S 4313APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CI'T'Y OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING. MECHANICAL,
PERMIT NO.
S 4313
' BUILDING PROJECT IDl2fPIFiCATION
BUIfDINGADDRESS:
SANITARY NO.
API'LICA'TION SUBMITTAL DATE
D
' 229
O ;R'S NA 1E: " seen /{ONE:
i D
CO MORS NAME LIC NO
/ L
NIC
CONTROL #
gMlI
CONI' CT: PHONE
"'BUILDING/PERMIT INFO
/ _ y�rsOo . /'/ ///
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm that I inn licensed under f C.m tai 9 connnennn'
y provisions n p ( g
QTY. El PERMIT - FEE
t � a I.
JO6 DESCRIPTION
with 5«tion](N70)of Division3of we Business and Pvtfnsions Code. end my license is
in lull force and eft y
Liccnsc l.ic.#
Date Comrvcmr
RESIDENTIAL:
0 SFDWL 0 KITCHEN REMODEL
❑ADDITION O PLUMBING RF. -PIPE:
PERMITISSUANCE
APPLIANCES -RESIDENTIAL
A {IT E(. TS DECLARATIO
I understand my plans shall he used as public records
PANELS
CMULTIANIT CSTRUCNRAL
MODIFICATION
UP'1'02WAMPS
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT 0SWIMMING POOLS
O BATH REMODEL/REPAIR 0 DEMOLITION
OTHER
LicenacIn ndession"I
onte ON
OWNER -exempt fr DECLARATION Contractor's
1 hereby affirm that 1 am exempt from the Contoo, Ca License Law for the
Qtde: Any city ni ntumY
following reason. (Semina ]If3 s5,". id
oss and hotness.
which requires a permit 9.requires
e wires me alar. nt for permiuLicenste ae statement
h Permit t ri repair g ed statement
prionoits cense thew
201-II00AMPS
OVER ]"AMPS
SIGNS ELECTRICAL
S!'ECIAf. CINCUII'/MISC.
lie is pursantlo the Can Law (Chapter 9
pursuant rotes positions nt the Conaonnr's ase
TEMP.METI?R OR POLE .NST.
COMMERCIAL:
(cot
(commencing of Disuse
'i (commencing with Scnian]0W)af Divisipn3 of the ltusiness and Professions Cade? or
and Prof
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 9131.5 by any applicam for u permit a dhecle Ilta app. ... it to n civil penalty of
amid,,.than five mndreddollers(SSW).
0 Las owner afthe property, or my employees with wages as their sole compensation,
will do the work, and the structure Nina intended m offered for ode (Sec. 70,f4, Business
❑NEW BLDG/ADDITION 0 DEMOLITION
CTf:NANT L-1 FOOD SERVICE
IMPROVEMENT
0 OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
OIITI.E1'S-SWITCI HS- FIXTURE•
and Professions Cale: lbs Conaicusev License Law does nut apply m an owner of
properly who builds or improves tbercnn, and who does such work himself or Through
that
his own employeese provided that such improvements are oat iyearofc or pll tion, for
re
end ad,Idcthe
Inch indidaernemsent
NEW ItLSIU1iNTIA1.IiLECfR lel'
sale. building is sold one yearofthe
SQ. FT. FLOOR AREA
USQ. FT.
ownerhadder will have the burden of proving that he did not build or improve for par
pose of sale.).
0 1, a owner of the proper, am exclusively contracting with licensed contractors to
TOTAL:
consmmt the prpjc,,.Sen. ]M3, Buomeav and Rofaaonns Code:) The Comma tar's Li.
- I
se law does not apply ton owner ofpropcny, who builds or improves thereon. and
QTY,' PLUMBING PERMIT
who contracts for such projects with a eomractor(s) licensed pursuant in the Contractors
PERMIT ISSUANCEO
Licit c Law.
lmnexentptunder Sea. ,B&PCfimbisreaon
- DRAIN & VET- WATER (EA)
Owner ]saleALTER
VALUATION
WORKERS COMPENSATION DECLARATION
BACK P10W PNOT[CT. DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
999 On.. '✓
DRAINS - FLOOR, ROOF. AREA, COND.
orker'
❑.hove and will maintain Ccnifiame ofComent toLabor some, bre for Workerse, of the
fpr by Section 3](0 of the labor Cade, bathe perfonnence of we
moon, as hich this
work lairwhich thispermit is
STORIES
TYPE CONST RUCTION
PIXTIIRES - PER TRAP
❑ 1 have and will maintain Workers
oras require)n Section
s CsI
3]Wnfwe Ichor Code, for performance of the work for whicyhyC�h[ia perpmit (is�i`ssued
pones w rkfor which i
m s:
My Workers inion dPnlwym
.lpsnranre cTrier an Wte'i('
GAS - EA. SYSTEM -I INCA OUTLETS
OC GROUP
r pp.
