S 4471 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PERMITNO.
BUII.DINGDIVINION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4471
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: R J SIDE ) SANITARY NO. APPLICATION SUBBlMII IAA/LL DAIATE
ILII O 'S NAM :� nO //rpPHONE CONS'y Q-1LA ./i�IC �UC
LIC NO
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Toa TSG �26 (�{/ N/C CONTROL p
A CHITELT/sNGINEER: LIC NO: ADORE, /n � �S / ❑1
CONTACT. PHONE: 3 C/i� a CrN 'J✓BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUM MECH
❑ ❑ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby a0irn that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
O�Z with Sectioe]000)of Div'ion3of Ne Businessand Professions Code,and my license is RESIDENTIAL:
1yOp ver
-4 1:1
Jul- in full fora ADDITION
C KITCHEN
i_ (�FJ Licensr. Lic.X APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Qo 0. Dae TScan DEor
to a []MULTI-UNIT ❑STRUCTURAL
ARCHITLCI"S DECLA IO
L,,,O m PANELS MODIFICATION
Z O land erhand my plans shall he used as public records UP TO 2(X1 AMPS
p Z�� El INTERIOR 11 CHIMNEY REPAIR
F�F- Licensed Professional 201-IM)AMPS IMPROVEMENT C]SWIMMING POOLS
�adF-i OWNER-BUILDER DECLARATION OVER IOTA AMPS C BATH REMODEIIREPAIR ❑DEMOLITION
W d Q I herchy own.that 1 am exempt from the Contracmrs License Law for are
xx0.O L U following reason.(Section 703 IS.Business and Prefes....a Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
Ja
W 3 LL F' which requirea a permit to construct,alter,improve,demolish,or repair any structure
tLLo prior to itsissuance,alsorcquim,11co,plicantforsuchPermiuofileasignedstatement SPECIAL CIRCUITMISC. da jV
} Nm he,is beensrdpursuanno the provisions of the Convenors License Law(Chapmr9
^0� (rommencingwith Section]dfX))of Division3nfthc Buriness and Pr.fessionx Code)or TEMP.METER OR POLE INST. COMME
0.yx o Y that he is exempt thercfmm and the basis for the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
W^ Section7031.5 by myap,hricat forapermit subjects theapplicantmacivil Pennityof POWER DEVICES ❑TENANT ❑FOOD SERVICE
mQnot more than five hundred dollars($500).
❑ Cl,as owner of m
he property,or my employees with wages as he,, cnpneirmsm, SWIMMING POOLBLECTEIC IMPROVEMENT
yd2 wdl JONe work,attd Nestmcmrtis nm imendrd"Low
for sale(See7044,Business ❑OTHER
ul and Professions Code.The Contmcmr'a License Low does no,apply to an owner a( OUTLETS-SWITCHES-FlXTU
�' .. property who builds or improves thereon,and who does such work himself or through
_77�AX hl
his own employees,providedthat such improvements are not intended or offered tnr NEW RESIDENTIAL ELF,Cfit
safe.If,however,the building or impmvemem is sold within one year of completion,the LFLO616ARE)C' E/.er-builder will haverhe burden of Proving that he did not build or improve for pm-p.o� ate,.1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:oneuvct the project(Sec.7041,Business and Pmfessions Cade:)The Contmct.rcenseLawdoes not apply to an owner of property who builds or improves Nercon,and QTY. PLUMBING PERMIT FEE
whocontrctsforsuchprojects withaconuactm(s)licensed pumuammtheComractar'sLicense law. PERMIT ISSUANCEC 1 am exempt under Sec. .B&P C for Nis reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dom
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hemby affirm under Penalty of Kdo,one of Ne following declationn x:
�5 C I have and will maintain a Certificate of Consent to self-insure for Workers Compete- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
ration,us Provided far by Section 37W of Ne Labor Code,for the perfommnce of the
work far which this pn an is issued. FIXTURES-PER TRAP
C I have and will maintain Worker's Compensation Insurance,as required by Section
3701 of the Labur alp PcrR ante the work for which this permit is issued. GAS—FA.SYSTHM-I INC.4OUTLETS OCC.GROUP APN
My Worker pc a and Policy
Carrier: Policy No., GAS—EA.SYSTEMOVER 4IEA)
CERTIFICATE E% PTION FROM WORKERS' GRF.ASFJINDUSTRL WASTE INTERCEPTOR
CO PENSATION INSURANCE BUILDING DIVISION FEES
thsection need not be completed if the Permit is future hundred dollars($100) GREASE TRAP
or less.)('llPLANCHECK FEE
I certify that mine performancaofthe work forwhich this pmnit is issued.)shall SEWER—SANITARY—STORM EA.200 FT.
not employ any person in any munner so as to become subject o the Workers'Contain- ENERGY FEE
O ,z seri..lows of California.Date WATER HEATER WNENT/ELECTR / GRADING FEE
ZApplicant -
VVV111 NOTICE TO APPLICANT:IL after making this Certifirme.1 Exemption,you should WATER SYSTEMaREATING SOILS FEE
a ^( haeme subject to the Worker's Compensation pmvisions of the Labor Code.you must
�..t+ forthwith comply wirdsuch pmvisions or this onxim shall W domed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.ET. PAID
I hereby affirm that hem is a construction lendingagency for the performance of
Col O Dam RoeiptX
U F the work for which this permit is issued(Sec.3091,Civ.CJ TOTAL:
OVlender's Name
DJ l.endcr's AJdrexs TOTAL:
ly 1 anify Nm 1 have read this application tradition that Ne abiwe information is BUILDING FEE
iF+ In correct.l agree to comply with all city and county ordinances and,state laws mlming to QTY. MECHANICAL PERMIT FF.E SEISMICFEE
UZ building convection,and hereby authorize repreamortives of this city to enter upon are
move-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m vve,indemnify and keep haralexs the City of Cupertino against ELECTRIC FE
liabilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADD TO MECH. PLUMBING FEE
in consequence of the grouting of this Permit. _
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IQOX)CFM) MECHANICAL FEE
SOU CE REGULATIONS.
n N AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
natureo AfidwortuCancractur IDote EXHAUST HGOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futum Wilding occupant store or handlehaiandmare-Wial HEATING UNIT(TO I Dy"BTU)
as defined by the Cupertino Municipal Code.Chapter 9.12,and Ne Health and Safety
Cade,Section 25532(.)? HEATING UNIT(OVER 100,0)0 BTU)
❑Yea No VENTILATION PAN(SINGLE RESID) PAID -
Date Recein,4
Will the applicant or future building occupant use equipment or devices which BOILER-COMP OHP OR 100,000 BTU)
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management TOTAL:
District? BOILER-COMP(OVER 100,0110 BTU)
❑Yea 7N
1 have read the hazardous materialsAIR CONDITIONER ISSUANCE DATE
requirements under Chapter 6.95 of Ne Cali-
f forma Health&Safety Cute,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.
huilAing fires not v
currently tenant,that sp
it is my reoreibilitYto na
otify the cupmt I
o rrcrVin, It rbc and 'ate ssuanceofa Cert if, meof cu may.Owners euNorizeJ agent m TOTAL: ISSUED BY: `
jC_
OFFICE