S 4226 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 4226`
C
,.BUILDINGPROJECIIDEVVIFICATION J �'t G v
BUILDING AA DRESS:�� � ��/� �� Caen r-4l � 1 �so q SANITARY NO. APPLICATION SUBMITTAL SUBMITTAL DATE
qqOW ' ' NAME' HONE: CONTRACf,U./F'S_+NAME ^/U/-� ��1 NO �COTR I/
a x ��emer! 3 — Con(t V NIC CON ROI.#
�:RCIIII'liCUENGINEER: LIC NO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
Inn �h e 3,7 y-h3// ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ G1l
LICENSED CONTRACTOR'S DECLARA'T'ION QTY F3LECTRICPGRMIT" FIDE
1 hereby alum mal I am reamed under provisl0ns of chapter 9(commencing JOB DESCRIPTION
WON with Section 11100)of Division 3 ofthe Boutualand , sxioas Coda and my license is RESIDENTIAL:
WOO / PERMIT ISSUANCE
FKUU in aforceClass
and elfect`a�Q / 2 ❑SFOWI. El KITCHEN RF.MODF.I.
V Licence Chrex Lmu
GZV Ai'PLIANCES—R1351DENTIAI. ❑ADDITION ❑PLUMBINGLPIPIT
tiD4 Date,' TSDEC
F>,� ARCHITECT'S DECLARATION PANELS ❑MULTLUNIT [-]STRUCTURAL
� ZOyZ I.��� ppppdmyIplans, IIbo f(9�publicrecptd���/�� ���\ MODIFICATION
O l I"r p � UPT02WAMP5 ❑INTERIOR [I CHIMNEY REPAIR
F. Licensed Professional 201-IW0AMP5 IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDERm Ce RAI Contractor's
OVER INY)AMI'S ❑BATH REMODEIJRI?PAIR ❑DEMOLITION
WC I naso .ffiratgran e e,1 ran exempt from the Contractor',e:Any c Law for the
3 L V following reason.granted t 7031.5 Business and Professions Coda:Any city nrcountyondme SIGNS ELECTRICAL ❑OTHER _
W 0 h which ttyuirtx n permit re conwmct alter,improve,demolish,or repair any statement
Oe poor wits issuance,also require the applicant for each Permit mflea signed smlemem SPECIAL CIRCl11T/MISC.
on
that he is licensed pursuant to the po.,Nismofthe Conmiscom'x License Law lChaffer9
r 00 (commenaing with Sectif70ypnf Division Jnflhe Buxin(,wand Premien.Cale)or TEMP.ME IHR OR POLE INSI'. COMMERCIAL:
p.0.c That he i,exempt therefrom:rod Lha basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
N Section J031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
not more than five Standard dollars($500). [I TENANT [I FOOD SERVICE
=O [11.as owner ofine progeny.or my employees with wages as their sole compensation, SWIMMINGPCOLELECTRIC IMPROVEMENT
F will do the work,and the structure is not intruded or offered fur sale(Spa, Business ❑OTHER
3 and Professions Code:11he Contactor',Licence Law does not apply to an owner of OUTLETS—SWITCHES—FIX'I'U
properly who builds or improves tlrereon,and who does such work himself or through
his own employees,provided that such improvements as not intended or offered for NEW RESIDENTIAL ELECTR FT.
