
U following reason. (Section 70315, Business and Professions Cole: Any city or count
F' which rc y
y quints a permit m wnswet, alter, improve, demolish, or repair, any strvdure
Prior to its issuance, also requires theapplicenl for such Permit o file a signed statement
ONat be is licensed Pursuant to the provisions of the Contractors License Law (Chip,
(commencing with Section 7003) of Division 3 oftae Business and Professions Code) or
e that he is exempt therefrom and he basis for the alleged exemption. Any violation of
Section ]031.5 by any applicant for a permit subjects the applicant to a civil penalty of
m
y no than five hundred shot... ($500).
woe, of the propertgm my employ¢es with wages nstheir.ale compensation,
e will do the work, and the structure is not intended or offered far sale (See, Business
eo and Professions Code: The Contractor's Laverne Law dues not apply tv an owner of
.. Property who builds or improve, thereon, and who does such work himself m ouri
his own employees, provided tam such improvements are not manded or offered for
tdid.If. however thebtildiog or imprnvememissold within meyearofcompletion,the te
r -builder will have lbe berdcn of proving that he did not build ur improve for Pur-
puse of wle.).
❑ 1, as owner of Ne property, am exclusively contracting with IicereeA wntmctors on
constmct the projml (See . 9!144. Basins.,, and Professions Code) TTe Contraemrs Li-
denseLaw does not apply toanowner ofproperty who build,or improves thereon,and
who contracts for such peaces with a contraction(s) licensed Pursuant to the Contractor's
License Lew,
P
❑ 1 am execat un a e. _ , B & P C f phis eason
i� i
201-10010 AMPS
OVER 1000 AMPS �
SIGNS ELECTRICAL
SPECIAL CIRCUIT/MISC.
'TEMP. METER OR POLE ]NST
AL
C NEW BLDG/ADDITION El DEMOLITION
❑TENANT L]Ji SERVICE
OTHE
POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS — SWITCHES — FIXTURES
NEW RESIDENTfALELECTR SQ Er.
1`
E/SQ FT
Py------------.
TOTAL
QTY, PLUMBING PERMITFEE
-
PERMIT ISSUANCE
ALTER — DRAIN & VENT —WATER (EA)
D
WORKER'S OMPENSATIONDEL ARATION
the byodirm under penal[ f
❑ ]have and will maintain u Cettlbcaleof 0on,em on �alf--Insu a ing declarations
r fm Warker's Compen-
satim. as provided for by Section 37W of the Labor Code, for the Performance of the
work fr andM1ill,omeriis issued
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section37M of the LobarCode, fm the performance oflee work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Policy Nu:
OF EXEMPTION FROM WORKERSCOMPENSATION INSURANCE
(This section toed not bo complemd ifthe pmol is Como¢ hundred dollars (S W)
or less)
1 certify that in the walk subject theperW rkersuCompm1i
pnyaricanceo as
nnl employ any penoo in any manner so as es become subject m the Workers' Compen-
Nation Laws of California, Dole1 Appliconl I
BACK FLOW PROTECT. DEVICE
VALUATION
DRAINS— FLOOR, ROOF, AREA, COND.
ISTORIE
TYPE CONSTRUCTION
FIXTURES—PER TRAP
GAS—EA. SYSTEM -I INC. 4 OUTLETS
GAS—EA. SYSTEM-OVER4(EA)
UP��ogpN,Carrier:
f<CERTIFICATE.
GREASEIINDUS'TRL WASTE INTERCEPTOR
GREASE TRAP
. BURRING DIVISION FEES
PLANCHECK FEE
SEWER—SANITARY—STORM EA, 200 FC
ENERGY FEE
WATER HEATER WNENT/ELECI'R
NOTICE TO APPLICANT If, after making this Cen imine of Exemption, you should
become subject to the Worker's Compensation prnv siom of the labor Code, you must
forthwith comply with such provisions or this Pcomt,vholl be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Nat there is a cnnstrvction lendingagency for the performance of
the work for which his Permit is issued (Sec. 3W7, Co. C.)
Lender's Name
Lender's Address
and state that the above information o
1 certify that 1 have read thirty an county
correct Iagreeto comply with allby cityand rountyotaiives of and entre la ntr.pangm
of this city mercerupon the
almsngconsteed property
above-( eiagreproperty for emnifyianpurposes.
inspection If
(We) agree e, ewe, indemnify and keep harmless two City of Cupertino against
liabilities,judgments,coF the wl., exIne, Feraich cony in any way acme against said City
of Nis permit.
' nICANTe UNDERSTANDS
tnPPLICANT UNDERST DS AND WILL COMPLY WITH LL NON -POINT
SO CE REGUh '10 `
C
Signal o pp c v n icon, Due
HAZARDOUS MATERIALS DISCLOSU E
illthe applitem., hmre building oceapaetsmreor handle h.milmsmmmim
re defined by the Cupnim Mookipl Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(x)?HEATING
C Yea
Will the applicant or favor, building occupant use emo menr or mesio,, which
emit hazardous air commitments as defined by the Bay Area Air Quality Management
District?
E] Yes
Ihave read the hazardous materials requirements under Chapter 6.95 of the Cali-
fcmia Health & Safety Code, Sections 25505, 25533 and 25534. 1 understand Not if the
Vldgqj�,�,,A�Im, tl haveate nbth itismy rcsponslbility nnolifyt eoccupamNEW
h be pn ceofu nif- of cyam
WATER SYSTEM/IREATING
GRADING FEE
WATER SERVICE
t#
NEW RESIDENTIAL FUND. SQ. FT.
TOTAL:
TOTAL:
r
UEE
QTY MECHANICAL PERMIT FEE
PERMIT ISSUANCE
ALTERORADDTOMECIL
AIR HANDLING UNIT (TO 18000 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,001 CFM)
EXHAUST IIODD(W/DUCT)
HEATING UNIT (TO 100,011(1 BTU)
UNIT (OVER 100,0010 ETU)
CONSTRUCTION TAX
HOUSING MITIGATION FEE
PAID _
Dale Receipt a
VENTILATION FAN (SINGLE REBID)
BOILER— COME p3HP OR 100,IXID BTU)
O
BOILER —COMP (OVER 100,000 BTU)
AIR CONDITIONER
^ ISSUANCE DATE
��h
BY:
RESIDENTIAL MECH. SQ. Pf.
TOTAL: ISSUED
OFFICE