S 4400 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMUTING.
BUILDING DIVISION API'I,ICNI'ION/I'F,RMI'1' PLUMBING-MECHANICAL S O O
1:1'' I-"4::: BINI,DINGPROJECI',IIIENTIFICATION',Y.fI IIf L},('�
BUILDING �DING ADDIOI.S �� SANITARY NO. APPLICATION SUBMITTAL DATE
K uYl d 'e✓G 7—'-411
OW 5f1 C`' PHONE: ONTRACI'OR'S NAME: 6,5 �NO� NIC ///C---OONNTii�ROL#
ARCHITIICT/ENGIN CER: - LIC NO'. AD) `� n -(,U ❑
CONTACT PHONE !1'1iI-fI'i i{Js BUILDING PERMIT INFO;" '
e N `� /_� ��� / ❑ Consultant Fees Paid by Applicant(Initial) BIAG ELECT PLUMB MECH
LICENSED CON I RACTOR S DECLARATION t ' I J, I'LICCTRIC PFRhIIT.Ls I!!!� I 1 11
lnereny orrm,tall ntlicensedad p renapmr9(amnme g QTY r i,1 ria.- D•rttt it.�lft-tJfi1ti 2E'tli, JOB DESCRIPTION
OZZ with Section](00)uf Di'i ion 3sf,he Nusi and Pn fits ns Clde.anJ mylice refs RESIDENTIAL'
lr � in Poll fort.and ellct N� PERMIT ISSUANCE
W� 19 W ❑SfIJWL [D KITCHEN REMODEL
I-UU Liccnn Class Lia. APPLIANCES-RF.SIUI'NTIAI. []ADDITION ❑PLUMBING BE PIPE
F-Z W Dam Contractor
Fly ARCHITECTS DELL RATION OuI IJ�/ . PANELS ❑MULTI-UNIT [I STRUCTURAL
Z p H Z I unde,nuul my Plans shall he null un public«coif, +�" (•I�/`� MODIFICATION
OZ�-0 UP 90200 AMPS I ❑INTERIOR [I CHIMNEY REPAIR
1=4 t:WLicensed PmfessiowL 201-1000AMPS IMPROVEMENT [JSWIMMING POOLS
OWNER BUILDER DECLARATION OVER 1000AMPS ❑BAI H REMODEL/REPAIR ❑DEMOLIT[ON
1 hereby nffinn that 1 am exempt from the Contractor's License law for the
Xd 0 a U following reason.(Section 7031.5,Business and Professions Code:Any city or coum>' SIGNS ELECTRICAL -1 OTI{ER
B13 Q•F which acquires u permit to construct,alter,ru mare,thomard,or repair any suumure 7/t'
prions its issuance.alunrn..up,thoapplicanl lorxuh permit e,file asignedstmenwn1 SPECIAL CIRCUIT/MISC.
.E > that he is licensed pursuant to the provisions of the Contractor's license Law(Chapter 9
= x020 (commencing with Section]0(0)of Division 3 of the Business and Professions Crdc)(it TEMP.METER OR ,:INST. COMMERCIAL:
11 IL c C that Int is exempt Werefmm and the basis for the alleged exemption.Any vidudon of ❑NI?W BLDG/ADDITION ❑DEMOLITION
.pro Section 7031.5 by any applicant for a permit wbjects the applicant to a civil penalty of POWER DEVIL ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars(SSW)F�>' IMPkOVIiMFNT
qZ6 ❑ 1,rte owner of the property,or my unployut,with wugm as lhuirroalc as t., idnn, SWIMMI POOL ELI?LTRIC
2FO will do,newark,and mertruCmullina,l I.ietadorave does ar:t apply.1. asahe,os HER
W 3 and P�fessions Cl he Contmnnrs License w does sol apply,o un owns of 0 TS-SWITCI{IS-FIX I URFS
property who build,or Improves lamina,and who doe,such work himself or,nmogh
his awn employee.,pmvWed that men improvements am not imcndell or offered fur EW RESIDENTIAL.ELLCfR SQ FX
sale.IL however.the building orimpmremem is sold within one year o(nrnple,ion,tM1e S ILOUR E1- SQ.FT.
owner-huilder will have the burden of proving that he did not build or improve for par- L O yk�k�
pos.of xuleJ.
