S 4466 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO Bull DINC-ELECTRICAL ERh11T NO.
BUILDING DIVISION APPLICATION/PERMIT PLOMRINC-MECHANICAL. S 4466
BUILDING PROJFJCI'IDENTIFICATION
NUILDING AUURIiSS, SANITARY NO. APPLICATION SUHMII'1'AL[]ATI
OWNER'S NAME: Pf{ONE: CONNIEACTOR'S NAME: LIC NO:
P ,yFAu-gty2`oie.� Z�.S'-32o /1.1,4 -T✓s�s+n.�,$ NIC coN�rRol—lila
ARCHITEC IEI}'c�PEEArl&000sIl LIC NO'.R: AUDI E.9S:)geoq ❑ J 3
CONTACII 1'I LONE: BUILDING PERMIT INFO
/,T_.al 13U�-,Da ❑ Consultant Fe"Paid by Applicant(Initial) B,LLDDG/ ELECT PLUMB MOCCHH
l'//C Y L� IJ lJ LTJ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby armor that I art licensed under pro—item of Chapter v(cmnmencing JOB DESCRIPTION
mZ wxh S,,Ion 7000),1 Ogvision 30 lot lbl,massu^Il Pmu,,icn,Codc,and fly llecnsa is RESIDENTIAL,
WOO PERMIT ISSUANCE
CWF in full func and after,. []SFDWL D KITCHEN REMODEL
QUU license Class Lica APPLIANCES—RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
E-ZW Date Counsel-
nna.W [j MULTI-UNIT OSTRUCTURAL
ARCHITECTS DECLARATION
(,,,�h PANELS MODIFICATION
Z O N Z 1 undersand my plans small M1c used as PUM1Iic records
pZ4Q UP TO 200 AMPS ❑INTERIOR El CHIMNEY REPAIR
F
t:ad Li'vowd Prote"io III 201-1000AMPS IMPROVEMENT []SWIMMING POOLS
�ad V; TOWNER-BUILImiR DECLARAi'[ON (IVIiR 1(NIUAMIM1 []BATH REMODEVRHPAIR ODEMOLITION
C)C G 1 hereby affirm Iha,1 ern exempt from,he Comm.ttfx License Low for the
3 a F following reason.(Section 0031.5.Business and Prnfeaions Code:Any city or county SIGNS ELECTRICAL []OTHER
wa which mond a a perms m conavuct,eller,on,mve,demolish,or mpain any structure
F�OJ ..norm its issmnec,do.agaim„hcapplicant nonsuch pctmiuo fleasignN sidemen. SPECIAL CIRCUTT/MISC.
pN..
that he is licensed pursue^ttothe provisions of me Comrucmr's License Lw(Chapter 9
ACp0 (mmmencing with Section7004p..(Divisinn3of,hc Buxinauvnd PmnmsimtxCtdc)or q'EMP.METER OR POLE INST. COMMERCIAL,
C,cac Iy Iran he is exempt therefrom and the basis for the alleged exemption.Any vitiation of ❑NEW BLDG/ADDITION ❑DEMOLITION
LL Section 7031.5 by any applicant for a per it subject, he applialmo.a nail pa�nahy of POWER DEVICES Ky'pIQANT OFOOD SERVICE.
W y w not..,ban It lammed dollars($5001,
F=QI.as owner of the nsotm tom,with woes as,heir wlc compensation. SWIMMING POOL-ELF IMPROVEMENT
FO [] PmPc 5 Ye^tP Y 6 pensi
will do the work,and the suunure is not intended or offered for ale(Sec.7fs14,Business
i 3 m and Professions Crile:The Cool tnr'x License law does no apPIY m an snvner of OU'CLETS—SWITCII URES
property who builds or improves hereon,and who ares such work nlmalf lit through
In,own amployccs,provided the such Intpro-occons are not occulted tr offered to NIiW RBSIDENf .EI q'R SQ FT.
