S 4417 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF cuPF;RTINO BUILCTR
DING-ELECTRICAL PERMIT NO,
HUII.DTNODI VIS ION APPLICATIONMERMIT PLUMBING-MECHANICAL S 4417
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
Por
OWN 'SN E: 111�1111 PHO CON/TB,ACLUR'S ME'. NO:
c L L � t r b c(f 7 NIC CONTROL M
RCHITECT/FIJGINIiF.R: t LIC NO: tr ADDµF�S(lll..��� H9 4fee,4 7 Cry ❑
'RWNTACT: PHONE: S/Z-4 BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Mr;CH�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE Ir+Nn/ •IIWrJ� Ltl rLfil/
1 hereby allirm that I am licensed under provisions of Chapter 9(,...act., JOB DESCRIPTION
F�d'Z with Section 700hmfDivisio Sof the Businessandi'micsions Cakandmy licenu is ��
SB in full force arW effect. PERMIT ISSUANCE RESIDENTIAL' Id'RITCHEN REMODEL
aUV License ac _ Lice 7276 0 D 3d ❑SFDWL
hGa )me Comracmr APPhIANCES-RESIDENTIAL 0ADDITION El PLUMBING RE-PIPE
RC I •CTS . LARATION PANELS ❑MULTI-UNIT 0STRUCTURAL
zo-z 1 .r anmy Ions be use herecords MODIFICALION
��
OZ—L. Up 1000 AMPS &KNTER1OR ❑CHIMN YREPAIR
[F�F"4: Li n. fessinn ~ 2014000AMPS I OVEMENT
ayyf� OWNER-BU .DER DECLARATION ❑SWIMMING POOLS
—y C W Q 1 hereby affirm that 1 um exempt from me Cwuanors License Lew for the OVER I(100AMPS ATH REMOD f/R PA 0 -M BION
x 3 a F following reamn.(Semon]031.5,Business and Professions Calc:Any city m rountySIGNS ELECTRICAL ❑OTHER
LLl 4-,A which requires a permit m construct,aItee Infamy,demolish,or repair any urucwre S
I']LL�q prior to its issuance,also requires the applicant for,such Permit o file a signed statementSPECIAL CIRCUIT/MISC.
S "y— per he is licensed pursuant o the provisions of the Contractor's License Law(Chapter 9 9/1 e
W c (aimmaneingwitb Scellon7n(N))of Divixio113orthcllusinesnund Vndnsinnx CrdeJ or 'If MR.METEROR I + S'T. 'yQ�'�+.0
d k e C that he is exempt tMrclinm and the basis for the alleged exemption.Any violation of (_1 NEW BLDG/ADDITION C1 DEMOLITION
W=w Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more than five hundred dollars($500).
❑TENANT ❑FOODSERVICE
Fr_� ❑I,as owner of the propertt or my employees with wages as their sale compensation. SWIMMING POOL ELE IC IMPROVEMENT
L is do the work,and the strucwre is not intended or offered for sale lSs.]Bat.Business ❑OTHER
63 m end Pro esion,Code:The Commerce,License law does not apply to an owner of 0l1TLLTS-SWITCH' -I�Xr ES /
property who build,or improves thereon,and who does such work formed or through
his own employees,provided Not such improvcn cnu are not intended or offered for NEW RESIDENTIAL ELECT FT
sale It,bnwcvcq the buildin,onmproventenl it cold within oncycarofaoniplrtion.the ri
R AR A t I $ISQ.PT.
�cr-builder will have the burden ofproving that he did not build Or improve for pur-
seofsale.). p/,1,a,Ownerofthe pmpeny,amexclusivelyttmumaing with licensW cnntmaors m A 1999
consumer the project(Sec.]Bum.Buxmc,s and Professions Code:)The eonnacmrs Li-
nsclawdoesnotapplymanownerofpropcnywbobuildsorimpmvesmereon.and QTY, PLUMBING PERMIT FEE•
who coutmns for such pn)jccts with a conuanot(s)licensed pursuant m the Contractors
Licence Law.
