S 43490
APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO
BUILDING DIVISION APPLICXI'ION/PERMIT
BUILDING - ELECTRICAL
PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
PERMITNO.
S 4349
HUILDINGADDRESS,
tl U be ou e'
1 4L
SANITARY NO.
APPLICATION .SUBMITTAL DATE
OWNER'S NAME: PHONE,:
CONTRACTOR'S
NAME: LIC NO:
3
N/C
EJL
CONTROL#
nRClll'TIiCI'/'GNEER: LIC NO:
ADDRESS'Q n
ioKh
nn 1'Ii
CO,YTACT: PHONE:
BUILDING PIiRMIT INFO
it, -n
CIA 1J7
ElConsultant
Fecc Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
❑ ❑ Z?"" ❑
LICENSED CON' TRAM OR;S DECLARATION
1 hereby arrnn that 1 ant licensed under provisions of chapter 9 (commencing
QTY
ELIiCTRIC PERMIT
FEE
JOB DESCRIPTION
PERMIT ISSUANCE
with Seclion7")of Division 3 oflhe Breineas and Prefcssions Code. and my license is
in fall(tree :mJ eRllcl. `` `` 6-3
RESIDENTIAL_
❑SFDWL ❑ KITCHEN REMODEL
_
APPLIANCES - RESIDENTIAL.
hicen. CP{{sa �O Lia#
❑ADDITION (_1 PLUMBING RE -PIPE
❑MUI.T1.UNIT [_1 STRUCTURAL.
MODIFICATION
❑INTERIOR C3 CHIMNEY REPAIR
IMPROVEMENT E)SWIMMINGPOOM
Dole � •ia � 1000 Ctnlrn 9s,
ARCHITECT'S DECLARATIO
I undenu al my plans shall Ne used as public records
LANCES
UP 10200 AMPS
Licensed Professlunal
201-HIMAMPS
OWNER -BUILDER in BUILDER DECLARATION
I hereby .Pili .hat I um Betula from the Contra C's Licenser Law roc the
following nustn. f5ecdnn 9onstrcB, ions Cade: Any ety to count,
❑ BATH REMODEVREPAIR [I DEMOLITION
El OTHER
OVFR10g0AMPS
SIGNS ELECTRICAL
dum
ifloms mpr ve. cla any mormre
which requires a permit m asawm, aheq Improve, demolish,
SYFCIALCIRCUIT/MISC.-
_
fie a sq ement
ferment peri' micen.w
prevision
of aw(Ch
mm he is licensed #Section m the previsions of the Contractor's License Law (Chapter 9
that hos liceuurdparmad to
(cat he,, ingwith Section nand a basis kamcl Business andn.Assiea Com) or
that he i.v exempt tberefnnn w.J .he basis ILr nhc nllegW exemption. Any violation of
Section 70316 by any applicant for a peril subjects the applicant o a civil pearly of
'(CMR METER OR POLE INST.
COMMBRCIAL'
[I NEW dLDGIADDITION ❑ DEMOLITION
[]TENANT [I FOOD S17RVICE
POWERDEVICES
not mom than five hundred doll ors (5500).
Laz owner of me proton)t or my employas wire wages as their sole compensation.
will cit me work, and meswnurt is not intended oruRered fo... [a(Sm.'/0D. Business
and Professions Code: The Contmetor's Licensee Law deers not apply to an owner of
IMPROVEMENT
0 ER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES - FIXTURES
NEW RESID17N'HAL ELF.CTR SQ FI'.
property who hudd, m impaves therem. and who doessuch work himself or through
his own employees, provided In., ...h impmvcmems am ool intended or offered for
sale. IL however. the Wildmi improvement iusold within mem,ea,mcompietitn.me
SQ. FI'. FLOOR ARG SISQ. FT.
IIJer will have the burden of paving that he did not build or improve for pur-
I
�,,{e
"2�D, 'µ°'1'
Ow`uv t a p pcnY civ IY contracting wire licensed r m
. TOTAL:
I•�--.�,-moi,^
xt 't dive 'report (S 1600 BrIumo and PoIcIlimICIA11,Ih C t car:I'.
,en,, Law day, rust apply movio,ofp pe ly whoharlds or amlptheman,d
1 ,
QTY.
PLUMBING PERMIT
FEE
whocontioncts for sucliprejects aith nn i s) licensedpu. ll th C mat 's
License Law.
