S 4317 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4 317
BUILDING PROTECT IDENTIF'ICAT'ION
BUILDING ADDRESS SANITARY NO. AP PLICATION SUBMITTAL DATE
IOszoq 77
OWNER'SNAMi: PHONE: C ACTOR'S NA E: O/ NIC CONTROLM
vfrerhr
-�ARCHITECT/ENGINEER: LIC NO: DDRESS: _
coNTnC1': PHorve: BUILDING PERMIT INFO
L 0�0 0 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECII
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby anion that 1 oat licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with5 conn 7( 01 of Oivision3ofNe Busine end l'm C e,ardmyliceneis RFS
F IyB in full force and eelj, 7 �3�0� PERMIT ISSUANCE Y ❑SFDWL El KITCHEN REMODEL
�U~ Liansc Glasse Lich ��y���pp__r APPLIANCES-RESIDENTIAL
rFisZW Dale Conwetor / ❑ADDITION ❑PLUMBING R&PIPE
ARCHITECTS DECLARATION / PANELS ❑MULTI-UNIT []STRUCTURAL
ZonK Iunderstand my fila..shall be used us public records MODIFICATION
OZ— UP TO 200 AMPS
[311[-1(4 j t I,icemeJ I•rol'cseinnal INTERIOR CHIMNEY REPAIR
L5` ,ya OWNER-BUILDER D[CLnRA'I'ION 20I-IOOIIAMPS IMPROVEMENT SWIMMING POOLS
I h mby affirm,hal I am exempt loom Tho Contruenn's License Law for the OVER 11X10 AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
O 4 U following reason.(Section 70315,Business and Professions Code.Any city or county SIGNS ELECTRICAL OTHER
CF which requires a permit 10 construct,alter improve,demolish or repair any svunum i
.F.'- prior m its issuance,also requires the applicant forsuch permit to tileasigned statement SP-CIAI.CIRCUIT/MISC. 7. _—
�'/,{a'�, that he is licensed pursuant provisions offac Comrucmis license Law(Chapter
9
�yp0 (commencing with$enion l,p0)of Division 3ofthe Business and Pmficohns Cosi TEMP.METER OR POLE INST. -
a y o Y That he is exempt therefrom end the basis for the alleged nemptinn.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
all X ro_ot u. Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICES
F Z p Oact more than five hundred do]].(5500). ❑TENANT [I FOOD SERVICE DI,as owner of the progeny,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will Ju the work,and the structure is not intended or offered far:ole(See.70o,L Business ❑OTHER
tail and Proassions Cade:The Contractor's License Law arms not apply to an owner of OUTLETS-SWITCHES-FIXTURES
prnpeny who builds or improves thereonr and who does such work himself.,in....h
his own enhgoyees,provided that such improvemeno are not intended or offered for NFW RFSIDENTIAL E lCTR SQ IT.
salt.IL hnwewr.Iho building Orlmpmvemam is snlA within nuc year ofvompletlnn.the FJ:23
S/SQ.TU
crbuilder will have the burden ofproving,hat he did not huild or improve for par.eo of sale.).❑ 1,as ownerof the property,aminclusively<omruefn,with accused cataactnn n, T L:cannon the projee(Sea.7044,Buainus and Professions Cndc)The Cotvnrs Lic se Law does not applyto nownerofpropenywhobuildsorimproveslhemon,and QTY. PLUMBIN E IT FEE
who nmtmns for such projects with v contmau ls)licensed pursuant to the Cnntmctor's
License Low. PERMIT ISSUANCE 11
❑l vat exempt under,Sec. ,B&P C hands..an
ALTER-DRAIN&VENT-WATER(E VALUATION
Owner Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
1 hereby alarm under penalty of perjury one of the following deelamfions:
I now and will maintain a Cenificme of Consent no self-hure for Workers Cou,sn- (TRAINS-FLOOR.ROOF AREA,COND' STORKS TYPE CONSTRUCf10N
scion,os pmvida l for by Section 3700 of the Labor Cale,fur the performance of rho
work for which Ihi,peril is issued. FIXTU RFS-PER TRAP
1 have and vi mould.Wn,trers Con,pensmlon Insnrunm,as minimal by Section
371NI Ofnle Labor GMe,for the performance of the work for which This peril is issued, GAS-EA.SYSTEM-I INC.4 OUTLQIS OCCGROUP APN
My War C�WPantion last ange tamer and Pal icy M1y yq�( 1'nn
Cameo ,kp(dM,TV Policy No.: dGYNI`/-111 GAS-EA.SYSTEM-OVER4 EA)
CERTIFICATED EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE I GREASDINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FRES
(OTiz senion need Out be completed if the peril is ionone hundrtd dollars(5100) GREASE.TRAP
or leas.) PIANCHECK FEE
Icenify that in,in aM..net an
mkfmwhich this th,Woresued,lshall
pen- SEWER-SANITARY-STORM RA.200 FI'.