sale.if,jowcve,,thebuildingnr impnwernam issold within one yam of rote...........the SQ.FT.FLOpN�R1.1999 ESQ.FT
owner-builder will have the human of proving that he did not build or improve for put- JUL 1
Nbw TOT
Py{as owner of the property,oro endwively contracting with licensed commcwts m
ms0ocuhe project(Sea.70,11,11.Baines and Professions Gde:)The Comrucmr's Li-
cause Law does hill apply mmtrwncrofprT,ny who builds or improvesthmcam and QTY, PLUMBING PERMIT FEE n
wnu nmlmed for smh pmjuts who a can Vatlm(,)Iiecowd pursuant no the Counoamr's Y
License I.u, PERMIT ISSUANCE
1 am exempt under ec. _.B&P C for this reason
ALTER—DRAIN&VENT—WATER(EA) VALUATION
Q Dare
ON C,1 C ENSATION DECLARATION ,TACK FLOW PROTECC.DEVICE 5000
IhmcnS dmnn and rpenahy ufperjury one ufthc following Jrclunnions: ttC..JJJ
[] Ibco,and willonniumaCcmificamtrConsent 1—ch-inaua for Worker's C^ntpcn- DRAINS—FLUOR,ROOF.AREA,COND. S'COMES 1 YpE CONST RUCTIOS
smion,is pnwid,d fur by Section 3710 of the Lvb..r Code for he wr onlob a In'he y /�
weak for which this pent.n is iauaJ. FIXTURES—PER TRAP 'Z_ I/
[]I have and will maintain Worker's Compensation Insurance,as require)by Section
3700 of the labor Code,for the Economical,of the work for which this Penni,is issoeJ. GAS—EA.SYSTEM-I INC. OUTLETS OCC.GROUP APN
My Worker's Compensation In-ranee carrier and Policy number are: ,-6 0�
Currier: Policy Nu.: GAS—EA.SYSTEM-OV (EA)
CER'1'IIICA'CH OV EXEMITION FROM WORKERS' GREASFJINDIJS'I'Rh WASTE IiNCEP
COMPENSATION INSURANCE BUILDING DIVISION FEES
7 (bis-mann mcdcat becstntp.mcrliOhepennd is fortune hundred dollars(SIM) GRIEASETRAI'
YLANCHF FEF.
^r less.) O
I verily that in the Wrfomunee of the soorkfor which this permit is issued.l shall SEWER—SANITARY—STORM
net employ any..conn in any mann.rs I as to become subject m the Workers'CmrdDm- ENERG
,Z -tion Laws of Gvlifomia.Dunt WATIiR DEATHS WNENT/ELECTR
Z2 Appllcanl GRAD GFE
= NOTICE TO APPLICANT'.IC at making Nis Ccmillcmc of Caemptire,you should WATER SYSTEM/I'REAIINC
> become sobjcOI bathe Wufkers Cmalen-lmm provisions of,he Lanny Codas You mad
funhwidt cunt,ly is hh Inch novbion,oOld,permit hall her deemed minded. WATER SERVICE
0
a CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL I'1-MB. SQ.F[ PAID pore Race 0
I hereby affinr that hem is aconametlon lcodingagency for the performance of
C.) z
H., F the work for which me,permit ix Issunt(Sec 3097.Clv.C.) TOTAL:
V lander,Name i(YfAL
- U.1 IanJ[rs Address
0. 1 comity that 1 have read this application and sure that the above info motion is BUILDING FEE
.F. OA correct.i agar to comply with all city amt county ordinances and sum laws m.eing m QTY, MECHANICAL PERMIT FEE SEISMIC FEE 6
U building constriction,and hereby authorize representatives of this city to enter open the
abuse mentioned prolmny far I cKma n purposes. PERMIT ISSUANCE ELECTRIC IEE
(We)agree o,save,indmnnlfy and keep hannles,the City of Cupenin,against
Ilvbilitics,juJgmm�ls,cons and expenses which may in any way accrue against said City ALTER OR ADD 11)MECH, PLUMBING FEE
in on-quence of the granting of this permit.
APPLICANC UNDERSTANDS AN ILL COMPLY WITH ALL NON-POINT ALR HANDLING UNITOO MOM CFM) MECHANICALFEE
SOURCE REG IONS.
AIR HANDLING UNIT(OVER 10.(AMICFM) CONSTRUCTION TAX
aevc nt P,if,' mora Ilam EXHAUSTHOODIWA)UCT) HOUSING MITIGATION FEE.
AJ-ARDOUS MAIERIALS DISCLOSURE
Will thea,ficantorfoure building havaent sormo,hanJle haaallous command HEATING UNIT(TO W.000 BTU)
as Jcruma by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safe,,
Cale.Section 25532(x)? HEATING UNIT(OVER H(LOW BTU)
❑Yes VENTILATION CAN(SINGLE RESID) PAID
l 'U
Date Receipt is
Will tire applicant nodding oiror BOILER—C(Ml (311PDR 100.((11Tl
,mil hevnux air cmmnalnsa,Je'mcd brdo,Bay Area Air Quality aanagemant
TOI'Ah:
District❑YeT []� ROILF-R—COME'(OVER 100.000 BTU)
2
I have madthe fluctuations materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fornix Health is Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDESD[AL MECH. SQ.PT.
buildtngdocsnh,umfmly Hoven tem Cd II my r.........obtymno0fythcn¢vpan,
II hoot lmm ''h mast Mr pr' ran eon .ninwmofu"afrory.
O amht 'sail age Uma TOTAL: ISSUE])BY: �
OFFICE