S 4387 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ON g:J it/_
CITFOF,$RERTINO BUILDING-ELECTRICAL—2—f_r149fPERMITNO.
BUILDING DIVISION APPLICATION4'ERMIT PLUMxmr..n$IacxwNlcn S 4387
BIJILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
(I I1 Y I-R JAP O'f. 06vC111
OWNS 'S NAME PHONE: CONTRACT'OR'S NAME: LIC NO:
SPt 6 Rua SIC CONTROL#
<'Hl'1'P /1: GINEE I` f W 1.1) O'. ADDRESS: ❑
C'}3�
CONO'ACT: PHON BUILDING PERMIT INFO
❑ Consultant Foes Paid by Appli"nt(Initial) BLDG ELECT PLUMB MECH
WAIJ LLA �FIS.b94. 1t ❑ ❑ ❑ ❑
LICENSED CON TRAC'TOR'S DF.C.I,ARATION Q'IY ELECTRIC PERMIT PEE
O Z I herehy allirm that I am licensed under prmidonu of Chapter 9(co Ging JOB DESCRIPTION
in
Sealm.7o0(BofDivision 3 eObe Bu,inessand Profession,Code,andnty li nsc RESIDENTIAL,
woo
VERM1fII'ISSUANCE.
Fps. I full lora and cbran. ❑SFDWL ❑KITCHEN REMODEL
aUU Licata Cloa Lic.# APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
H Z w Dam Comracmr
F5H ARCHITECT'S DECLARATION PANELS ❑MUUFI-UNIT El STRUCTURAL
vsZ Iun�jei 1pWerydans shall be used as pu rrep�`!+n / •(JG UP T02IXI AMPS MODIFICATION
O Z=G �j/ (0�'�'("•r 1� _{I ❑INTERIOR ❑MODIFICATION
REPAIR
on-,F'ul lacensill Vro&s,imud \SVECIA
S IMPROVEMENT (]SWIMMING POOLS
C C¢' I Mrthy affirm Ihm IOWNlam lexcmp Efrolm the C tuftalON dors Liccnee Law fur the Ps ❑BATH REMODEIBF.PAIft ❑DEMOLITION
XOaO following reason.(Section 9031.5.Business and Professions Cute:Any city or county RICALEl OT'FIER
vicarin.... .itIrdwinuemrrtoi ficnmmncgaluarncome movisiosof forCoolonniuofienseLaw(Cha ter9 UI1'IMISC.
Ythat he is licensedpursuanuuthe provoionx of the Cummers l.ieensc Low(Chapmr9W<Y�Q (commencing with Section 7000)of Divlslon 3.ahe Business and Professions Code)or OR POLE INST. COMMERCIAL:
eca C that he is exempt the clrom mrd the basin for me alleged exemption.Any vivlmion of ❑NEW BLDG/ADDITION ❑DEMOLITION
X^w Section 7031.5 byony applicant for a peril whjects the applicantm a civil penalty of POWER DEVI 'S #KTENANT ❑FOODSERVICE
W y raft more than five hundred dollars($5110).
FAQ Las owner or the norm bees with wages their sole compensation SWIMMING POO LF.CfRIC IMI'ROVF.MENT
r �S❑ property. Yen�P Y gas as penes ❑OTHER
[- willdothewnrk.mulfar monmac isnot iummlcduroReredforvab Sec.7(aft Boniness
and Professions Code:'rhe Cme randoex License Law docs not apply to an owner of OUTLETS-SWITCH -FIXTURES
ati
property who builds or improves thereon,and who docs such work himself or through
his own employees,provided Nal such improvements arc not intended or offered for NEW RESIDENTIAL EL R SQ FT.
,ala.It.hnwescr.thebnifingonimpmvemam is soldwilloome,ymatifcocnftcdn,the SQ.IT.FLOOR AREA 5/SQ.FT
overecolailder will have the burden of proving that he did not build or improve for per
pose of soled.
