S 4432 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY O' UPER'1'INO BUILDING.-ELECTRICAL PERMIT NO.
wx B ,D G DIVISION APPLICATION/PF,RMITPLUMBING-MECHANICAL S 4432
BUILDING PROJECT IDENTIFICATION
>UjjXNG ADDRESS: SANITARY NO. APPLICATION SUBMITIN.DATE
OWNJ;9;L1FA,kf F.: �� PHONE: �. CONTRA( NZ: LIC NO
NIC CONI'HOh a
ARCHHEC'UENGINEER: LIC NO: ADDRESS: 7 �V ❑
CONTACT: , - P ONE: BUILDING PERhfIT INFO
�- r95 v ❑ Consultant Fact Paid by Applicant(Initial) BLDG ELGCI' MECH
�c��p /ArAZv y 7 El ❑ �00PLU ❑
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE,
1 hereby aamn mat 1 at licensed ander provisions of chapter 9(matmmeing JOB DESCRIPTION
WO0in fall fortes andsBecDivisinnJaOM1e Businessand t'mfesshms Codaand to,ll mill is RESIDENTIAL:
IAO PERMITISSUANCE ❑SPOWL ❑KITCHEN REMODEL
QUU Liccn,,e Class LIC.N APPLIANCES-RF,SIDENTIA- ADDITION ❑PLUMBING RE-PIPE.
y6 Data Cmmmcor
�Q. ARCHITECT5 DECLARATION PANELS ❑MULTLUNIT ❑STRUCTURAL.
Z O�s Z I understand my plan,,shall he used as public reaods MODIFICATION
OZN� UP TO 2B)AMPS ❑INTERIOR ❑CHIMNEY REPAIR
H�fJW Liammd Podu.mirld 201-1000AMPS IMPROVEMENT E)SWIMMING MOM
OWNER-BUILDER DECLARATION
o:Y OVER HXXIAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
yI)C Q I hereby affirm that I am exempt from the Contractor's License Law for the
X G U following nnaon.(Section 9871.5,Bminaas and Profusions Cock Any airy oe county SIGNS ELECTRICAL [IOTHER
W a h which requires a permit to construct,alter,improve,demolish,or repair any structure
Ip".�-f�fnnQ prior to its issuance,also requires the applicant four such perino file a signed statement SPECIAL CIRCUIT/MISC.
mat he is liccmnt
cd pursua .the provio,movi the Com ructor's license Law(Chaptar9
IA�00 (commeaing With Section]000)of Division J ofine Businessand Profusions Ccdc)or
TEMP.METER URP EINST. R
0.Xe LL thin he is exempt therefrom and the basis for the alleged esvmption.Any violation of BLDG/ADDITION ❑DEMOLRION
Xlm Seebon]BJ1.5 by any applicant Eur. trout subjects the applicem to u civil peraltyof POWER DEVIL,.' []TENANT �1�ATRSERVICE
not more man five hundred dollars(SS(10)� 1
IMPROVEMENT
Q ❑ I,usnwmr nl the pmpeny.onnye.upluyea with wages axtheir sola compcnsmion, SW1MM1 PUUI.ELICCfRIC
�p=..0 will do the work,and me structure is not attended ororternl for sale(Sm.'/tY4f,Rosiness THBR
Wim. and Poda"mr,Codc:The Contractor's License Law docs not apply to an owner of OUT -TS-SWITC FlXTURES
0'3^ property who builds or improves therm,,,and who does such work himself our Ihmugh
his own employees,provided that such improvements are mol intended or.tiered for 'W RESIDF,NTIA SQ FC
sale.If,however,ilia holding or in frrovamem is sold within one year of completion,the SQ.FC FI. .FC
owner will have the burden of proving that he did not build or improve for pur-
pu l of sale)' 74
TO
7 [,as owner of the property,urn exclusively contracting with licensed contractors to
construct IM1e project(Sec.9614,Nosiness and Professions Coleco The Contractors Li- D
se law docs ten apply to an owner of RS IT property who builds or improves thereon,and QTY. PLUMBING PEPEE
who metracts for such projects with a coommu ms)licensed pursuant to the Conterrou s
License Law. PERMIT ISSUANCE
I am exempt under Seo- ,R&P C for thone.on 1 1
lnn��
ALTER-DRAIN&VENT-WATER(G) VALUATION
Owner Data
\4'O11KER5 COMI'ENSA'I'I on DIfCefollo following
RACK(LOW IR(YI IiC'I'.DEVICE vi I
I hereby affirm araer penalty of perjury one of the frlhswing declarations
❑ Ihave;rodwill for
inetor.3700 ofConsent Lalylk Calf-insure forairkumaaeof the DRAINS-FLO(1R.R(I)P.ANIiA,COND. ION
smirk,as provided for hY Section PIX)of the IsMtr Call,tic the pertorance of the
ark ford this penult is issued. Iq%TURI3-PER TRAP
Elan
1 have and will maintain Wnrku'n Cnm{sunsvtirn nourrom.whi h required t i Section
P00 Rhe laMtr Code,lanhe performtce rf IM1e xork for which this permit is issued. GAS-EA.SYSTEM�I INC.40UTLE'TS OCC.GROUP APN
'm ' Co�nPcnoyi lnalmom Caric,arra Policy tj�Dytr4�� /1(�
Cricq = ( �� Policy No: b— '/G GAS-IiA.5Y5'fCM-(lVHR 411iAI l'
CERTIFICATEOFE%EMPTION FROM WORKERS' ORCASIIINDUSTRL WASTE INTERCEPTOR
COMPENSM ION INSURANCE BUILDING DIVISION FEES
(This.,I,.need not be completed ifthe peril is Barone hundmddlars(Si00) GREAMTRAI'
or toxo � PIANCfiL'CK 10JE
Ic'ertify that in live performance of the work for which this peril is isowd,l shall SEWER-SAN 1'YARY-ST ORM EA.2110 IT.
