S 4465APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING -ELECTRICAL
PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING -MECHANICAL
- S 4465
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
9 333 4L ilda
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OWNER'S NAME: PHONE: J C"ALT9x'S NAME: LIC NO:
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CONTROLx
ARCHITECDENGINEER: LIC NO: ADDRESS:
,SL'oca ./6$9 //7,5—&, ),Aw Ave. �!/i✓
coNTAGD PHONE:
BUILDING PERMIT INFO
CSt,V - uµ�� ❑ Consultant Fees Paid by Applicant(Initial)
BLDG _ ELECT � PLUMBS M6F�
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LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby afBrr" Nat I am licensed under provisions of Chapter 9 (commencing
with Section 70IXq of Division3of the Rosiness and Nofessions Code, and mylicensc is
in full Lombard Weer. PERMIT ISSUANCE 3
License Class Lia.is
Datc Common, APPLIANCES - RESIDENTIAL
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
[]ADDITION El PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
AR IT' DECLARATION
un my plat !, des lie rec^ PANELS
OZ
UPT0200AMPS
El INTERIOR 11 CHIMNEY REPAIR
Tastopor
OWNER-BUILDER DECLARATION 201-100BAMPS
1 hereby affirm that I am exempt from the Contractor's License Law for the OVER 1000 AMPS
following reason, (Section 7031.5, Business and Professions Cm1e: Any city or county SIGNS ELECTRICAL
C Q
�L O d U
IMPROVEMENT SWIMMING POOLS
❑ BATH REMODEUREPAIR 0 DEMOLITION
[]OTHER
w.]
which require.%a front to common, altar, improve, demnlish, or repair any structure
prior to its issuance, also requires theapplicam for such permit n rile a signed statement SPECIAL CIRC C.
}
that he is licensed pursuant to the provisions of the Contractors LvAmm Law (Chapter 9
COMMERCIAL:
.❑. NEW BLDG/ADDITION ❑DEMOLITION
� •NANT ❑ FOOD SERVICE
[]OTHER
00Y
N
Bmannencing with Section7000) of Division 3 of the Bri,messanl Professions Case) or TEMP. METER L
tet he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section IBI IS by any applicant for a permit subjects the applicant to a civil penalty of POWE . ICE
m more than five hundred dollars (3500)IMPROVEMENT
� 1. as owner of the property, or my employees sent wages as their sole in SWIMM G O I IC
will do the work, and the snacture is mol intended or offered mr tole (Sec. ]044, Business
ca ..
and Professions Code: The Contractor's License Law does not apply to as owner of OUTLETS - SWITCHES -T
ad
property who builds or impasses thereon, and who docs such work himself or trough
his own employccs. provided that such improvements are not intended or offered fm NEW RESIDENTIAL ELECTR Q Fri.
A x
h�
SISQ. FT.
sale. If, however. the building or improvement is sold within one year of completion.the-
owner -Wilder will have the burden of proving that he did not build or improve for par.
IW'S owner^( theproperty,amexclusively contracting with to IOTA r
)To,, Ccnnactorss
construct the es not (Sec. 7044, owner
of and Professions Codds or i Tac Contractors nd Q
case Law doesnmApply toan ownerofproperty whobuildsImproves thereon, and TY PLUMBING PHRMIT FEE
1 6 1999 D
who for such projects with acamracmr(s)licensed pursuant to the Contracwrx
JUL
Law. PERMIT ISSUANCE
License exempt x
El 1 am exempt under Sec. , H & P C for this reason
ALTER - DRAIN & VENT- WATER (EA
Own m
VALU
—
B
ATION BACK FLOW PROTECT DEVICE
Df
WORKE C Mof
,jury o the
Ihcrebyefirmun f penalty of ITjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Workers Compen- DRAINS- FLOOR, ROOF. AREAC ND.