❑ Las owner of the property,amexclusively contracting with licensed contracmrsm TOT C�1J1 I�11/F
construct the project(Sec.7014,Business and Profcsxiom'Code:)The Lbmracmr,G-
ccaNc Law docs not apply to an owner of Instantly who build or improvesmcasm,and QTY, PLUMBING PER IT FEE
who contracts for such projects with a concessions)licensed pursuant to the Contractor,
License I,aw. PERMITISSUANCE
❑ I am exempt under Sec. ,B A,P C for this reason
ALTER-DRAIN&VENT-WATER( ) VALUATION
netDare
WORKERS COM PENSATION DECLA RATION BACK PLOW PROTECT.DEVICE
I hereby a0lrat under penalty of perjm0 one of the following declarations:
❑ Ihavc and will nminmin aCenificam ofCon¢nuo toff-innate far Worker's Co.,.- -PLOOH OOR ARBA,GOND. STORIES TVVF.CONSTRUCTION
,cion as provided for by Section 3](x1 or the labor Code fin the performance of the
work far which this permit is issued. FIX - If
❑I have and will maintain Workers Compensation Insurance as required by Section a aL
39110 of me huMU Cada for the pvr[mtwncc of me work for which chis permit is issued, SS e� S" < T b S OCC GROUP AVN
My Worker's Compensation Insurance carrier and Policy number are: /✓�
Currier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' W I TF: CE
COMPENSATION INSURANCE, eS 0R pe BUILDING DIVISION FEES
(Tht,section need not be completed if the permit is forone hundred dollars($100) rys e
or less.) aIEI S T JF PLANCHECK FEE
I evilly that in the performance name work lin which this permit is issued.l,hall m
Dol employ mty petson in any manner so as to become whjeet to the W'mkers Compxrf Ou I S tiT M EA. ( FT. ENERGY FEE
O Z saliva Laws of California.Date er ' 'r I:I 13C7R GRADING FIE
Z L APPlicam days
ail NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WAITER SYSTE EATI 1.1118 Ey
SDIIS FEL'
a , become xabjcn m the Worker's Comrymxotion provisions of the Labor Code,you most
forthwith comply with inch prasnionevcthi,vera it,hall be ro WATER SE
a �
Z CONSTRUCTION LENDING AGENCY NEW RESIDENIAE PLMB. .FT. &PAIDV O Therebyoust thatthem is a construction lending agency for the Perforance t S ReceiptI. — Inework far bid, his Permit is n,ard(See 309),Civ.C.) JJ �eC) U Lender,Name TTOTAL:
W IsnJer's AdJms 0. I certify that I have read thin application and state that the above infaratic
F^ to Co.,.I aI—It,comply with all city and county ordinances and state laws relating to QTV. FEE
U Z building construction,and hereby affinities,representative,of this city to enter upon the SEIS IC '.E
aMrvomemioned property for inspection pmywex s PERMIT ISSUANCE
(We)agree m nave,indemmdy and keep harmless Cupertino
eless the City of against ELEC ICF ?
Iiahilhic,,judgnmm,.cn,u and capcnws which may in any stay accrue against said City ALTER OR ADD TO MECH. PLUM1IB GFEE
in consequence ort granting of this peril.
APPLICANT U ;RSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHACAL FEE
SOURCED T "
AIR HANDLING UNIT(OVER 10.00)CFM) CONSTR CTION TAX
Si,mancrol p,huncJContmeor l0 Dum/ EXHAUST HOOD(W/DUCT) HOU SING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building uccepant,mrc or handle horsdous material I IEAT ING UNIT(10 100.(XX)BTU)
as deleted by the Cupertino Mmalipal Code,Chapter 9.12,and the Ileaph and Safety
Cmc.Section 25532(a)? HEATING UNIT'(OVER 100.000 BTU)
❑YezPAID
VENTILATION FAN(SINGLE RIiSID) Date Recciptp
40 Will the applicant or future building occupant use equipment or devices which BOILER-COMP(7HPOR IOD,INIU NIU)
On Kiair contaminants as defined by the Bay Arca Air Quality Management O
Dilaill? BOILER-COMP(OVER 100,010 BTU)
❑Ve,
I have read the hsntdous materials requirement,under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
tomia He I h h Sut Code.Sections 25505,25533 and 25534.1 unJemand that if the NEW RESIDENTIAL.MECH. SQ.Elf.
he
Join not rR tly ha,camnanL that it bat,rtzpnroibilitymnotify me«cupant
of the require is mel#norm ixsunnm ofo C11"ltglf a 4u7acy.
Uwner oA authn cd.,va `` 1/O #�D(ate TOTAL, ISSUED BY:
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