S 4492 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. S 4492
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY IS APPLICATION SUBMITTAL OATS
.I OWNER'SNAME: PH(lN.: CONTRACTOR'S NAME'. LIC NO:
_ N/C CONTROL#
ARCHIT CT/ GINE LICNO: ADDRESS: ❑
CONTACT. PHONE:
.BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRd under
DECLARATION ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under previsions on Chapter 9 my license i
�pZ with Section7000)of Divlsion3oftheBusinass and Professions Cada,and my license is �Y LOB DESCRIPTION
PERMIT ISSUANCE RF ID NT'IA
Fa Iy in full force and effect
U License Class Lie.# ❑SFDWL ❑KITCHEN REMODEL
d V
Hoa Dae Contractor APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
'Z0 Z I understand my plans shall be used as public records PANE MODIFICATION
O Z
—M UP TO 200 AMPS
F uy. ❑
W Licensed Professional INTERIOR ❑CHIMNEY REPAIR
201-1000AMPS IMPROVEMENT SWIMMING POOLS
^y' OWNER-BUILDER DECLARATION
c�' I hereby affirm that 1 am exempt from the Contractor's License Law for the OVER 1000 AMPS ❑BATH REMODEVREPAIR DEMOLITION
W 3 W-, following reason.(Section)031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
F which requires a permit m mnswct,alter,improve,demolish,or repair any structure
�y0 prior to its Issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
} that he is licensed pursuant to the provisions of the Co eracmr'a License Law(Chapter9
WigO (commencing with Section 0000)of Division 3 of the Business and Pmfesaiona Code)or TEMP.METER OR POLE INST.
that he is exempt therefrom and the basis for the alleged exemption.Any violation of NEW BLDG/ADDITION ❑DEMOLITION
titCl 4y Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of POWER DEVICES TENANT ❑FOOD SERVICE
Qnet more than five hundred dollars(5500). IMPROVEMENT
01,as owner ofthepropertor my employees with wages as their agile compensation, SWIMMING POOL ELECTRIC
will do the work,and the stmemre is not intended or oBcred for sale(Sce.7044,Business ❑OTHER
3 m and Professions Code:The Commuters License Law dres not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided 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 ofcompletion,the 1� PT. R A FT.
ownecTuilder will have the burden of proving that he did not build or improve for pur- U
me.).
s,as owner of the property,am exclusively contracting with licensed contractors to QA'd J U L 1 9 egg
construct the project(Sec.7044,Business and Professions Coda)The Contractor's Li-
cense Law does not apply to an owner of progeny who builds or Improves thereon,and QTy, - PLUMBING PERMIT FEE
who contracts for such projects with a contratm(s)licensed pursuant to the Contractor's '
License Law. PERMIT ISSUANCE �# p5,r
empunder Sea�aA ,B&PCfo thisr nsn of
ALTER-DRAIN&VENT-WATER(EA)
r
Data VALUATION
F WO KERS COMPENSATION MCLARATION BACK FLOW PROTECT DEVICE
Ihereby affirm under penalty of perjury one of the fallowing declarations:
G ❑ I have and will maintain a Certificate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
satian,as provided for by Section 37M of the Labor Cede,for the performance of ma STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
37M ofthe Labor Code.for the performance of the work for which this permit is issued. GAS-G.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Worker's Compensation losumrc
nco carrier and Policy number a '
Cancer: Policy No.: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASE/INDUSTRL WASTE INTERCEPTER _ BUILDING DIVISION fEQ9
(This section need not be completal if the permit is forone hundred dollars IS I W) GREASE TRAP
caries,.)
PLANCHECK PBR
Loy any thminthe perfieranymannce rof the work for&objectch to the nit is Worker,ued,
pact- SEWER-SANITARY-STORM EA.200 FT.
net employ any person in any manner so as to become subjecna the Workers'Compact- ENERGY FEE
O � satian Lawso[California.Data WATER HEATER W/VENT/ELECTR
Applicant GRADING FEE
h NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTEMCREATING
a ? become subject to the Workers Compensation previsions of the Labor Code,you must SOILS FEE
gyp]
forthwith comply with such previsions or permit shall be deemed revoked. WATER SERVICE
'az CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL TEAM SQ,FT. PAID
U. k farIyatBthi thatpermit
issued Sir.construction( lending agency[Babe performance of Data Receipt#
� [~# the work for which this permit is issued(Sec.31n7,Civ.CJ
O V Lender's Name TOTAL:
W Under'a Address TOTAL:
1 citify that I have read this application and score that the above infom.ation is -. BUILDING FEE
Val correct.i agree to camply with all city and county ordinances and state lows relating to QTY MECHANICAL PERMIT FEE
C.>�
building ro and hereby auttionm M)%e representatives of this city to enter upon the SEISMIC FRE
aMrve-mentionedpropene for inspection keep es' PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the Clry of Cupenlno against ELECTRIC FEE
Ilabilities,judgments..,amid expenses which may in any way acenefoalnstsaid City ALTER OR ADD TO MICH. C
an onsegoence of the grunting eB this permit. PLUMBING FEE V
APPLICANT UNDERSTANDS AND WILL COM .Y WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
S URCE REGULATIONS. - MECHANICAL FEE
AIR HANDLING UNIT(OVER I0,000 CPM) CONSTRUCTION TAX
i6 urea "T"i of tar t )alif EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PRR
HAZA OUS MATERIALS DISCI RE -
Will theappliwntor wre building eccupantamreor handle hazardous mawial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino unicipal Cade,Chapter 9.12,and the Health and Safely
Code,Section 25532(a)? HEATING UNIT(OVER 100,0OD BTU)
❑Yes XNo VENTILATION FAN(SINGLE RESID) PAID --
Will the applicant m future building occupant use equipment or Date Receipt#devices which BOILER-COMP DHP OR 100,WO BTU)
emit haeanlous air contaminants as define)by the Bay Area Air Quality Management TOTAL:
Diatrict7
E-]Yes BOILER-COME(OVER 100.000 BTU)
�o
V
1 have re$f the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISIUANCE DATE/
Boris Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
building doesnUtcurrentlyhaveammafthat it is mere O'lity m notify the recupant
of a reconversion which must be an 'or to i'.. ofn enificateof Occu cy
wor
Erj or authorited as ate I TOTAL: ISSUED BY:
IF OFFICE