not employ any person in any manner su a to become%object m me wurkeri Crmpen- ENERGY FEE
,ZxaI La—ut Cullfornlu.Date WATF,R II FATE WNENTMLECfR
2 pplimm GRADING FEE
UfICE TO APPLICANT:IL after making this Cmihcme of Exemption,you should WATER SYSTEMG`REATINC
hemme subject or me Worker's Compausua n provisioeat'the Labor Code,yen.nuua SOILS FEE
W forthwith comply with such provision,or this permit shall be deemed revoked. WATER SERVICE,
aQ
CONSTRUCTION LENDING AGENCY NEW RES ID17N'I JAL(•LMB, SQ F'1'. PAID
U 0 thereby vffir that hem is a construction lending agency for the performance of 1 Hccetpmk
V. L-' the work for which mi,parmlt i......d(Sm..109],Civ.C.)
U Lender's Name Tfyl'AL:
I.crdr,'s Address TOTAL:
�r tT.1information BUILDING FEE
F 1 sonify that 1 have road thisapplication
and ciunand%into cwt the above ii.
mrrect.lagree mmmply Welty mh...wmaro,camrve,oland staelaws
ama,.ptinma QTY. MECHANICAL PERMIT FEE
U z buildingmmtrucmion.and hereby au.hnrix mpresenmtives nllhis city menta upon the SEISMIC FCC
above mentioned property for inspectionpmr oas. PERMIT ISSUANCE
(We)agree to save,indemnity and keep Eamdess the City of Cupertino against ELECTRIC Flat
lubilitic,,,judgmmn...caslsand espeoses whatimay in any way accrue aguinm said City ALTER OR ADD'TO MSCIL S
I'LUM81NG
in onsudna of thc granting ofthis permit
cq
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO lo. FM11)
MECHANICAL FEE
fd'
GUTATIONS.
AIR HANDLING ON[17(0 1o.WOCFM) CONSTRUCTION TAX
Aplicunt/Commn r Dame ' li%HAUSTHOODIW/ CT) E{OUSING MITIGATION FEH
HAZARDOUSMATERIALS DISCLOSURE
heupplia,mature building occupant store or handle havardoux nmarial HEATING UNITE- IIgJX18 BTU)
y the Cupcnin.Municipal CWe.Chap¢.9.12,and the Health and Safety
Code.Scalkn 2953200' DENTING '(OVER 100.1100 BTU)
C1 Yes ❑No VEPAID
NTIL ION FAN(SINGLE RFSID) Receipts
Will the applies..future holding occupant use equipment or device,,which
emit hmordous air contaminants a%defined by the Bay Area Air Quality Management BO .'R-COMP QHP OR Imt.UfNl BTU) TOTAL: aS
f Ustdal^
❑Yes No
801-1711-COMP(OVF,R IIIa,I0 t'1'U)❑
Thaw nail Omhaeadaus nuneriuls.e ms under Cho mrfi95 o(the Cali- AIR CONDITIONER I NCE DATE
quire
Ltmiu1 dohsn erre Gage,Satires 255(15.is at, and 255]4.1 umlcnland th.ifine NEW'RfS1UliNTIALMECH. SQ.FI'.
.,a dame no currently have umnsnt.that his my nsM'mibilitytonotify 0c mcupam
/In ha mquircntemsx is sal is mel prior to olummerf.C�,{{ili`al ol(=v1'�ncv.
( xassee=kizartheag rot �� Dates TOTAh: ISSUED BY:
OFFICE