S 4329 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION APPLICATIONIPF.RMIT PLUMBING-MECHANICAL. S 4329
BUILDING PROJECT IDENT "
IFICATIONt
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'S NAME/1 PHONE: CONT'RACfORS NAME:� QgdKf` LIC NO:
{J�Y� NIC CONTROLM
�..ARCHITECT/ENGINFHR: LOGIC lNO: V ADDRESS: ❑
CONTACT: PHONE: - BUILDING PERMIT INFO
El Fces Paid by Applicant(initial) BLDG ELECT PLUMB MECH
r/M, 329-670L-)
'�.7 0 O
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby arum that I am licensed under previsions of chapter 9(commencing JOB DESCRIPTION
iw4'z with Section 7")of Division 3 ofthe Business and Professions Code,and my license is RESIDENTIAL:
�- in full forte and effect O y PERMIT ISSUANCE
B G7 Y �J ❑SFDWL ❑KITCHEN REMODEL
�UU License Cluss LkaN APPLIANCES-RESIDENTIAL []ADDITION - El PLUMBING RE-PIPE
h Q 47 Date T*SCtaDECLARATION
ARCHITECT-S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z O�Z 1 understand my plans shall be used as public records PANELS ^ MODIFICATION
oz-•C UP TO 2M AMPS ❑INTERIOR ) ❑CHIMNEY REPAIR
P4Hw Licensed Professional 201-1000AMPS IM PROVEME
g,4^-q ❑SWIMMING POOH S
NJ OWNER-BUILDERexempt
ContRAIractor's
OVER IfHp AMPS ATH REMODE RiEPA1R 0DEMOLITION
�CC� I hereby affirm that 1 am exempt from the Cmnmemr's License haw for the
X3 a U following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL HER
W LL LL which requires a Permit to construct,alter,improve,demolish,or rtpair any nmcmrt
�0Q prior in it,issuance,also requires theappiicant for such pennitto file aligned sraremem SPECIAL CIRCUIT/MISC.
re, that her,donmedpursmuu to the pnokior,of the Cmeraemr'x Licenso l,aw(Chapter 9
Q� (commenwng wllh Section 9110119o[Dsvisien9of the Rusincsn and Pmfessinns Gde)nr TEMPMB'1'ERORPOLIII COMMERCIAL•
a d p that Ito is exempt unchain and the basis for the alleged exemption.Any vi Nation of ❑NEW BLDG/ADDITION ❑DEMOLITION
^y Section 7011,1 by any apphism for a permit sabical the applicant la acivit penalty of POWER DEVICES TENANT 01700 SERVICE
^Ezpof more than Eve hundred dollars(SSM). IMPROVEMENT
Cl.mownerman,property,or my employees with wages as theirsoleconaurmadma, SWIMMING I'OOLELECfRIC
will do thework,andrhesrucrosis nm inmededoroffoned fmsule(See 9044,Business ❑OTHER
63 and Professore Code:The Contractor's License Law docs not apply to an owner of OUTLET'S-SWITCHES-FIXTURES
property who hulls,or improves thereon,and who deet.such work himself or through
his own employees,e provided that such i enters sold within thin not iyearof or offered for NEW RESIDENTIAL ELECT# SQ FT.
sale.ILhowevertliebuilthe hurimpmvememisat heidone year improve for
pm- SQ.FT.FLUOR AREA LSQ.FT.
