S 4225 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTIN'O BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4225
BUILDING PROJECT IDENTIFICATION . '
BUILDING ADDRESS: ^ SANITARY NO. APPLICATION SUBMITTAL DATE
R'S'AM :�r-LL PHi F.: CONTRACTOR'S NAME: LIC NO
le-
:
7IYO N/C CONTROLx
ARCHITECT NGINEER. LIC NO: ADDRESS: ❑
CONTACT: PH I
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EL�B�CT//PCOME MECH
❑ C ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONnwz O QTY+ ELECTRIC PERMIT' _ t FEE
I harehy am th
ffirat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
two, with Suction 7000)af Division3of the Business and Professions Cark,rnd my license is
IRESIDENTIAL
FOIn full force and etfxt. PERMIT ISSUANCE
UV license Class Linx ❑SCOWL 11 KITCHEN REMODEL
,P�R Dam Contractor APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RF.-PIPE
b.Orn ARCHITECT'S DECLARATION PANELS L1 MULTI-UNIT ❑STRUCTURAL
Z O�Z 1 understand my plans shall be used as public records MODIFICATION
O Z UP TO 2M)AMPS
W Licensed Professional L1 INTERIOR [I CHIMNEY REPAIR
SS❑
201-1000AMPS IMPROVEMENT (]SWIMMING POOLS OWNER-BUILDERDECLARATION OVER IWO AMPS ❑BATH REMODEUREPAIR El DEMOLITION
pt w 6 1 hereby affirm that 1 am exempt frommthe Contractor',License Law for the
C 4 U following reason.(Section 7031.5.Business and Professions Code.Any city or county SIGNS ELECTRICAL ❑OTHER
which mimics a Permit to construct,alter,improve,demalisb,or repair any structure y-
I"��.Q] prior mhs issuena,also requires the applicant for such permit m rile a signed statement SPECIAL CIRCUIT/MISC. e C
y that he is liceneedpureuam to thatiowsimmifrhe Cotnrannr's License Law(Chapter 9
(commencing with Section 7")ofDifum,3oflheBusinessandProfessionsCode)nr TEMP.METP.RORPOLEINST COMMERCIAL:
F{y o a
that he is exempt Iherefmm and the basis for the alleged exemption.Any violation of ❑NEW G/ADDITION ❑DEMOLITION
Section 7031.5 byway applicant font permit subject,thcap,liat to a civil penalty of POWER DEVICESE T ❑FOOD SERVICE
th
not more an Five hundred dollars($500).
^x�xQ ❑ I,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC CEMENT
(.Q will do the work,and theawmmre is not intended oroffered forsele(See.7044,Business OTHER
3 m and Professions Code:The Camuccon,License Low does not apply to as owner of OUTLETS-SWITCHES-FIXTURES 12 )
property who builds or improves thereon.and who does such work himself or through
his own employees,presided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however,the building or improvement is sold within one year of completion,the SQ.IT FLOOR AREA $/SQ.ET.
I -builder will have the burden of proving that he did not build or improve for pur-
o!vvry T p
of the property,am exclusively conuacnng with IicenseJ conlmemm to
construct me project(Sec 7044,Business and Professions Cod,)The Cionaotors Li-
cerse Law does not apply to an owner of proper who builds or improves thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such pro Pres with a commemrm)lleenned pursuant to the Corrosion a D
License Law. PERMIT ISSUANCE
❑I am exempt fir See LB&P C for Ni.reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) L
®
WORKER:$COMPENSAT DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of pe jar enf the following declamtians:
❑Ihave anJ will mninreina Cenihcatcol'Cumenuo self-insurefor Worker's Cnmpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CO STRUCTtON
sation,as provided for by Section 3700 of the Labor Code,for the Performance of the Y
work for which this permit Is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is issue. GAS-EA.SYSTEM-I INC.4 OUTLETS ------CTC-GROUP APN
My Worker's Compensation Insurance carrier and Policy number aa:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASMNDUSTRL WASTE INTERCEPTOR .BUILDING DIVISION FEES
(Thiesedionneed ant Imothiplawd iftheperion is became hundred dollars(SIM) GREASETRAP
or less) PLANCHECK PfiE
Ioy any that in the any
o thea,t work fur which this the W rkesued,lshot[ SEWER-SANITARY-STORM EA.200 FT.
net employ any Person in any manner so av to become subject m the Workers Cnmpen- ENERGY FEE
O z ppli Laws of Cafibomia Date WATER HEATER W/VENT/ELECTR
z AApplicant GRADING FEE
pt NOTICE TO APPLICANT.IL after making this Candies¢of Exemption,you should WATER SYSTEM/BEATING
a ; Become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
bonM1with comply with such provisions or this forma shall be deemed revoke. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID Date ce tx
V Q work
reby which rm la,that there ice ed Are.i30 leading agency for the performance of
C) the work for which this permit is issued Are.l09],Civ.CJ
U Lenders Name TOTAL'.
GU Lender's Address TOTAL:
a 1 certify that 1 have read this application and state that In,drive information is BUILDING FEE
tr In const.I agree to comply with all city and county ordinances and state laws relatingm .QTY.. - MECHANICAL PERMIT -FEE
building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-menlichoul property for inspection purposes. PERMIT ISSUANCE,
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FEE
In cones ponce of the gmming of this permit.
APPLICA UNDEry ANDS AND\ ILL C MPLY WITH ALL NON-POINT AIR HANDLING UNIT TO Riskin CEM)
SOUR EGULA( MECHANICALFEE
AIR HANDLING UNIT(OVER IO,OMCFM) CONSTRUCTION TAX
�Sigratxfrn of Applicant Cunttaeter to EXHAUST HOOD(WMUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIAI DISCLOSURE
Will the applicant or future building have ant store or handle hmardous random HEATING UNIT RTO I(OOM BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER IW.000 BTU)
❑Yes E]No VENTILATION FAN(SINGLE RESID) PAID .-
Dam Receipt x
Will the applicant commitments
or future a buildingrind by the Be,use equipment my Management
which BOILER-COMP QHP OR 100,000 BTU)
mit hmardous air comaminunu as def neJ by the BArea Air Quality Management TOTAL:
It District?
' ❑Yes L_]No BOILER-COME(OVER 100,(X10 BTU)
I have read the hazardous materials uireme I un der Chapter 6.95 of the Celi- AIR CONDITIONER ISSUANCE ATE
fomla Heahh&Safety C Sections 25 ,25533 and 25534.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.PT,
buihn rk6 not care v tenant alit" y responsibility to notify the occupant -7�-L ,�� Q
ofth ch issuance ofd CeniOcyte Oec C /
Ow audmrcwd agent am 1 TOTAL: ISSUED BY:
OFFICE