sale If.hnw'ccro the building or improvement is sold withinone year of completion.the SQ.FT.FLOOR AREA VSQ.LE
weer-builder will have the burden of proving that he did nm build or improve for pur-
pose of,a r.),
❑ 1,its owner of the property,en exclusively contracting with I'named enntnnon,to TOTAL:
consumed the project(Sec.70.14,Business and Professions CodcU The Contractor's
c w se ladoes not apply mnmowner of progeny who builds or improves thrown,and Ory.. PLUM3dNG,PERMIT F is
who contracts for such projects with a contmemr(s)licensed pirsoamvo the Contractors - -License Law' PERMIT ISSUANCElam exempt under See. ,B&P C for likoea,on
ALTER—DRAIN&VENT—WATER IEA) AI J
Owner Date
WORKERS COMPENSATION DECLARATION BACK FLOW PROTEGE DEVICE
t hereby iti ire,under penally of Perjury one of the f.11twong declinations
EI I have and will maintain a Certificate of Consent m self-inmrc for Worker,Cnmpen- DRAINS—FLOOR,ROOP,AREA,GOND. STORIES TYI'IiC NS'fkUCfIUN
,alio.,as provided for by Seen..37M of the Labor Code,f r me,permumanev of the
9o k I,,,which thi,permit ix I,mad. FIXTURES—PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
00 of the labor Crile,for the per6rnanccof the work for whichthis permit is issued. GAS—EA.SYSTEM-]INC.40UTMlS OCC.GROUP APN
My WnrA r'.C sari Indy { WP' bcralc
Carrie�asf Anja SYY'1PYP}n)icytN �1 �)rl�y5� ar GAS—EA.SYSTEM-OVER 411:A)
CERTI FICAIH Of ENEM PITON FROM WOR KI7RS'
COMPENSATION INSURANCE; GREASE/INDUST Ill.WASTE Ull ERCEPTOIt # vBUILDING-A,;
Thi.ssection need not hecomplend iftbc permit is favor hundred dollars Short) GREASETRAP or less) PLANCHECKFEE
I certify that in me performance of me work for which this permit is isstad,lshall SEWER-SANITARY-S"rORM EA.300 FT
not employ any person in any manner so a.,m became subject m rhe Workers Camper-
ENERGY FEE
zsunion Laws of California.Da
Q te WATER HRAIhI<WNENTIIi1.13C'1'I<
O Apglieam GRADING PEE
r~A NOTICE TD APPLICAN'D IL after mating his Cetlfieme of Exemption,You should WATER SYSMMG`REATING
become subject to On Workers Corn,amion prawtoc a of the Union Code,Yea must SOILS FEE
forthwith comply with such precoma,or this permilsha116edained revoked. WATER SERVICE
Q
CONSTRUCTION LENOINGACENGY NEW RESIDIiM'IAL PLMII. SQ,FT. PAID
V � Thereby afrtm that lhareisaamstruetien lending agency for the gerformnnoeof � Dare reign#
U. Fhe work for wh)chthis permit is issued(See 3097,Ci,C.)
0 Lenders Name TOTAL:
WLenders Address TOTAL:
I candy that I have read this Implication and state that the above infatuation is BUILDING FEE
PERMI
M
IG correct.I ngrce m amply with ell city unA eunnty ordintmees and state Inwx ralming m QTY. ECHANICAL. T t PkiF.;
V Z building construction,and hereby summim representatives of this city to enmrap,m the Lr SEISMIC FEE
ti above-mentioned noperiy for in,,,Iioa purposes. PERMITISSUANCE s
(We)agree ted save,indemnify and keep hartnles,he City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way aveme against said City ALTER OR A DO TO MECH.
in conwgtenca of the gmali ag of his permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010.0IBCFM)
SOURCE REGULATIONS. /� MECHANICAL FEE
I Y agar - 00 `Z0 AIR HANDLING UNIT(OVER IQ(g)CFM) CONSTRUCTION TAX
Signa/tum of ApplicaatC.ntrdcmr �./� I y� Data EXHAUST FOOD(W/DUCT) HOUSING MITIGATION FEE
HA9ARDOUS MATERIALS DISCLOSURE
Will dla applicant or more building occupant stone or handle heaanlom mammal HEATING UNI'I'(IV)100,000 BTU)
as defined by the Cuperino Municipal Code,Chapter 9.12,and he Health and Safety
Code,Section 25532d)1 HEATING UNIT(OVER 100AR BTU)
❑Yes ❑Nn VENTILATION FAN(SINGLE RF,SID) PAID
J Dam Receipt#
Will applicant building by the Buy Anal Air Quality arnagi mor MOILER—COMP(.3HPOR 100,000 BTU)
mit District
a nuv air tontvnfinnnte rte defined by the Bay Alien Air Quality Mmmgom°est TOTAL
Disvict9
❑Yes E]No BOILER—COM P(OVER 100,OfXIBTU)
1 have read the hazardous tttatenals requiremems under Chapter 6.95 of the Cali- z AIR CONDITIONER D ISSUANCE DATE.
draft Health&Safety Code,Sections 25505,25533 and 25534.1 understand that a do, NEW RESIDENTIAL MECH. SQ.FT.
buildingdow,not currently have o lennnl.Our it is my re,ponsihdity m mnlfy dauu,,apanl 7-
f e ren ant hidr Ibe Ip tors, fe�q'ficate fOccupanc
Burned agent Dam ISSUED BY:
'OFFICE