S 4397 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO,
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4397
BUILDING PROJECT IDENT'IF'ICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
21717 q 6W1Q c r
OWNBR'S E: _ PHONErn: CONTRACTORS NAME LIC NO:
CHITECTIENGINEIiIi: LIC NO: ADDRESS: - ❑
CONTACT PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL MB MECH
❑ Q ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 washy affirm that 1 am licensed under provisions of chapter 9(commencing JOB DESCRIPTION
qQO with Seation]fN)lp of Divi,vion3nl the Business and Professions Code,unit my license is pERMITISSUANCC RESIDENTIAL'
in full force and effect.
�VUF (]
License Class Lion SFDWL ❑KITCHEN REMODEL
Nae Date Contractor APPLIANCES-RESIDENTIAL []ADDITION [I PLUMBING RE-PIPE
ARCHITECTS DECLARATION ❑MULITUNIT ❑STRUCTURAL
F• h PANELS
Z ptr�Z l understand my plans shall be used as public records MODIFICATION
OZ—O UP'1'02W AMPS [I INTERIOR ❑CHIMNEY REPAIR
a 4!:W Licensed Professional 201-1"AMPSi IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION 10yµµl(X)OAMPS [I BATH REMODEU ❑
REPAIR DEMOLITION
Q I hereby affirm that 1 am exempt from the Contractor's License Law for the
6 V following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
F F which requires v peril u)constmct,alter,improve,demolish,or repair any stmcturc
prior to its issuance,also requires the applicant for such Permit o file a signed statementSPECIAL CIRCUIT/MISC. �—
F. N that he is licensed pursuant to the provisions of the Contractors License law(Chapter 9
W no (commencing with Seminn]g1(I)nf pivieion lofthe Business and Pmfessinm Code)nr TEMP METER OR POLE INST. COMMERCIAL'
d y o C that he is exempt therefrom and the basis for the alleged exemption.Any violation of [I NEW BLDGIADDITION El DEMOLITION
W LL. mnSection 7031.5 by any applicant for a peit sufficient the applicant to a civil Penalty of POWER DEVICES
tL—m ❑TENANT ❑FOOD SERVICE
five hundred dollars($500). IMPROVEMENT
f 0
1=0 the propeny,onny employees with wvgesm nicotinic campwsztion. SWIMMING 11001.ELECTRIC
P. will do thework,and thestructure isnot intemdedornRered for side(See JBW,Business ❑OTHER
Wand Professions Code:The Conlmcmrn Lic...a Law does not apply to un owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,unit who dues such work himself or through
his own employees,provided that such improvements are not intended m offered far NEW RESIDENTIAL❑LECTR SQ FT.
sale.If,h.wcvep the building or improvement is told,ann nae ,mor completion,the [T IYAOR-ANE�
r-huilder will have the burden of proving that he did not build or improve for put-
pose
ut- // \,
rn 1,assale.). D
1,as owner of the tropically,not exclusively enmmeing with licensed contmetors to TOTAL:
ell..tract the project(see q(ma,Business and Professions Codr;)[he Contractor's Li. - �� 9
cense law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE JUL
who contracts for such projects with a contrncmr(s)licensed pursuant to the Conlmcon's
License law. PERMIT ISSUANCE
❑ lam exempt e 5 ,B&P C fortis mason
/7 79
Owner 40
ALTER-DRAIN&VENT-WATER(EA) By VALUATION
pate_
WO ER PENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I herehy affirm under penalty of penury one of the fallowing declarutium:
Thaw and will maintain a Certificate ofConsent o self-insure for Worker's Compen- DRAINS-FLUOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,us provided for by Section 37W of the Labor Code,for the Performance of the
work for which this Pert 11 issued. FIXTURES-1'FR TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
37W ofthe Labor Code,for performance of the work for which this peril is issued. GAS-FA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy mandorue
Career: Policy hi GAS-HA.SYSTEM-OVER 4 EA)
CERTIFICATE OF EXEMPTION MOM WORKERS'
COMPENSATION INSURANCE GREASP/INDUSTRL WASTE IN'ITRCEPTOR
This section need not be completed if the permit is for onehunded dollars($100) BUILDING DIVI$IUN FEf1S
or less) GREASE TRAP PLANCHECK PER
I certify that inthcl'<rinnanec.fthe work for which dnispemnit is tented,Irhol SEWER-SANITARY-STORM FA.2W FT.
not employ any Person in any manner so as to became subject to the Workeri Compen- ENERGY FEE
O z ration Lowsafcolifomin.Date WA'1'IIR I{EATBiIi WNENT/CLECTR
C Applicant GRADING FEE
NOTICE TO APPLICANT:IL alter makingthis Certificate of Exemption. should
You WATFiR SYSTEM/fµLATING
a '
become.abject to the Workers Compensation previsions of the Lathan Code,you must $OIL$FF.P.
IJJ ti fnnhwith comply with such pmvininas or @is'Pemth shall he AcemeA revoked WA'1'ERSERVICE
7 z CONSTRUCTION LENDING AGENCY �) NEW RESIDEM'Idl.PCMB. SQ.FT. PAID
T.J 0 I herebywhichtn thatthereisvo-d(Set.i30 len ding agency for perfornutnceof m Receiptp
� F' the work for which this Permit is isaucd(Set.3097.Civ.C.)
O lenders Name TOTAL:
WLender's Address TOTAL]
as I certify that 1 have read this application and state that the above information is BUILDING FEE
V) corral.l agree to comply with all city and county undinances and state laws evistingto QTY MECHANICAL PERMIT FEE
U huildinguonstruclion.and herebyauWonic repres<matives of this city to enter upon the SEISMIC ITE
alnve-mentioned property for inspection purposes.
(We)a PERMIT ISSUANCE
gree to save,indemnity and keep harmless Ne y ac ru Cupertino n againty ELECTRIC FEE J
in
of thes.costsandof this esmit. may inany way aacrucugainnl said City ALT ER OR ADD TO MCCH.
in consequence ul the gaming of this peril. PLUMBING FEE
APPLICAN NDERSTANDS D WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURCE E . D MECHANICAL FEE
AIR HANDLING UNIT(OVER 110,000 CFM) CONSTRUCTION TAX
S r o Ap nun/C nart Pfall EXHAUSTHOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applieam or future building wcapant rancor handle haemdonstnamost HEATING UNIT(TO I W."BTID
use defined by the Cupertino Municipal Code.Chapter 9,12,unit IM Groh and Safety
Code,Section 25532(a)l HEATING UNIT(OVER 100,000 BTU)
0Yes Nn VENTILATION FAN(SINGLE RESID) PAID
Dare Receipt p
Will the air contaminants
a building occupantuseequipment ordevices which BOILER-COMP QHP OR I Ol BBV)
emit District?
s air contaminants as defined by the Nay Area Air Quality Management TOTAL.
❑Torted]
E]Yet XNo BOILER-COMP(OVER IW,IXIO BTU) O
I brae real the hazurJnus mmerials requirements under ChaPterfi95 of the Cali- AIR CONUIt'IONL'R ISSUANCE DATE
hard.Health&Safety Crude,Sections 25505,25533 and 255U.1 understand that if Ne NEW RESIDENTIAL MECH. SQ.FT. `��� Q
building doe. marmly haveaana Nat ilismy responsibility to notify die occupant / /
oflhere t 'ch tet hem pivoloissoaner.f eaifcate nl'
Owne a thmia Iagen c van TOTAL: ISSUED BY:
OFFICE