nm employ any Pcmnn in any manner m ax m become suM1jen to the Workers'Compen- ENERGY FEE
2.e union laws of C.1ifomi..Date
Z O Applicant WATER HFAT[R WNENTBLECfR GRADING FEE
prq NOTICE TO APPLICAN'U.If,after making this Certificate of Exemption,you should WATER SYSTEM/IREATING
a become subject to the Workers Compensation provisions of the Labor Code,you must SOILS FEE
fortbwilh cmnply with such provisions or Ibis permit shall be deemed revoked. WAFER SERVICE
Q
Uz CONSTRUCTION LENDINGng agency
NEW RESIUENTIALPLME SQ.FT PAID
U p k for
thi lhanhercisaco (Sec.3097.
agency fur the performance of Date ReceiptM
Vat Hthe work fur which this peril is issued(Sea 3097.Civ.CJ
Lender's No. TOTAL:
} l51 lander' Address TOTAL:
I certify that 1 have read this application and sate that she above information is BUILDING FEE
Ir V) cornet.l agree to comply with all city and county ordinances and nate laws mining to QTY. MECHANICAL PERMIT FEE
V z building conswction,and hereby announce representatives of this city to enter upon the �,/�y-� SEISMIC FEE
e
ebovmentimmid pmpany for in.spcctinn pmHweee. PERMIT ISSUANCE r ) q
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC PEE SJ
Iiibilitics,judgmeno,cnnsand expenses which may unity wayaceme almmosaid City ALTI111 OR ADD TO MECH.
in unscquenceo1 gaming n(thi ,mots PLUMBING FEE
APPLICA IND S ND WILL Y /WII,TH ALL NO1,fP0INT AIR HANDLING UNIT TO 10,000 ChM) AN�yAL "7 D
SOU K pC7— 1CPM)(OVER I ^
AIR IIANI3LINC UNIT10,110010,1100 CONS'I'IiUCI'ION TAX
s Signature of Appllcunt/Contmcmr Date
HAZARDOUS MATERIALS DISCLOSURE li%IIAUST I100D(W/UUCT) HOUSING MITIGATION FEE
D
Will the applicant Or future building Occupant suite or handle hmallous material HEATING UNIT(TO 1ID.000 BTU) ZX
as defined by the Cont inn Municipal Cade,Chapter 9.12,and the Health and Safety
Coi Section 25532(01 HEATING UNIT(OVER 100.(N BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID
Dam Receipt If
Will the air want or future building by the B Inc equipment or dMana which
emstant,tdnus air comaminano as leaned by the Puy Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Disaiul U
Fl Yea [I No IIOILP.R-COMP(OVER IOO,,NIO BTU)
e
Alit CONDITIONER G
I have .Saferid hazardous....mals mspdran.533 iasan under 1 and 6.95 ,hethat Cali. ^ ISSUANCE DATP,
linnin Ilunl,h&Snfmy Cale,Swoons 5,25533 o„J 255]4.I understand that ifthe NEW RESIDENTIAL MECH. SQ.FI'. ^ /1,/n
hnWing,tnes h to ,Nati ' responsibility to notify the occupant G _--f �7y
thcrc missuarce of u cull' wp�Qoy.
awhorized age.. ) D_mar ISSUEIi
OFFICE