❑1mcxemplunder5 B&PCT m m
r`f✓'///
It Iii, �I
I V U IC{�nfA
PERMIT ISSUANCE
R(EA7
)wneriherehyefWrunderpenall
PEINSofIferJD(onemmefdmw
BACK FLOW FROM= DEVICE
following declarations:
CI [have and will mainmin a Certificate of Consent mself--insure for Worker's Compen-
scorn, as provided for by Section 3700 oI the Labor Code, forme Performance of the
DRAINS- FLOOR. ROOF, AR G. COND.
TORIES TYPE CC1i7STfUCTION
work for which his peril is issued
FIXTURES - PER TRAP
1 have and will maintain Workers Cnmpcnanir Insurance, as required by Section
3700 of Im Lubar Code. for the perforaeccothe work for which Ihis permit is issued.
OCC, GROUP AI`N
GAS - EA. SYS TFM- I INC.4 OU'I I -FTS
My Worker. Compensation Insurance carrier and Policy number am:
Carrier. Policy bbu:
GAS - G. SYSTFhf-OVER 4 (!A)
GRf:ASFIINDUSTRL WASTE INTERCEPTOR
CERTIFICNIT OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
BUILDING DIVISION FEES
(Thkssection mard, the monFeleddihe pernis Europe hundred dollars C$HXb
uv les„)
GREASE TRAP
PLANCHECK PEE
I certify that in the perionunceofthe work forwhich this peril is issued l shall
not employ any person in any tanner so as m uo bccomc subject the Workers' Consists -ENERGY
SEWER - SANITARY - STORM HA. 200 F,
PCG
WATER HEATER WNEM'/ELF.CTR
GRADING FCC
SOILS FEE
cairn LuwCay)nmia. Dalt
Applicant !!'' —r+z—tet /
r—
NOTICF. OAPPLICANI`.If, After making this Certificate of Exemi you should
become aanjea b) the Worker's Compensation provisions more Labor Code, you .nu 7
WATER SYSTEM(TREATING
WATER SERVICE
fonhwim comply with such provisions (Ir this peril shall be deoneJ revoked
NEW RESIDENTIAL PLMB. SQ, F -C
CONSTRUCTION LENDING AGENCY
I hereby affix thatthere iv a construction lending agency for the performance of
PAID
Dam °rpt
T 'fAL:
the work for which this turn is issued (Sea 3097. 6v, C.)
Lenders Name
'TA L: 0
Lenders Addov,
BUILDING FEE
1 ccnify that 1 have reud Ihis application and stem mat the .lave information is
correct, l agree to comply x'ith all city and county ordinsincevand sum laws relating to
building emxmteitn, and hereby aumodre representatives of this city to enter upon the
QTY.
MECHANICAL PERMIT
FEE
SEISMIC FEE
PERMIT ISSUANCE
CLECfRIC FEIi
aEo—memomyJ progeny for ialr;ctlon pu poles.
(Wee) agree m s,c, y admear and keep barndcsa the City of Cupertino ugaind
ALTER OR ADD' 10 MECH.PLUMBING
FEE D
Iiabilines,judgmemv.coa. and expenses which may in any way uccme against said City
r
in asequence of me granting of this peril.
AIR HANDLING UNIT (TO 10,000 CFM)
MECHANICAL FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNI'[' (OVER 10.00() CFM)
CONSTRUCTION TAX
[I
�2
Sigamrtaf App'in1Co immor Dale
HAZARDOUS MATERIALS DISCLOSURE
n
EXHAUST HOOD IW/DUCO
HOUSINGMI'I'IGATION FEE
HEATING UNIT (TO [00.000 BTU)
Will the applicant or future building rx.'cupant stem or handle ba>,allous.atcoal
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(.)”
-
HEATING INIT(OVF.R 100,(100 [1 TO)
Yu El No
VI!N'TILATION FAN (SINGLE HCSIU)
PAID Uma Receipt
Will the applicant or future building occupant use equipment or devices which
z most hazardous ter eonmmm.... as Germed by the Bay Amo Air (Jualiry Maagement
BOILER -COMP 3HP OR 100.000 BTU)
AL.
BOILER- COMP (OVER 100.X10 BTU)
DisuiclP
❑Yes 0 N
AI It CONDITIONER
I hove raw me hazardous m:neriul myuimments under Chapter 6.95 m thee Cuf.
Eomia Health & Safety Code. Sections 11505. 25533 and 23534.1 andesmnJ than if the
ISSUANCE DATE
NEW RFSIDP.NI bad. MECH. SQ. FT.
building does not currently have a tenant, mat it is my responsibility to notify dre racupanl
l N ^
of me �quimments which must be ren pdonoirsuara ofa Ctnificaco_ cuPaay."
4 - ���
/
ISSUED BY:
TOTAL,
O tr .unhorse gent Uum
OFFICE