S 4491APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELRCTRICAL
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL S 4491 1
ItUiUn NG PROIRCT IDIrN'FIF'ICAB'ION
LICENSED CONTRACTOR'S DECLARATION
I hereby
affirm that I ant licensed under provisions of Chapter 9 (commencing
X06 with Section 91XXd of Division 3ollhe Busine,,mod i'mfensinnsCode. end mylicenxc is
Fes- O in full force and most.
aUV License Class U1. Is
N Z m mot Contractor
m ca. ARCHITECTS DECLARATION
z op 2 z I understand my plans shall be used as public records
OWNER -BUILDER DECLARATION
I hereby affirm that I tan exempt (corn the Contractor's License Law for the
following rcasvn. (Section 7031.5. Business and Professions Cade: Any city or county
which requites a permit tan construct, alter, improve, demolish, or repair any,ouaure
far... to its i..uunca, also mimics the applicant fnr such permit on li In a signal s,am n set
Brad he is licensed pursuant to the provisions of the Contractors License law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt Ihurchmm and the basis fnr Ilse alleged exemption. Any vmlminn of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
nm more than five hundred dollars Wild).
❑1,usowner of thepropcny, or my employees with wages ax Inchsole noprominu.
will do the work, and the stm me, is not intended oroffered lactate (Sec. 7044. Business
and 1'rnfe..... is Code: The Contractor', License Law does not apply ,, an owner of
,no coy who build, or impmwc, there m, and is does such work himself or thnmgb
his awn employees, provided that such improvements am not intended or offered for
sale. If, however, the building or improvement is sold within one year of compledion, the
own ct-builder will have the horden of proving thal he did tan hadd ter improve fnr pur-
pose aown.
Fl I, as , owner of the Sec. 7(a vin s ad contracting with licensed contractorstor,i-
mshoeltheesnot apply
to an BusinessandrtywhobuvCod,dsor improvesno-uaon, std
wa Taw ctts f not apply to an owner of Pact Is who builds or improves thereon, and
ho contracts for such projects with n contract Is) licensed pursuant m the Commcor',
Liccnsm Law.
filum exempt under Stt. ,B&PClot this rcnson
❑ Consultant Few Paid by Applicant (Initial)
ELECTRIC PERMIT
PERMIT ISSUANCE?
APPLIANCES - RESIDENTIAL
PANELS
UP I0 200 AMPS
SIGNS ELECTRICAL
SPECIAL. CIRCUIT'/MISC.
THMR MCI IR OR POLE'.
POWER DHVICIS
SWIMMING POO ;LEC
OUTLETS-SITCHC``S_-
NHW RE' )1?NI'IAhA
/ ❑ 9s-3<
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
E�r' 0— ❑ ❑
FEE JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION GPLUMBING RE -PIPE
❑MULTLUNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVF_MENT SWIMMING POOLS
❑ BATH REMODEL(REPAIR (] DI:MOI.ITION
❑ OTHER
2
COMMERCIAL:
❑ NEW BLDGIADDITION [D IMMOLATION
❑TENANT El FOOD sPRVICF
IMPROVEMENT
[]OTHER
I OTY. PLUMBING PERMIT I FEE I
r Doc
wn WORKERS COMPENSATION DECLARATION
1 herchy affirm under penalty of perjuryane of the following declvmtions:
I lave and will mnimain a Cenlneme of Canxcnnn,ell'-insure fnr Wnrkc,, Cnntpen-
satine.. as provided for by Section 3900 of the Labor Code, for the performeme of the
work fnr which his permit is issued.
iF7 1 have and will mai main Worker's Connpcnsmion Insurance, us required by Section
3700 off(mree Laabor�PCode.
for the Performance of the wask for which this permit is isucd.
Norrie 11 Lo und, Noc niynp�arg,y` 0 /-
Polk Nu. �/
CERTIFICATIi OF EXEMPTION FROM WORK17RS'
COMPENSATION INSURANCE
IThiuueion need not be completed if the pemnil is Intone hundred do11.,151101
odes'.)