CI 1,as owner of the prapeny,am exclusively contracting with licensed comments to TOTAL: 10
onrtmet the pro per(Sea 70.14 Bu,ine,siond Pri,fiessions Cale)'Elie Contractor,Li a f 4 s it -{ { r
close alar does rtoppi, fp f 1 l ldrn npmvex thereon I QTY.' ,Ifs PLUMBINCPrRM11s�I,qss jfil tl;('j l EE19"11 By
xnocontets fur suMp jetsx thacomract s)l tensed pursuant the Carnaaan's
License Law. PERMFIISSUANCE
❑ 1ant.xemp,under Sea ,II A,P C brands reason
ALTER-DRAINNVIiNT-WATER(EA) VALUATION
0, Dale
WORKER'S COMPENSATION DIiCLARATION BACK FLOW PROTECT DEVICE 3JI�rU 0 �
1 hereby affirm under penaltyof per,.,ane of"Lha following de.lurnams: f '�
❑I have and will maintain a Certificate of Conan to sel6iusure for Worker's Contain- DRAINS-FLOOR,ROOF.ARRA.COND. Stt)RIES TYPE CONSTRUCTION
,inion,to provided for by Section 37(0 of the Labor Cada,for,he perforatance little
work air which this p.rnrili,,mad. FIX'I'USES-E'ER TRAP �-�. Al'E]I have and will maintnin Winker',Comryasution Insurance,as required by Section
3700of,he]alar,Code,to,the pe,fir alleadit,work for which,hie permit is issued. GAS-EA.SYSTEM.]INC.4 OUTLETS OCC.GROUP APN
My Worker's Coor,;W' rancatafrier and Polieynmahcr aro:
Camer. [.he,No.: GAS-EA.SYS'FHM-OVER 4(EA) -3 e64`115
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASMNDUSTRL WASTE 1 RCEPIOR - BUILDING DIVISION IBES
('Dissection necchat be completed it the permit i,for nuc hundred dollars IS l ri GREASE TRAP ^
or less.) ` PLANCHECK FEE
Itinily that in theperfonnanccafihe work for which this permitls issued,I shall SEWER-SANITA -STORM EA.200 FT.
not employ any person many antarctic,arm hecomc uubjecun the Worker"Compan- ENERGY FEE
Z scion tsars of California.Date WATER HEAT W/VENT/F,LEC7pR
O Applicant GRADING FEC
VI
NOTICE TO APPLICANT:If,a arr ataking this Certiied¢of Exemption,ion,you should WAflil2 STEMII'RIiA'ONG a SO]LS FEE J, became subject to the Workers Compensation previsions of the Lmor Code,you must
foithwA comply with such provisions or this wornit shall be deemed revoked W �R SERVICE
G Q
CONSTRUCTION LENDING A NEW RESIDENTIAL PLM#. SQ.FT. PAID
U affirm that Ihereny affirthat there isaconsounagency lending agency for the performance or Dote Receiptp
U O tiro work for waich this,pe.....I ix ia,ucd(Sao 3097,Ci,C)
IE' Lind :N IDEAL:
C.) Lend Add : TOTAL
1 my Ih,1M1' dth p on and acute 0vt tl bin f , rt 1 ? /. TIE I } I BULLDINC FCE ; �.Qd
rn tarred g , ply with Ell city d county ordhlmvcs and state ft I,n 0]Ty, •MECHANICAL IERMITJF" i'hE' 1�
U 7, building construction,and hereby shimm a mpresenlalrves of this city to enter upon the _ +-trI 1 G r 'll. rtj SEISMIC FPI: 5-0
above mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree to save,Indemnify and kccp has ,a the City of Cupenbio aguin,t ELECTRIC FEE
liahiliiies,judgments,tvotaxm expenses which an any way uccme again.said Ciry AIT ER OR ADD TO MECH.
