S 4385 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F.LF.CTRICAL P1?RMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4385
BUILDING PROJECT.IDEN'TIF'ICATION'; .t
BUILDIONO ADDRESS: SANI TARY NO. APPLICATION SUBMITTAL DATE
OWNERE: /1 PHONE: C RACTOIfS ll LIC NO:
y /V`(wNA NUC CONTROL#
IARCUrrEeVENZANEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PGRMIT,INFO
l¢V��� ❑ COn$nitant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICENSED COM'RACfORS DECLARATION QTY ELECTRIC PERMIT _ PEE
I hereby officiation I licered aider yr or Chapter 9<e+mmmen.mg ..t JOB DESCRIPTION
�azO
O_ PERMIT ISSUANCEwith Serum,70111pafD" i 3 rlheproc dP lfin, isCcde.ndmyleameis RESIDENTIAL'
'
�1yy in rens free and effort
�UI"' License Cl.sx Lic.p ❑SPDWL ❑KITCHEN REMODEL
H<W Date C...mcmr APPLIANCES—RLSIDF.NTIAL [ ADDITION ❑PLUMBING RE-PIPE
F,py ARCHI'LECTS DECLARATION PANELS ❑MUI.TUUNIT ❑STRUCTURAL
z O H z I understood my plans shall be used as Public records MODIFICATION
Oz-•Q UP'rO2OOAMPS ❑INTERIOR 1-1 CHIMNEY REPAIR
W Licensed Pr..re"iunul 201-1000AMPS IMPROV'MENT
[4j OWNER-BUILUEk DECLARATION AVER 1(NIO AMPS ❑D EMODEIBEPAIR ODEA OMIT OING N SLS
Q 1 M1ereby affirm that I am exempt from the Contractor's License Law for the
O a F following reason.(Section 7031.5.Business end Prnfesainns Code:Any city or county SIGNS ELECTRICAL. HER i AmrC '
W which requires a permit to construct,alter.imprade,demolish,or repair any structure
FSO poor to in issuance,also requires the applicant for such permit to file a signed smmment hSPECIAL CIRCUITIMI
that he is licensed pursuant to the,mvisionsofth.Com conics License Law(Chapter9
Sy
(commencingwith Seetion70t Dlvirion3oftheliusinessund ProfesniansC.J.)or I HMP.METER OR POI ,IN COMMERCIAL:
�
that he is exempt thcrefimn and If.basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Ir.
Section 7031.5 byuny applicant fora Permitsobjectsthe opplicanno a civil penalty of POWER DEVICES
�`n=Qf am than five hundred dollan(S5W). ❑TENANT ❑FOOD SERVICE
❑Las owner or the prpeny,or my employees with xuges ac their sole compensmian, SWIMMING POOL ELECTRIJ IMPROVEMENT
p, will do rhe work.and the..,am is not imandedmrafRted rnr sde(Sec.7fF14,Business ❑OTHER
6 3 m and Professions Code:The Contrwmr's License Low docs not apply to an owner of OUTLETS—SWITCHES—FIX
TUkH.
property It.Wilds.r im,mves Iharc.n,card who dues such work notwif or tnn'ugh
his own employees,provided that such improvements on,not intended or offered for NEW RESIDENTIAL 11LEC'IR SQ
sale.if,however.the building or improvement is sold within one year ofcampinl.r,the SQ.IT.FLOOR AREA S/SQ.Fp
ter-builder will have the burden of,ruing that he did not build nr improve for pur-
pose of sale.).
