S 4379 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING
-MECHANICAL S 4379
BUILDING PROJECT IDENTIFICATION '
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
/ Ao C-F Diwu 11 e —�O—Q
O :S NAME PHONE: CONTRACTORS NAME: LIC NO:
�yp7 / NBC CONI'ROLk
AR RTE-C'DEN IN F.R: `LIC NO: ADDRESS: ❑
CONTACT: PHONE. BUILDING PERMIT INFO
❑ Cnni ultent Fees Paid by Applicant(Initial) BLDG ELECT PLUMB SUCH
DUh 73 ❑ ❑ ❑ L�
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby nu irm Ilial l am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
IQ0O whh Seedun WlW)nfDlvishrn3.fN.Ifminesstnd lhnfcvainnc Cnde.and my licenseisPERMIT ISSUANCE /� RF_I�$DENTIAL_
Fa,,F in full force and ellen. ❑SFDWL El KITCHEN REMODEL
bt V[) License Class Lick - APPLIANCES—RESIDENTIAL ❑AUDITION El PLUMBING RE-PIPE
rF�a Dare Cmaracmr
ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
ZO-Z I understand my plans shall be used as public records PANELS MODIFICATION
OZ-o UPT02MAMPS
[I INTERIOR ❑CHIMNEY REPAIR
;.H.f"W Licensed Professional 201-1000AMPS IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IINM)AMPS ❑BATH REMODEVREPAIR El DEMOLITION
pW G 1 hereby affirm that 1 am exempt from the Contractor's License Law for the ❑OTHER
a O following reason.(Section]031.5.Business and Professions Calc:Any city or county SIGNS ELECTRICAL
la.y which requires a permit to construct,almm improve,demolish,or topoir uny swnure
(pp'�C)J zrimmilsissmncgaJr.requires theapplicanl for inch pemd0.monsignori statementSPECIAL CIRCUIT/MISC.
2�¢ that he is licensed puroom to the provisions of the Contractor's License Law(Chapter 9
W y�pO (commencing with Section 7")of Division 3 afthe Business and Professions Code). TEMR MISTER OR POLE INST. COMMERCIAL:
ayi5 c ee That he is exempt therefrom and the basis home alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W:2ti Section 7031.5 by any applicant fm a permit subjects theapplicamt ton civil penally ofI'OWIiR DEVICES []TENANT ❑FOOD SERVICE
SSCKurt,than five hundred dollars(1500). IMPROVEMENT
w I,asnwneroflhe propery.or my employees.,In wager us theirsole compensation, SWIMMING POOL ELECTRIC
Sp. n Jothewm
ork,oadmiamicreis not intended or offered forade(Sce.J044,Business ❑OTHER
aroand Professions Cale:The Contactors License Low does not apply to an owner of OUTT.F.TS—SWITCHES—InIXTs]RES
papery who builds nr improves Iherenn,and who does mch ,,,it hinnself nr though
his own employees.provided That such imprvvements ore of intended or offered for NEW RESIDENTIAL ELECTR SQ FT.
salc.lf.however the huilding orimprovemem is codwimmoreyourel'c.mplmloa,Ne SQ.FT.FLOOR AREA $/SQ.FT.
cvccrcr-lbufildcr will have the bonen of proving that he did not build or improve for pur-
pose of sole.).
