S 4308 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL PERMIT NO
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4308
BUILDING PROJECT MB IFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL
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tLS .a' v6 / z 2 ( 9
1 OWNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO: N/C (l9 CONTROLS GR TI c- yob -0114 AR- 2D 3109
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
AJIA a 014 nun n7 San 6�ylli%
CONTACT: PHONE: BUILDING PERMIT INFO
Eric 601ei tm- Nq✓$y0 ((oS'b)593-N5oD gG
❑ Consultant Fees Paid by Applicant(Initial) B�pG� ELECT PLUMB MUCH
❑
LICENSED CONTRACTOR'S DECLARATION 1:1 E]ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commencing Q' JOB DESCRIPTION
Q0O 'with Section 9000)of Division 3 of Ne Business and Professions Cade,and my license is PERMIT ISSUANCE RESIDENTIAL,
O
W,P: is full force and effec
V License Clae Lick 93(0982 ❑SFDWL ❑KITCHEN REMODEL
PF Z� Dart Comrdmmr AC'ARO APPLIANCES-RESIDENTIAL
❑ADDITION ❑PLUMBING RE-PIPE
an ARCHITECT'S DECLARATION
O Z 4 i understand my plans shall heated as public records PANELS ❑MULTI-UNIT ❑STRUCTURAL
MODIFICATION
UP T0200 AMPS El INTERIOR El CHIMNEY REPAIR
eee14Eqqz"1Lsensed Professonal
OWNER-BUILDER DECLARATION 201-11"AMPS IMPROVEMENT SWIMMING POOLS
❑
6 W 6 1 hereby affirm that 1 am exempt from the Contractor's License Law for the OVER I"AMPS ❑BATH REMODEL/REPAIR DEMOLITION
W 3 LL F following reason.(Seale.7031.5.Business sad Professions Code:Any city or county SIGNS ELECTRICAL D OTHER —
.F,.0..0 m which requires u permit to consumer,alter,improve,demolish,or repair any structure
JN
dd prior to its issuance,also requires the applicant for such permit to file a signed slammem SPECIAL CIRCUIT/MISC. ec+`J that he is licensed pursuant m the powim.mof he Chancrous,s License Law(Chapter 9 41
mell
W 'C 0O (commencing with Section]WO)of Division 3 of the Busineasand Prnfeliftns Code)or TEMP METER OR POLE INST. COMMERCIAL-
0. n that he is exempt therefrom and the basis for the alleged exemption.Any violation of
..
Section by any applicant for a permit subjects the I ❑NEW BLDG/ADDITION El DEMOLITION
applicant to penalty of POWER DEVICES
tet mare than Five the progeny,
or my employees
[I TENANT -1 FOOD
q❑Q Lazne work,the pmpeny,ormyemntendes with wages Bred for ilei(See7,14.Business
SWIMMING POOL ELECTRIC IMPROVEMENT
^�S
will do the work,ands structure oContisnot s License Lwe due,act
11,.]044,Bu sine ss ❑OTHER
0.
property
Pliferty whe b Cade:The oyes thereon,
License Law does nm apply m if net of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ FI
sale lf,however,the building orimprovemem is sold within one year of completionthe SQ.FT.FLOOR AREA S/SQ.FT.
ncobuilder will have the burden of proving that he did not build ar improve for pus-
pose of sale.),
❑,1,as owner of the property,am exclusively contracting with licensed contractors to IOTA
construct the project(Seo.7M4,Business and Professions Cade:)The Contractors Li-
censeLowdoesnotapplytoanownerofpmpertywhobuildsorimprovesthereon,and QTY PLUMBING PE
who contracts forsuch projects with acontramm(s)licensed puraman of the Commetar's
License Law.