F-1 PERMIT ISSUANCE '�lam exempt under See. ,N&PClpYim this reason
AITIiR-DRAIN&VENT-WATER(EA, By
Owner Date VALUATION /}�J
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LSO OO s�V
140 1 hereby affirm under penalty mperjury one of the following declaration: ;z
I have orad will maintain a Certificate of Consrom at off-insure for Workers Coni DRAINS-FLUOR.ROOF AREA.COND,provided far by Section 37W of the UNIT Code,for me performance of me STORK TYPE CONSTRUCTION
work n
for which this per mit is issued. 0 FIXTURES-PER*MAP �
[:]I have and will maintain Workers Compensation Insurance,as required by Section
00
3700 of the labor Cate.for the performance of the work for which this perntit is issued. GAS-EA.SYSTEM-1 INC.d OUTLETS OCC GROUP APN
My Work Q9 syp!ao In carrier and Polity nM G
Carrier: �79 e.f b 'tureycec Tic Policy No.: f�� / GAS-EA,SYSTEM-OVE i(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be completN if the perntit is foronc humlrml dollam(Slip) BUILDING DIVISION FEES
nrlas,)
GREASETRAP PLANCHECK 1�,
I certify that in mFEE e perfennance mm,work In which this pe.if is issued,I tha11 SEWER- ;6 v
net employ any person in any manner so as tit become subject e subjeco the Worker+'Camper- SANITARY-STORM EA.200 Fr. ENERGY FEE
2'
at I Laws of Cal,lona,War
z O APPlicam WAI'13R IIEATER W/VENT/ELECTR GRADING FEE
rjy
NOTICE 10 APPLICANT':If,after making this Cent icate of Exemption,you should WATER SYSTEMOREAd INC
become subject to the Worker's Compensation provisions of the Labor Code,you most SOILS FEE
forthwith comply with such revisions or this femur shallh deemed revoked. WATER SERVICE
.�- 2 CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Fr. PAID
V 0 l hereby affair that there is a construction lending agency for the pedarance of Date R...in,Is
4. P the work for which this Permit is ismed(Sec.3197,Civ C.)
lender's Name
O V
Lcnd,A Address, "�o
OTAL'.
'� a I certify that 1 have read this application and crate that the aMve information is TOTAL. a h condingcoect.I reemco.plyand with all city ane ceanty ressnoiives Of and late ityit)ws nterupingm QTY. MECHANICAL PERMIT FEE ���Zabovengcoomed proend herfor mathon prrepresenmtives of this cityeienterupon m<aMvemeei agreptupeny fur inspection keepxhouPERMIT ISSUANCE(We)agree throve,indemnify bads,Ne airyof m,amninoadCity tocausem,en. anJex11hrN which may in any way acemeageinn said CityAMHRORADDTOMECIL !,in ai s enhnmng of this iv LAPPLIe DBMS' ND$ N ILL f MPLY WITH ALL NON-POINTAIR HANDLING UNIT'(101n,000CPM)- .EER , E
7_11_G C+ AIR HANDLING UNIT(OVER IO,IXNI CFM) CONSTRUCTION TAX
Sicylim,of Applit VC trap IiXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future building orcupantstorc or handle hazatdon material HEATING UNIT(TO I ounf10 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 255326)i 1IiA'1ING UNIT(OVER 1(0!(X0 BTU)
❑Ye. litho
VENTILATION BAN(SINGLE REMD) PAID
Will the applicant or future building occupant use equipment or devices which Date Receipt M
it hazardous air contaminants as defined by the Bay Arca Air Quality Management BOILER-COMP(3HP OR IUUpO BTU)
nein! TOTAL:
❑Vas `I�No BOILER-COMP(OVF.R 100,000 BTU)
have read the hoe ba,mateda,requimnmn,under Chapter 6.95 of me Cali- AIR CONDITIONER
I'nmiWd�
afely Code,Ssz'on: 550 25533 and 255W 1 understand Not d the ISSUANCE DATE
huilJnentl' tib lh' it my rcxpnn46ilitytonattily the occupant NEW RESIDENTIAL MECl1. SQ.FInlmu wM1i m pet pi r ce ofa Ceprf�ute nf(kxvpuncy ^clim em Dme TOTAL: ISSUED BY.
OFFICE