S 4302 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4302
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: S SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAM-. � PHONE: CONTRACTOR'S NAME: LIC NO:
NIC CONTROL#
EN INF,E LIC NO: ADDRESS: r r ❑ Q c0
?T
a 19 /
CONTA : r PHONE: 5 i BUILDING PERMIT INFO
uy. q bq-3313 ❑ Consultant Fella Paid by Applicant(Initial) BLDG ELECTPLUMB MECII
LICENSED CONORAtTOR'S DECLARATION QTy ELECTRIC PERMIT FEE
I hereby affirm that l an licensed under previsions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Section 7000)of Division 3 mfthe Business and Professions Code,and my license is RESIDENTIAL:O —/
LLOPIiRMI'T ISSUANCE ❑$FUWL bGKITC14EN REMODEL
Fon in full(mire#antl effect. ®/
Ut) Lunnom Class Lid.#
I-Zal Date Convector APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
F.,DN ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
ZO'nz I indersmnJmy plans.,hall be temd1mpublienwordx MODIFICATION
OZ—M UP 10 200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
Q4E'W Licensed Professional 201-1010AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION
C Q I hereby#(firm that I am exempt from the Contractors License Law for the OVER 1000 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
X 3 4 F fallowing reason.ISecGon 101 L5.Ilmoee,and Professions Code:Any city mf county SIGNS ELECTRICAL [I Of
GI LL m which acquires a permit to construct, imstructstructurect,alter, prove,demolish.or repair any sere
Is.
prior to its issuance.also requires the applicant fmsuch Permit o file a signed statement SPECIAL CIRCUFMISC.
Iso Q�J that he is licensed pursuant m the provisions of the Contractors License law(Chapter 9
W a�pO (commenciagwith Sewion 7000)of Division lotion Business and Professions CoJe)or TEMP.MEI ER OR POLE INST COMMERCIAL'
Q.Xc y that he is exempt therefrom and the hasis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION [I DEMOLITION
4• Section 703 IS by any applicant for a permit abject the applicant to a civil penalty of POWER DEVICES
m to ❑TENANT ❑FOOD SERVICE
t more Nan five hundred dollars($510). IMPROVEML-NT
Q FII,as owner of the progeny.or my employees with wages as their sole comparmadma. SWIMMI GPOOL ELECTRIC
will do the work,and the sternum is not intended or offered for sale(Sea 7(94,Business ❑OTHER
2 and Professions Code:The Contractor's License Law does not apply to an owner of OUTL - ITCHES-FIXT S
propcny who build.,or improves thereon,and who does such work himself mf through
his own employees,provided that such imprevemen s am not intended or offered for NEW*#9fhliIWL E R
sale.If,however the building or improvement issold within arc,,.,ore miction,thege SQ.FT.FLOOR AREA $/SQ.Pf.
builder will have the burden of proving that he did not build or improve for par. PWd
owner
as uowner
property,theproperty,nm exclusively contracting with licensed contractors to 0 Alcul
TOTAL:
construct the project(Sec.704}Business and Professions Code:)The Contractor's Li- /
cense law does not apply m an owner of pfniteny who builds or improves therron,and Q'rY. PI-No P' PC FEE V 7� a
p
who contracts for such prejecu with a conuacmf(s)licensed pursuant to the Contractor's
License Law. PERMIT ISSUANCE
❑IameaemptanderSm. ,B&PCfor Nisressom
AUPER-DRAIN&VENT'-WATER(HA) VALUATION
cr Cmc
RKER'SCOMPEN TION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of Perjury one of the following dedamtions:
and will maintain a Certificate of Consent o self insure for Workers Compen- DRAINS-FLUOR,ROOF,AREA,CON U,
on.rav provided fin by Section 3]W of the Labor Coda,fin the per ariance of the STORIES TYPE CONSTRUCT]ON
work for which this Permit is issued. FIXI'U RES-PER TRAP I
❑ 1 have and will maintain Worker's Compenwtion Insurance,as required by Section
3700 of the Labor Code far Ne performance of the work for which this permit is issued, GAS-EA.SYSTEM I INC.4 OUTLETS OCC.CROUP APN
My Worker's Comlrensation Insurance tamer and Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA) 4GO �S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREEASMNDUSTRL WASTE INTERCEPTOR
Clfiis cation need not h completed if the pemsit is(Drone hundred dollars(S1O0) GREASE TRAP BUILDING DIVISION FEES'
or l"".) PLANCHF.0 PEE e
Loy any that in Performance nanrofthewmk for which this thePermitis issued,I shall SEWER-SANITARY-STORM EA.2W F.. 2a
not employ any person in any manner so as m become subject m the Workeri Compere ER
zZ sadon Law.,of Cahavaiia.Dan WATER HEATER W/VENTMLECTR
O Applicant A CY
w2i NOTICE licant'U APPLICANT':If,after making this Certificate nl Exemption,you should WATER SYSTEhVi'REATING
a , become subject m the Worker's Compensation previsions of the Labor Code,you must SOI FE
foMwith comply with such previsions or this permit shall M deemed rtvokM. —in XI HI
WATER SERVIC17
0
U0 CONSTRUCTION LF,NDINGAGENCY NEW RES]Il1iN'I'IAL PLM It. PAID
UQ work
rwhich thi that issued(ree 30lenCis.agency for the performance of Dam Receipt
LLQ P the work for which this permit is issued(Sec.Jo9],Civ.C.)
Q U Isndcrs Name TOTAL:
19 Lender's Address T TAL:
1 certify that 1 have read this applicatinn and state Pat the above allsfntaimis h BUILDING FEE
h coned.l agree to comply wish all city and county ordinances and sate law.,belatingto QTY. MECHANICAL PERMIT FEE
U Z building construction.and hereby uwhone,repersenmtives of this city nr enter upon the SEISMIC FEE
above mentioned prefer}for inspection pareses' PERMIT ISSUANCE
(We)agree to save,indemnify and kap harmless the City of Cupertino against ELECTRIC FEE
iabilitics.judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
'�HAZARDOUS AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
ignarureo ppli<aHAZARDO US MATERIALS DISCLOSURE Dare EXIIAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
Will the applicant or future building Co e,Chapter 9.12,
orhandlethe Health and Safety 111?nTING UNI'('p'O 100,M)BTU)
a,defined by the Cupertino Municipal Cade,Chapter 9.12,nnJ the Health and Safety
Cade.Section 255320a0? HEATING UNIT(OVER I00,IX0 BTU)
❑Yes L]No
VENTILATION FAN(SINGLE RESID) PAID
\ Date Radeipt 0
Will the ircapplicant or furore building btheoccupant use equipment or JMana which
�.ous air nmtwrdnan¢a,defined by the Bay Area Air Quality Management BUILIiR-COMP(JHP OR I00.000 BTU)
TO AL:
r]
E3 Ye, FIN. BOILER-COMP(OVER I01.000 BTU(
I have read the hazardous marcrials mirmonme under Chapter 6.95 of the Cali Atli CONDITIONER ISSUANCE DATE
forma Health&Safety Cute,Sections 25505,25533 and 2551.1 undersmml that if the NEW RESIDENTIAL MECH. SQ.PT
building Joe,amt currently have a mown,that it is my responsibility to notify me occupant
Lots uiremene,which must
the er prior m nuance of a Ceniheme of Occupancy.
ti C a "U
el or need agent Dam TOTAL: ISSUED BY: r
OFFICE