in courac to ncc or he grating of rams permit. PLUMBING LLE
APPLICANT UNDERSTANDS NO I. MPLY WITH ALL NON-POINT AIR HANDLING UNI'I'(FO OJ00 CFM)
SOU tGULATIS. MIiCIIANICALFEE
ON
AIR HANDLING UNIT(OVER 10,0"1 CONSTRUCTION TAX
Signor f 'stns Data EXHAUST I{GOD(WIDl1Cf) HOUSING MI'UGATION FR.P.
i HA'LARDOUS MATERIALS DISCLOSURE
Will tae applleamorfuntre buildingaccupanl sore or handle hreadmis nominal HEATING UNIT(TO 10k TU)
os defined by the Cupertino Municipal Cnde,Chapter 9.12,and the Hardin and Sabot,
Code,Section 25532(x)] HEATING UNIT(OVI' 100,000 B'I'U)
❑Yes �N'o PAID�� 399(0
V17NTILA'1'ION P (SINGLE BESIDE Duto Re<tipl#
Will the applicant or future building occupant use equipment or devices which
emir harardaaa air communal an s as defined h the Ba Areu Air Quality Management BOILER- . P UHPOR 100,(100 BTU)
Y y TOTAI.:iyzryo
Dints tl BOIhE -COME(OV HR 100,000 BTU)
C]Yes No
A CONDITIONER
I and me huanrdons mnmria qui scnu under Chapter 6.95 of Cali- ISSUANCE DATF.
fomia Heald Y Safety Code, ti ), 55331m . . . elaand In.,if the NI?W RESIDENTIAL.MECH. SQ.I4.
built res no,curmntly ha imitix responsibility to notify the occupant
ar m „wn"E a atm ixana •ash an a, are, aa��//ss
O ' am rizcd agent Dm TOTAL: ISSUED BY:�/�e /Q N7,Dsk Ca:-s
- OFFICE
ADDITIONAL PERMIT FEES S V716
V
a• BUILDING PROJECT IDENTI FICATION VALUATION
BUILDING
OWNEPS
NAME E SUMMARY _
PONE
CONTRACTORS BUILDING i
NAME
UO,No. PLAN CHECK
CON"ACTOR 5 FEE
AooREss
SEISMIC FEE
OTY. ELECTRIC PERMIT FEE
UTLETS-SWITCHES-RECEP ELECTRIC
LIGHTING FIXTURES PLUMBING
" PPLIANCES-RESIDENTIAL
PANELS MECHANICAL i
SIGNS
SIGNS TRANS. TOTAL
SPECIAL CIRCUIT
EMP.METER OR POLE INS. PERMIT VAUOATION
MOTORS SEE FEE SCH.
SERVICE CHANGE
O
Z z
F o TOTAL—
jr
ISSUANCE DATE
> OTY. PLUMBING PERMIT FEE 05, EnT. PLG. MECH.
d v
2 ALTER DRAIN&VENT-WATER (EA.) El Ll
V O BACK FLOW PROTECT,DEVICE 1
U' U DRAINS.FLOOR,HOOF,AHEA,COND.
( a FIXTURES-PER TRAP
• . . ( ♦— 2 GAS-EA.SYSTEM.I INC.4OUTLETS ,
C.J GAS-EA.SYSTEM-OVER 41EA.1
INDUSTRIAL WASTE INTER.
• LAWN SPRINKLERS-I INC 5 V.B.
LAWN SPRINKLERS-OVER 5(EA.)
SEWER-SANITARY-STORM EA.7001[/
WATER HEATER W/VENT
1
WATER SYSTEM I
WATER TREATING EQUIP.
TOTAL
OTY, MECHANICAL PERMIT FEE
ALTER OR ADD TO MECH.
APPLIANCE
AIR HANDLING UNIT(TO 10=C.F.M.) p
AIR HANDLING UNIT(OVER 10=C.RM.)
EXHAUST HOOD(WITH DUCT)
HEATING UNIT(TO 100,000 B.T.U.) II
HEATING UNIT(OVER I00,000O.T.U.) (- ,
VENTILATION FAN (SINGLE)
— BOILER-COMP(3 H.P..,I00,000B.T.U.) i
BOILER-COMP IOyPl 100 n000TU1 SF:[FEE SCH. -
TOTAL As