S 4369 (2)APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT IDENTIFICATION .
PERMIT NO,
S 4369
BUILUING ADDRESS
4 l C �Q �d e c �J V',1 � e44,_1 o
SANITARY NO.
APPLICATION SUBMITTAL. DATE
- 3 v- Q
OWN 11 NA ✓/ L PHONE:DO �! - /�
1MRACTOR'S NAME / LIC NO:
KAs'
NIC -
❑
CONTHOLM
.RCHI'IECTIENGINCER: I.ICNO:
ADDRESS:
CONTACT.PITON
❑ ConsUltent Facts Paid by Applicant (Initial)
BUILDING PERMIT INFO
BLDG ELECT PLUMB /MECH
❑ J ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm him, I am licensed under provisions of chapter 9 (commencing
with Seclion7")of Division 3 ofthe Business and Professions Cadl and my license is
in full force and eRect.
License ClassLIcN
Dare Commemr
QTY I ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
DSFDWL ❑KITCHEN REMODEL
[]ADDITION [I PLUMBING RE -PIPE
DMULTI-UNIT El STRUCTURAL
MODIFICATION
El INTERIOR DCHIMNEYREPAIR
1 MENT DSWIMMING POOLS
lATHREMODEIJREPAIR DEMOLITION
D OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL
ARCHITECT'S DECLARATION
1 understand my plans shall be used os public retard
PANELS
UP TO 2t30 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt ham the Contractor's License Law fnr the
following reason. (Section 7031.5, Business it Professions Code: Any city or county
which requires a Permit to construct, altim improve, demolish. or repair any structure
prior to its issuance, also requires rhe applicant for such Permit o file a signed statement
that he is licensed pursuant o the provisions ofthe Communes License lww(Chapter 9
(commencing with Section lIXX)of Division 3 ofthe Business and Professions Code) ar
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not marc In.. five hundred dollars ($500).
❑ I, as owner of the property. or my employees with wages ns their sot<compenxetion.
will do the work, and the structure is not intended or offered for sale (Sec. 1044, Business
and Professions Code: The Commuters License Law does not apply m an owner of
property who builds or improves thereon, and who does such work himself or through
his own employees, Provided that such improvements arc not intended or offered for
sale.Uhome tolthe buildingorimPmvemcm is soldwithinone Year of rnmplction.the
ownernbaer will have the burden of proving that he did not build or improve for par -
pose I.J.l
owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec 9844. Business and Professions Code:) The Contractor's Li-
cense Law dews not apply toonowner ofpropenywho builds or improves therenn.and
whocontracts forsuch projects with aco muchr(s) licensedpursuantm the ConOactors
Licenx Law. -PERMIT
I am exempt under $ B&PC Imiwr s
201.1000AMPS
OVER IIIIW AMPS
SIGNS ELECTRICAL
SPECIAL CIRCUITIM1SC.
'1' EMP. METER OR POLE INST.
OMM R IA
�—i
D NEW BLDGIADDITION D DEMOLITION
❑ TC•NANT ❑FOOD SERVICE
IMPROVEMENT
DOTHER I
POWER DEVICES
SWIMMING POOL ELECT RIC
OUTLETS -SWITCHES -PIXY S
—S 1
NEW RESIDENTIAL ELECIR
!
SQ iJV1'1 3 01911 !I
L'
By
TOTAL:
QTY. PLUMBING PERMIT FEE
ISSUANCE a 0
Da d
WORKIiRWSCOMPENSATIONDEC. RATION
1 hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Cenificate ofConsenno self-insum for Workers Comped-
Section 31 W of the Labor Code, for the performance of the
nation, as provided for to
work haanthis permit L. Lsued.
ofthuv ldeamnehi h required by Section
E]1 haveve and will maintain Worker's Compensation Performancefor which this permit is issoW.
My of lb's Co Code.
sationthe
surance cancer and Policy
Cm Workers Compensation Insurance carrier and Policy number are:
Cartier. Policy Na.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if lbs permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this Permit is issued. )shall
importer employ any person in any ver so as to become subject to the Workers' Compen-
..tion Laws of California. Date
Applicant
AIA'ER-DRAIN & VENT -WA'IT'ER TA)
VALUATION
/J -C
BACK FLOW PROTECT. DEVICE/
DRAINS- FLOOR. ROOF AREA, COND,
STORIES
/
TYPECONS UCOON
IsIX TURES - PER TRAP O
GAS - EA. SYSTEM -1 INC. 4OUTLETS
pCC.GROUP
APN
GAS- EA. SYSTEMOVER4 (EA)
GREASFJINDUSTRL WASTE INTERCEPTOR
BUILl31NGUMS10N FEES
GREASE TRAIT'
PLANCH[CK FEE
SEWER -SANITARY -STORM EA. 200 FT.
ENERGY FEE
WATER HEATER WNENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you should
become subject ut the Worker's Comped sat inn provisions of the Labor Code, you must
foMwith comply with such provisions or this Permit shall be deemed mvoked.-
CONSTRUCTION LENDING AGENCY
I herebyaffinn thauhem is anntonto n lending agency for the pottormunec.f
the work fnr which this permit in issued (Sec. 3091. Civ. C.)
Landers Nome
WATER SYSTEMbTREATING
WATER SERVICE
SOILS FE
PAID
NEW RESIDENTIAL PLMB. SQ. FT.
D a Reaiptk
TOTAL:
Lenders Address
T
7
BUIL N E
71
1 certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building cansuvction, and hereby outhorim representatives of this city to enter upon the
above mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, cowls and expenses which may in any way name against said City
inconsequenu ofth r raidgofthispermis.
APPLICANT STANDS AND WILL COMPLY WITH ALL NON -GIN'[
SOURCE 10 /
Lee6 ip 6
`
QTY. MECHANICAL PERMIT FEE
SEISMIC FE
2-40
PERMIT ISSUANCE
PERMIT
ELECTRIC FN
ALTER OR ADD TO MECH.
PLUMBING FEE
D
AIR HANDLING UNIT (TO I BJI(X) CPM)
MECHANICAL FEE
CONSTRUCTION TAX
0
AIR HANDLING UNIT (OVER ItL000CFM)
Signature of ApplicanVContmcmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant orhinmbuilding occupantwmreor handlehazamausmmenal
as Code,Sectionby theCo a) iso Municipal Code, Chapter 9.12, and the Health and Safety
C] Yes ❑No
Will the applicant or future building Occupant use equipment or devices which
miI burned.., air Innbrminanls as dE etl by the Bay Are., Air Quality Management
District 1 Yes F1 No
I have real the hwardous materials rtquirerrenls under Chapter 6.95 of the Cali-
fomid Health & Safety action. 25505, 25533 and 25534.1 understood that if the
building docs sol cooly mtenanl, Ihm it ism nsihiliry to man the ixcupa
.It
f the require n¢w' nava he met prior ace afa Certificate cupancy
EXHAUST HOLD OAMUCD
HOUSING MITIGATION FEE
HEATING UNIT (TO 100,001 BTU)
HEATING UNI r (OVER 100,010 BTU)
PAID
Date Receipt M
-
VENTILATION FAN (SINGLE RESID)
%OILER -COMP (JHP OR I(IO,fXp BTU)
T
BOILER -COMP (OVER I00,M) BTU)
CONDITIONERr
ISSUANCE DATE
ISSUED BY:
NEW RESIDENTIAL MECH, SQ. FT.
AL:
net or eothon agent Da
OFFICE