❑ I,as owner of the prapcny.um exclusively contracting with licensed contractors to ^
construct the project(Sec.7044,Business and Prifessions Cede:)The Contractor's Li- ( ^
cense Law does not apply to an owner of popery who builds or improves thercanond QTY. PLUMBING PERMIT FEE
who conrecls for such pmjects with a contamar(s)licensed pursuant o the Commences
License Law, PERMIT ISSUANCE I
❑ 1 am cxempl under 5 .13&Ir C for this meson 1 rlcili1
Owner
ALTER—DRAIN&VENT—WATER(EA)
Date U
s l'
WORSHIP'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE s
1 hereby am=under penalty of perjury one of the following decla itions:
❑ I have and will maintain is Cmifiame of Consent to ulf-in.wre for Worker's Compen- DRAINS—FLOOR,ROOF.AREA.COND. STORIES "1'YPEC 11CTION
smion,as pro,led!for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued. Fix rURIS—PER TRAP
FJ 1 have and will maintain Worker's Compensation Insurance,as required by Section 11
371m of the laMn Code,for the performance of the work for which this permit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS YOCC.GROUP APN
My Worlsers Compensation Laurance wrier and Policy number arc:
Came,: Policy No.: GAS—F.A.SYSTEM-OVER 4(EA)
CERTIFICATE 017 EXEMPLON FROM WORKERS'
COMPENSATION INSURANCE GRPASFl1YDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION TEES
(This acellnn cited not he complete(]if the p'%rmhis(Drone hundred dollen(S 1001 GRIIASL'TRAP
or Inst PfANC11ECK FEE
I ccnify Wut inlheperfamancced the work f.rwhich mirpenam,issued.Ishii SEWER—SANI'T'ARY—STORM EA.NNI FT.
not cmpiny any person in any manner so us m become mbjca 10 the Workers'Compen- ENERGY PER
sabot Laws of California,Dale z WATER HEATER W/VENT/ELECfR Q Applicant GRADING FEE
h NOUCH TO APPLICANT:IL atter making this Certificate o(Exemplion,you should WATER SYSTEMHRLATING
a become subject o the Worker's Compensation ori of the Labor Cale,you must SOILS FEE
fonhwim comply with such pmerisions or this permit shall he deemed retakes. WATER SERVICE
aQ
.7Z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL I'LMR. SQ,FT. PAID Do Rcceiplk
V O I for by which do that mere iso cad(Sea 30 lending agency Truths Performance of
fi Hthe work for which Nis permit is issued(Sec.Jfy)],Civ.CJ
4:nder's Nume TOTAL:
V Lenders Address TOTAL:
t� y 1 ccnify that 1 have read this application and state that the above information ie BUILD
rFa N correct.I agree o comply with all city cad county ordinances and slide Taws totaling to QTY, MECHANICAL PERMIT FEE
V Z building construction,and hereby authorize representatives of this city to enter upon the
SEISMIC FEE
'—' above-mentioned property for inspection purp.sex.
(We)agree m save,indemnify and keep harmless the City of Cupertino net PERMIT ISSUANCE r Q ELI?CTRIC Ice E (,
liabilities,judgments,casts and expenses which may in anyway oceme against acid City ALTER OR ADD"rO MECH.
.,sequence of the grmuing or ilia permit. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010,(100 CFM)
MECHANICAL
SOURCE. TIONS. IT AIR HANDLING UNIT(OVER 10."CFM)
\ CONSTRUCTION TAX
Co
Signature at'Applictua ntmnor Data EXHAUST HOOD(W/DUCD HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Willtheapplicamor future building oecupant sore or handle Intim
handle BEATING UNIT(TO IW,B(N]BTU)
as defined by Ne Cupertino Municipal Cade,Chapter 9.12,and the Health and Safely
Cade,Section 25532(x)? I HEATING UNIT(OVER 100J)00 BTU) `
El Yes E3 No PAID
VENTILATION PAN(SINGLE RESID) Dale Receipt k
•
Will flit applicant or future building occupant equipment or devices which BOILER—COMP(3HP OR 100,0(10 BTU)
emit hozmou
ds Dir amtaminame as defined by the Buyy A Arca Air Quality ManagementU
Dislrlcl?
❑Yee ❑Nu BOILER—COMP(OVER 100,030 BTU)
1 ^
1 have toad the hazardous materials Iationa lents under Chapter 6.95 of the Cali- AIR CONDITIONER 'J
ISSUANCE DATE
forrda Health& afes k.SSutinns 25505,25533 and 25534.1 understand Nat if Ne NEW REMDFN'1'[A].MECH. SQ.FT.
la,dingd otc yha"'ateret,that it is my responsibility.notify the occupant ¢/
.fine regoreme mm met prior to issuance of a Cenificate of Occupancy. q7--( ' ,a
Owner nr awhnrrze ugaT Dam T Al.: ISSUED BY:
OFFICE