provided for by Section 37M of to Labor Code, for the performance of the
work far which this permit is issued. FIXTURES - PER TRAP
STORES
TYPE CONSTRUCTION
.a
EEas
❑ 1 have and will maintain Workers Compensation Insurer - rtyuired by Section
3
37M of the Labor Code, for to performance of the work for which tis Permit is issued. GAS - EA. SYSTEM- I INC. 4 OUTLETS
OCG GROUP
APIA
My Worker's Compensation Insurance canner and Policy number arc:
Carrier: Polley No.: GAS - HA. SYSTEM -OVER 4 (HA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASIVINDUSTRL WASTE, INTERCEPTOR
(This section need not be completed if the permit is for one hundreddollan ($100)
or less.) GREEK
BUILDING DIVISION FEES
^ p I Z O
PLANCHCCK FEE LO
O Z
77 �
x7 N
a
L7 rs
�z
U O
L4 H
ich jetio cut the W[eiss'Compn. SEWER -SANITARY -STORM EA. 200 FT.
-SAP
Ioys,tainthe fiffiany
not employ any person in any manner sn as m become subject m the Workers' Compen-
as toed for subject
Laws of California Date
ENERGY FEE
x
AWATER []EATER WNENTMLECTR
pp li
Applicant
GRADING FEE
NOTICE TO APPLICANT: If, after making this Cedifieme of Exemption, you should WATER SYSTEMfBGTING
become subject to the Workers Compensation previsions of the Labor Cade, you must
fanhavt comply with suchprovisinnxor this permit shall Is, deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RFSIDEMIALPLMB. SQ. PT.
I hereby affirm that there is a ecnstmeli^n lending agency forte perfmmanmof
the work for which this permit is issued (Sec. 3097, Civ. C.)
SOILS FEE
PALD
Reaciptx
C V
1F"iy
U Z
Lender's Name
- TOTAL:
Lenders Addresx TOTA x TU
I
BUIEDI FE 3 3
I certify that 1 have read this application and store tat the above information is
cormer l agree tocomply withal[ city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
building construction. road hereby autarim representatives of this city to enter upon the
SEISMIC
r
above-mentioned property, for inspection purposes. PERMIT ISSUANCE
(We) agree to save, indemnify and keep harmless the City of Constitute against r
liahilities,judgments.nrs¢and expenses which may in any way accrue against said Cily ALTERORADDTOMECH. / a
in commerce of lhegrantingf othis permit.
EL ECfRI FEE C O
PLUMB GFEE
APPLICANT UNDERSTANDS A ILL COMPLY WITH ALL NON -POINT AIR HANDLING UNIT (TO 10,000 CFM)
SOURCE :UI TIONS.
x7 D
MEC H ICAL FEE J
CONSTR ON TAX
AIR HANDLING UNIT (OVER IBOI10 CFM)
Egna ore ppli oneDam EXHAUST HOOUIW/DUCp
AZARDOIN MATERIALS DISCLOSURE
HOUSING TIGATION FEE
ill th pplicramfaturebuddingmeapant sm.cialundlelmzardnmarmerial HEATING UNIT (TO 101,000 BTU)
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Code, Section 25532(0)! HEATING UNIT (OVER 100.000 BTU)
❑Yes E] No VENTILATION FAN (SINGLE RES ID)
Will the at, r.mat or fmure building occupant um .Air Qu or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Arta Air Quality Management
District, BOILER - COMP (OVER 100,000 BTU)
E] Yes 71 No
PAID -"
Date Receipt#
TOTAL:
r C-
Ihave mail the hazardous materials rryuiremmeaonderChapter 6.95 mthe Cut i- AIR CONDITIONER O
ISSUANCE DATE
forma Health & Safety Cade, Sections 25505, 25533 and 25534. 1 undersand not a tM NEW RESIDENTIAL MECH. SQ. FT.
buildingd"cs tcuncnlyhaveamn mit' y respomibility to notify to occupant
_ �]
/
oto is which be t m enc uCeniricama upancy.
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v
ner am o' i a TOTAL'
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ISSUED BY: �