❑h as owner of be Property,am exclusively contracting with licensed enmocalms to TOTAL:
construct the project(Sec.0044,Business and Professions Coil The Contractors Li-
ceLowdoe, 1 r,p,to anowre,afprpmty svt nuimanr Wpm.,.,thereon.and QTY. PLUMBING PERMIT, mFEE't
who contra's 1'or such projects with u'maactor(s)licensed pursuant o the Conuacc is
License Low. PERMIT ISSUANCE❑lam exam under. ,B&PC fmthism...n
At:[ER—DRAIN&VENT—WATER(EA) VALUATION
00 a
cr \ ORKER'. OMPi A 1 CI,ARATION BACK FLOW PROTECT,DEVICE
I hereby all of under Penalty of Perjury one of the following r Work, a declarations:
In, au m will miinby Section a Certificate 7of Ce sent inLabor C It.for thererforma Camper- DRAINS—FLOOR,ROOF,AREA,GOND '1 IES TYPE CONSTRUCTION
,abort, r provide)for mi Section 39141 of the labor C.Au,for the performance of the !�
work for which this permit is i,raker FIXTURES—PF.N TRAP
I of the
will maintain Workers Compensation Insurance,h required by Section
My .fthelaMe Code.for Insurance came,
and work for which this permit is issued, GAS—EA.SYSTEAi-I INCA OUTLETS OCC GROUP APN zf
My Workers Compensation Insurance confer and Policy number ore: ,
Gurria: Policy Na: CAS—EA.SYSTEM-OVER 4(533)
CEIfTIPICATE OF EXEMPTION FROM WORKERS'
COMP17NSATION INSURANCE GREASOINDUSTRI.WASTE.INTERCEPTOR .BUIL NG DIVISION IT
(Dissection need nor bro,mo feed ifido, .it is formic hundred dollars(51110) GRP.ASETRAP -
or less.) PLANCHECK FEE
Ioys,tpero the perfmmen,so trowork for emica. bl,at to perthe Workers Cmr,pall SEWER—SANITARY—STORM EA.HHI FT.
not employ any person in any manner xn as m become suFjcm m the Workers Compen- ENERGY TEE
Z outran Lowsol'Cold fin.Date
12 Applicant WATER HEATER WIVI?NTELECTk GRADING IEE
NOTICE TO APPLICANT:If,aOat making this Certificate of Exemption,you should WATER SYSTF.M/1'REA'1'ING
a , become subject nm the Workers Compensation previsions of the Labor Cale,yon must SOILS FEE
forthwith comply with,ach provisions mads permit shall W deemed revoked. WATER SERVICE
. U O affirm
ST RUCHON LENDING AGENCY NEW RESIDENTIAL.PLMB. SQ,Fr. PAID
I hereby arm that there ix.,onuracr m lending agency for the Krmrmance of Date. Receipt It
thu work for which this permit is iasueJ(See.3097,Ci¢C.)
O U lander',Nam, 'TOTAL:
r W Lender's Addresc TOTAL:
0. I certify that L have read this application and sate that the also,information is BUILDING FEE
Fm correct.i agree to comply with an city and county ordinances and state lows refining to QTY. MECHANICAL-PERMIT FEE.
'
rz building construction.and hereby authorize representatives at this city to enter upon the SEISMIC TEE �r
above-mentioned pmpeny for inspection purposes. P51t MI'f ISSUANCE(We)ugrca ,,save,indemnify and keep harmless the City(if Cu,crtino ngainst 4LEC1, ?E
Iirbilities,judgments,costs and expenses which may in anyway accme against said Cityin onsequence of the granting of this Permit. AI:I'ER OR ADD TO MECfi. EE
APPLICAN UNDP STANDS AND WILL PLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IB,0O0 C . 1S. LEEE
VE AIR HANDLING UNIT(OVER PITH FM) ION TAX
Sm re ol'Appllctuu/Contoomor Dom EXHAUST'HOOD(W/DUCT) HOUSING TI ONG
HAZARDOUS MATERIALS DISCLOSURE.
Will the applicant or future building occupant store or handle hamNous nmteoal HEATING UNIT(TO 100,000 BTU) Y
as defined by the Cottonton,Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)^ HEATING UNIT(OVER 100,000 BTU)
❑Yes E]No PAID
VIiNTILATION FAN(SINGLE RE51U) me Itcc rpt#
ill tho
Wndous applicantcontaminants
an,fined comfort By Area
Air Qualitnt y
Management
anageus ant ROIIFR—COMP(3HPOR 10O,O0URTU)
emir hazurdoua air a nmminanvs us Jellied by the by the B y Arcm Air Quality Munn gem art
District? TOTAL:
E3 Year Fl No BOILER—COME(OVER 100,000 BTU)
I have re ad the nazandous mmerialx requirements under Chapter 6r95 ufine Cali- AIR CONDITIONER ISSUANCE DATE
famla HeHth&Safety Code,Sedian.,25505,25533 and 25534.1 undemmrid that if the NEW RESIDENTIAL NECK SQ.FT
huilJing does note n0y camnu tit is myre osibisi ty ,,amity the no tpant
of mgwmme wren a,t b, .pd. mi,ana aeertnreeam ntneeahaney.
v
c ager Umc TOTAL l ISSUED BY:
OFFICE