S 4464 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 4464
BUILDING PROJECTNTI
IDEFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
1-17,751- N11 L-r-el (L, 72- CUPterl NO I epr giblot6
OWN R' NAMC: /r PHON COM'RACTOR'S NAME: LIC NO:
1If�.���a 10 N/C COMROLp
ARCHITECT/ENGINEER: �JICT7 la LIC NO,:a� J ADDRESS: El
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT - PLUMB MECH
0 ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
wish sh Section 7WO)of Division 3 of NC Busines,lnd Pndasiom Code,and,.,license is RESIDENTIAL
010 nfull favored ell'ece PERMIT ISSUANCE ❑SFDWL El KITCHEN REMODEL
t_Z U License Class ' Lic.a
6� Dom Contractor APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
Dy ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
Z O 1 understand my plans shall be used i s public records PANELS MODIFICATION
OZ � UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH REMODEL/REPAIR DEMOLITION
tY Q 1 hereby officer that 1 am exempt from the Contractor's License Law for the
Ly following m...to.(Section 7031.5,Business and Professions Cede:Any city or county SIGNS ELECTRICAL ❑OTHER
a W which requires a permit to construct,alter,improve,demolish,or repair any structure I� C
00-1 priorm its iasumee,alsn requireannamplicant far such pemiinn file.signed atatemeal SPECIAL CIRCUIT/MISC. �Je�r-
y that he is licensed pumuunRo the provisions of the Contractors License Law(Chapter 9
W CC (commencing with Section 7")df Division 3 oftlie Business add Professions Cade)or TEMP.METI?R OR POLE INST COMMERCIAL:
6 c e' that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
{r•
Scene.7031.5 lomy mplicam to,.lommitsuhjec¢the mplicannaa civil pe..It,.f POWER DEVICES
M'tn ❑TENANT ❑FOOD SERVICE
nu mom than five hundred toilers y employees
F Z N IMPROVEMENT
�6 wiLo the vorofthethemradm myempbyeeswlthwages al forrlt,(Se .ale 044,Buinen. SWIMMING POOLELECTRIC
wiland Probe wons end a 'Me aura roma i License Law does not
apply to
an Business ❑OTHER
W�� and Professions ills or imp Commerso License Law does not apply to if owner of OUTLUTS-SWITCHES-FI URPS ,
property who builds or improves thsuch i and who dtcs such work himself or through
his own however.
the provided that such improvements are not ionated m offered for NEW RP.SIDCNTIA SQ FT.
sole.IL however,the builAingmimpmvanem is sold wiNin nn<year of cnmPlctinn.the SQ.FT.FLOOR AREA LSQ.FT.
caner-builder will huve the burden of Proving that he did nm Wild or improve for pur-
pose of sale.). '
❑ 1,as owner of the property,um exclusively contracting with licensed contractors to TOTAL'
construct Ne project(Sec.7044,Business and Professions Code:)The Cmtmemr's Li-
se Law does not apply to an owner of propmy who builds or improves thereon,and QTY.. PLUMBING PERM FEE
who contracts for such projects with a commands)licensed pursuant o the Contractors
License Law ISSUANCE
am exNn
der So. ,B&PC fouhi rte
sort ALTER-DRAIN&VENT-WATER(FA) VAL N
WORKER'S M ENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perjury one of the following declamdons:
❑ I have and will maintain a Certificate of Canute to self-insure for Workers Cooper- DRAINS-FLOOR,ROOF.AREA,COND.
cation,as provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issam. FIXTURES-PER TRAP
❑ 1 have end will maintain Workers Compaesmion Insurance,as required by Section
3700ofthe[,,be,Code,for the performance of the work farwhich this permit is issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance committed Policy number art:
Carter: Policy No.: GAS-HA.SYSTEM-OVER 4(EA)
CER'HFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEIINDUSTRL WASTE INTERCEPTOR
('Phis section need not hemmplemd ifthe permit is fonmc hundred toilets(EI00) ` BUIL 1 (VISION FEES
or less) GREASE TRAP PLANCHECK FEE
(certify the performance ofthe work for hichhhi inartatisisseedjohall Sh?WER-SANITARY-STORM EA,203 IT. �(]
not employ an pe on in any manner so e!1 17 AQP n the Workers'Compen- Y .7
O .,.G
ia.Dae VI WATER HEATER WNr:NT/BLECTR
AQTI
PPliuent V GRADING FEE
ICE TOA Atop If,.f«t m is nif¢ete of Exemption,you should WATER SYSTEMITREATING SOILS FEE
Mcome subject to the Worker's Compensation provisions of the Labor Code,you must
4TJ forthwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
.0.U. z CONSTRUCTION LENOING AGENCY NEW RFSIDEN'HAL PLMB. SQ.Ff. PAID
LJ 0 I hereby aRrm thatpermit
issued(Sec.3097,Cing agency for the perfntmmcc of Dam Rwciptp
t-+ rhe work for which this permit is issued(Sec.71199,Civ.CJ
IL U Lender's OTAL:
LenderAdd.s Address - TOTAL:
I anify that 1 have read this application and atom that the above information is BUILDING FEE _
In correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT h FEE
C.) in building consuuuion,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above-mentioned property for inspection purpreaea. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino agm tot ELECTRIC FEE
Iiabilitiesjudgmems,costs and expenses which may in my way accrue against said City ALTER OR ADD TO MECH.
iacecceofch graining of this parfait. PLUMPING FEE
APP(s' NT UNDERST SND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0.000 CFM)
SOI 'RF.GUTATION MECHANICAL FEE
/� AIRHANDLINGUNI'I'(OVER 14W0CF1,) CONSTRUCTION TAX
Sib entre ofAloplicm K7.wctur Dae EXHAUST HOOD(W/DIfCq HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Wilimeapplicantorfar.building occupant smrem handle h....dom material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety or
Code.Section 25532(e)9 HEATING UNIT(OVER 100.(100 BTU)
❑Yea ON.
VENTILATION FAN(SINGLC US ID) PAID Will the applicant or future building occupant use equipment or devices which Dao wciph p
. emithazarddua air cameramn,.,defined by the Bay Area Air Quality Management BOILER-COMP(3HPOR 100,0000TU)
District? TOTAL:
❑Yes F-1 No BOILER-COMP(OVER 101,050 BTU)
I have read rhe himallous dm enals res oirementr under Chapter 6.95 of rhe Cali- AIR CONDITIONER ISSUANCE DAT13
forma health&Safety Code,Sections 2.550.5,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
building does notemnally have a tenant,that it is my responsibility as notify the owul a d
of hbe ror,mmments which most Ica mu prier m issuance of a CenlOcao of Occupancy.
Owner or authorized agent Data TOTAL: ISSUEDBY:
OFFICE