❑1 am exempt ander Sec. ,B&P C for this masrm PERMIT ISSUANCE
ALTER-DRAIN&VENT-WATER(EA)
caer Date ALUATION
low
WORKER'S COMPENSATION DECLARATION �D O
BACK FLOW PROTECT.DEVICE
I herehyll maiunder penalty
teperjuryone ofthe following wmkor Co
❑Ihave and will far by Sc Ceni fonts of Consent to hila Car Cher Workete Gsmpeu DRAINS-FLOOR,ROOF,AREA,COND.
workf as vt,.,tried far ri Ss ram 3]00 of the Labor Cade,for the perfonnanoe of the - STOR BS ��UCTION
work for which[his permit is issued. FIXTURES-PER TRAP
Q I have and will maintain Worker's Compensation w Insurance,which required by Section
MY ork Labor Con for the perfonnaneeofthewhrk numbethis permit is issued GAS-F.A.SYSTEM-1 INC.4OUTLETS OCCGROUP Z APV!
My Worky��[ Comppen``tiggnlnsumnce,,py and Policy number ale n
Carrier: Far[ CERTIFICATE
OF 1XEMPTIlicy No: WORKERS' n20l GAS-EA.SYSTEM-OVER 4(EA) // '-5 3�
CERTIFIC OMPEN COMPENSATION
EXEMPTION WORKERS' /` lC
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be cum letedif the BUB,DINO DMSIO FEES
p permit is Throne hundred dollars($I W) �
nr lessJ GREASE TRAP PLANCHECK FEE
Toy any thatmthe no,areame, of as 1.
he tikmvC rpaml SEWER-SANITARY-STORMEA.200FT.
not employ any person is any manner so as m become suhjed m the Workers'Chmpen-Z moNERGY FEE
0an Laws of CaliforniaColifarnia Date WATER HEATER W/VENT/ELEC R
7 2 Applicant GRADING FEE
G 0 NOTICE TO APPLICANT:If,after making this Compton,of Exemption,you should
a 5 became sub act m the Worketa Com p P WATER SVSTEM/fREATING
j Compensation mvisioms of the Labor Code,you must SOILS FEE
LkI forthwith comply with such provisions onhis permit shall be deemed revoked. WATER SERVICE '
Q
O
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIL SQ.FI'. PAID
I hereby affirm that there is a coommmme lending agency for the Performance of Date Rewiptk
{L H the work thi
for which s permit is Issued(Sec 309],CivJt.i.CJ
Lender's Name
L) Lender's Address TOTAL: VI TOTAL:
Fa 1 certify that 1 have read this application and state that the above information is BUILDING PEE -
w. V) correct.i agree to comply with all city and county ordinances and state laws miming to QTY. MECHANICAL PfiRMIT FEE
AF
U � building construction,and hereby authorize representatives of this city m enter upon the SEISMIC FEE
above-mentioned Property for inspection purques. PERMIT ISSUANCE
(We)agree 0 smva,indemnify and keep harmless the City of Cupertino against ELECTRIC FE
liabilitiegjutlgments,costs and expenses which may in anyway accrue against said City ALTER OR ADD TO MECH.
chnseyuence of tM1e graining of is permit. PIAMBING FEE
APPLIC UNDERSTAN AN WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOU .'R rGUTAy'IONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER 10,000 CPM)
G- 2-9 CONSTRUCTION TAX
Signature ofApphcaWCou tar Date EXHAUST HOOD(W/DUC10
HAHOUSING MITIGATION FEE
Z OUS MATERIALS DISCLOSURE.
Will the applicant or fumro building recupinatioreor handle hazardous material HEATING UNIT(TO 100,00)BTU)
as defined by the Cripenino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(al^ HEATING UNIT(OVER 100,000 BTU)
vicf'
❑Yes _1 No
VENTILATION PAN(SINGLE RESID) PAID ..-
Will the applicant or future building occupant use equipment or devices which Date Receipt If
mitict' a,air contaminates as defnN by the Bay Area Air Quality Management BOILER-COMP QHP OR 100,000 BTU) -
DieTOTAL:
71 Vic, LIN. BOILER-COMP(OVER 100,1000 BTU)
I have read the hainst materials requiremems under Chapter 6L95 of the Cali- AIR CONDITIONER /! ISSUANCE DATE
fomla Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,IIT. G _ UA 2._TE
buildi dries not currently eat namJhatit is my responsibility mnmify Nc rocupainIP
of swhic me[prior he issuance of a Certificate of Use pone.
O a mumo,o,l nt u 'Date TOTAL: ISSUED BY:
OFFICE