I cenify that in the vinfnmmnce of the work for which this Permit is issued, I shall
nal employ any person In any in:m rm sa as to omomc odiF coo the WorkersCompen-
0Z: smionlawnof Califrom.Dare
u Q Applicant
NOI'ICIi TU AI'PLICAN 1': Ih after making Ihis Cenllieme of lisemptinn, you should
a ; become subject to the Workers Compensation provision of the Labor CrNe, you must
form. th comply with onh prnvisiom or his permit shall be deemed resulted
a�
=z CONSTRUCTION LENDINGAGENCY
L7Q Ihereby IowhichtmlW .mit i issued(ec.3VOlending agency fire,he pedormance of
� Hthe work fur which Ihis permit is issued (Sec. 31x)]. Civ. CJ
VExto 's Name
Lender's Address
1 caddy that 1 halt, mud Ibis epplicmioi and ,lata that the above inicerunion is
FVat c arca. l agree to comply with all city and county insinuates and sure laws relating to QTV.
U Z building construction, and herchy uuthociac repm,emalivmnf this city to enter upon the
mvwv ,nod prolmry fin impaco". pu,pus
(Wes) agree to eve, indemnify odd keep truthless the City of Cupcnina against
habilhies, judgment,, costs and expenses which may in any war seems against said City
..sequence t I grunting of this permil,
APPLICANT . )ERSTANDS AND JVILL COMPLY WITH ALL NON -POINT
v HAZARDOUS MATERIAL' DISCLOSURE:
Will the applicum ter!mare lwilJin «cup out store or handle hncardeas material
as defined by the Cupcnino Municipal C aptcr 912, and the Health end Safety
Code, Sechon 255321,)'.'
❑Yes 0 N
Will the applicant in lulure building occupant use equipment or devices which
mil hanum us air contaminatl, as defined by the Bay Area Air Quality Manugement
I)itldee
❑Yes F1 No
I have he hazardous meat"', rvquiremems under Chapter 695 of me Cali -
I Hcelth alety Code, S vans 55(15, 25533 and 25534, 1 uad.... and that if the
gd sly��/f
me Lmmil is my mspansibilitymnalily the wtvpant
of the res t sTCvhyjyf�M1l herimr ao iacuvnea ofv Cenifcam nf�kcup�rty.�
PFRMI'I' ISSUANCIi
ALTER - DRAIN & VENT- WATER (EA)
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. ROOF. ARFA, COND,
FIXTURP_S - PER TRAP
GAS -G. SYSTEM -I INC. 4 OUTEXTS
OAS- EA. SYSTEM-OVER4(EA)
GREASPANDUSTRL WASTE INTERCEPTOR
GREASE'I RAP
SEWER -SANITARY - SIORM EA. 2001"L
WATER HEATER WA TNITMLECTR
WATER SYS DEMO REA'11NG
WATER SERVICB
NBW RESIDENTIAL PLMB. SQ. FT
MECHANICAL PERMIT
PFRMIT ISSUANCE:
ALTER OR ADO TO MF.CH.
AIR HANDLING UNIT TIO 10.000 CFM)
AIR HANDLING UNH' (OV FR I fish) CFM)
RXHAUST HOOD (WIDUCD
HEATING UNIT TO 100j") BTU)
HBATING UNIT (OVER 100,000 If
VENTILAHON FAN (SINGLE RESIDE
BOILER - COMP (3HP OR IugINNI BTU)
BOILER- COMP (OVER 100,000 BTU)
AIR CONDITIOul
NCW RF5IDBN'I'IAi, MI?CII. SQ. FT.
FEE
CCT 111999
VALUATION
- _ _
Is"FF
R-3
F16 —Zr c2ii
BUILDING DIVISION FEES
PLANC14ECK FEE
1.5-16" Y O
ENERGY FEE: . ^
V
S S• i
GRADING FEF
SOILS F�EE/q
PAID ,—
Dale
Rttciotp
SEISMIC
PAID
TOTAL: LZGYj 7a 9'0
FEB
ISSUANCE DATE
K43 -s -P9
imAL: ISSUED BY:
OFFICE