J J�
7S-
Carrier. ��S Pnllay Nn: U iG—
CERTIFICATE
CERTIFICATE: OF EXEMPTION FROM WORKERS'
OAS-EA.9VSTBM�OVER4(EA)
COMPENSATION INSURANCE
(This section retract be rontpleted if the permit is forone hunJeed dollars lSl W)
or less.)
GREASEANDUSTRL WASTE INTERCEPTOR
,
NI111,UING III VISION FEES
GREASETRAP
PLANCHECK FEF.
SCW13R-SANITARY-STORM EA. 200 IeL
I cenify that in the ratiocination ofthe work lin which this pemtit is issued, Iahall
not employ any person in any manner so as to become subject to the Workeri Compen.
ENERGY FEE
WATER HF.A'1'EN WNGNT?:LEGIT
scorn Laws or C Dom�y(
Applicant ��lTF2
GRADING PEE
NOTICE TO PI.ICANT: IL after making this Cenifteate of Exemption, you should
hecnme subject m the Workers Compensation provisions of the Labor Cade, you most
WATER SYSTEM?RFFATINQ`,
SOILS FEE
forthwith comply with such provisions or this permit shall be decmeJ revokal.
WATER SERVICE "
CONSTRUCTION LENDING AGENCY
In ... byaffimvhm there is a comarectic n lending agency for the to rmarris ec of
NEW RESIDENTIAL PL S
D
Receipt #
the work far which this pemtit is issued (Sec. 3097, Ci, C.)
TOTAL:
Lender's Nan¢
es ^�
T AL, t�
Lenders Addmss
1 cenify that 1 have read this application and state that the above information is
UILDING
neet.I agree to comply wow an city and otomy ordinances and are lawsreefingm
building ron0runion, and herchy muhariu rep Ida mini ves of this city to enter upon the
Q'I'Y.( tMECHAN Art PERM11fT FEN.
C'f
EISMIC ,
.have mentioned property far inspection purposes.
(We) agree In save, indemnity and keep Famous, the City of Caperton against
PERMIT ISSUANCE
ELECT FEE
ALTER OR ADU"1'O MIfCH'
lemilities,judgmenN, casts and expenses which may in any way wrcni agmast said City
mmsequencc of the graining of this pemtit.
PLUMBING EE
AIR HANDLING UNIT (TO 10,000 CPM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -MINT
SOURCE REGULATIONg.
AIR HANDLING UNIT(OVIiR 10,000 CFM)
CONSTRUCTION' FAX
6_yz,q
SigmI reo1ApplinmVCandcCIm Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEA'L'ING UNG (In I100,000 BTU)
Will iheapp.icant or Nmrebuolding occupant edresrhandlI, haaurdint material
as defined by the Cupertino Municipal Coda Chapter 9.12, and the Health and Safety
Code, Scetian 25532(x)'!
HEAPING UNIT (OVER 100,00p) BTU)
0Yes ON.
Will the me co vm or future building ymeoccupant ase equipment or devices which
nit huanious aircontaminams as Jcfined by Ne Bay Arca Air Quality hlvnvgemcm
Darin?
PAID --
Date Receipt#
VENTILATION FAN (SINGLE RES ID)
BOILER-COMP(3HP OR 100,000 BTU)
T L:
❑Yes - 0No'
BOIL.?R- COMP(OVP,R 100,000B'fU)
AIR CONDITIONER
I have read the hamnlous materials requirements under Chapter 6.95 of the Cal.
p
fomia Heshh &Safety Code, Sections 85(15, 25533 end 85N.1 unJerstand wvt ifthe
building does not cunemlyha th
is a at it is my mponsihility to nobly the ttccupam
ISSUANCE DAIE
0 r —cy
/
NEW RESIDENTIAL MECH. SQ. FT.
ofwcrc taus nisi la norm isaaanwof a Cenllintte pTOcropurn
/OA G�
ISSUED BY.
'O outhmrredagem Dam
TOTAL:
OFFICE