owner-huiWer will have the burden of proving that he did not build or improve for pur-
pose elowne
❑ Lacs owner of the See,7 y,am exclusively convecting with licensed Contravenes
to �� D
consumer the project(Sec.9(141,Rosiness and Professions C(de:)The Cnntmctors Li- ,
cense Law does not apply to an owner of progeny who builds or improves thereon,and QTY. PLUMBING PERMIT FEF, p`
who contracts for such projects with a commcmg)licensed pursuant to the Contractor's JUL - 1999
License Law, PERMIT ISSUANCE
F1 ma exempt under See. ,I3&P C Ito'thlsreason
Owner Date
ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE
I hereby noir.under penalty of perjury one of the following dediou em:
Fl Ihavc and will maintain.Criificnm of Consent to self nsum for Worker's Comped- DRAINS-FLOOR,ROOF,AREA,GOND, STORIES 11 TYPE CONST RUCTION
tion,as presided for by Section 3700of the Lubor Code,for the pedormance of the
1�far which this permit is issued FIXTURES-PER TRAP
1 have and will maintain Workers Compensation Insurance,as inquired by Section
39M of the Lehr Code,for the performance aline work for which this parrot is lsound. GAS-EA.SYSTEM-I INC.4 OUTLETS OCCGROUP AI'N
CarrierMy Worker'S[pamens:tani v2ricn and POicy::Z!Iii-�iy• . GAS-FA.SYSTEM-OVER 4(EA)
�CERTIIICA'I'E OF EXEEMVI'ION FROM WORKERS'
COMPENSATION INSURANCE GREASUINIIUSTRL WASTE INTERCEPTOR
flTissatiun neat nut le conadeors ifthc pemtir is forone hundred dollen(SIM) BUILDING DIVISION ,ES
nr less.) GREASE TRAP PLANCHECK FEE
I certify that in the performance of the work forwhich this permit is issues,I%hall SEWER-SANITARY-STORM EA.200 FE
not employ any person in any manner ss ns to hecomc subjml rt the Workup'Gtmpen- ENERGY FEE
� z cation Lavaof Califomia.Date WATER H EATER WNEN'P/HLECTR
Z 2 Applicata s GRADING FEE
y NOTICE TO APPLICANT:If,after making this Cta iftcam of Exemption,you should WATER SYSTEbVBEAT ING
abecome subject to the Worker's Compensation provisions of the Labor Code,you most SOILS ME
GQ forthwith comply with such previsions or this permit shall he deemed revoked WATER SERVICE
:DZ CONS1'RUCTION LENDING AGENCY NEW RESIDENTIAL PLMI3. SQ.ET. PAID
UO l hereby aRum that lhereiseconxaunion lending agencyforthe perfnnametof Dam Receipt#
E' the work far which this lcnnit is issued(Sec.JM],Co.C.)
Q U Lender's Name I TOTAL:
w Leadina Address L:
1 cenity that I have read this applicmion and stain that the above information is BUILDING FEE
(n correct.l agree to comply with all city and county ordinances and tote laws relating to QTY' MECHANICAL PERMIT FEEe
U Z building construction.and hereby authorize representatives ofthis city to emeruon pthe SEISMIC FEE
r above-mentioned property for inspection purposes. PERMIT ISSUANCE(We)Noreen save,indemnify and keep harmsslethe City of Cupertino moony ELECTRIC FEE
Iiabllitien,judgments,costs and.pensm which may many why nsxmeagninst said City AcrER Olt ADDTOMBCA. PLUMBING FEE
in cnm+cgocn.e of the grunting of this permit. y
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.0010 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION FAX
Sigmatim ul'ApplicanVConwetor Date EXIIAUSTIHOOD(W/DUC'1) HOUSING MITIGAHON FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous nmmrial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532001 HEATING UNIT(OVER I00,000 BTU)
El Ycs El No VEN'HLA' [ON FAN(SINGLE RESID) PAID
Will the applicant on furore building occupant use equipment or devices which Dam Receipt#
mit hazardous air comnminams as defined by the Bay Arta Air Quality Munegement BOILER-COMP(3HP OR I00.000 BTU)
TOTAL:
Distort? TOTAL
❑No BOILER-COME(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chester 6.95 of the Cali- AIR CONDH'[ONE R
9 p ISSUANCE DATE
fomia Healthgdoes&Safety Code,Sestinas 25505.25533 and 25534.1 undersand that upant NEW RESIULNTIAL A1ECFl. SQ.FT.
building does not t It hhaveameantohmoismyvesc`.Cert to notify the occupant
erne mqm ems wmen mon art.issuance eracertir reeracupancy. -
Owner or tponzen agent 12Dme TOTAL'' ISSUED R�
OFFICE