S 4377 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
c�4 INO BUILDING-ELECTRICAL. PERMIT NO.
CIT I DI G DIVISION
BUILDING DIVISION APPLICATION/PERMIT PINGPRNG CT IDENTICAL S 4377
BUILDING PROJECT IDENTIFICATION
OUILDING ADDRESS: SANITARY NO. APPLICA'I']ON SUBMITTAL DATE
31S-7,5- 4 no. C-A 9So _ _
WNI. , AME: 'I PHON is C( ALTO S NO:
O V G _ O r�'1 NIC CO ROL A
NCH H I ' x V hI N O ADI R SS: J�oC ❑
C1 Yoe) PHONE ❑ Consultant Fees Paid by Applicant(Initial) IILDG BUIIEDECI PERMITLBNFO MECH
1Z Z
yl
LICENSED C091 RACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby allirnt that I min licenced under provddons of chapter 9(commenomg JOB DESCRIPTION
IC),
with Secion 7000)of Division 3 ofthe Husumis and Professions Code,and my License,, RESIDENTIAL:
n n It PERMIT ISSUANCE
lull lnac nd elf �� oSK ❑SFDWI, ❑KITCHEN REMODEL
Liccnc Lic.p Un¢ CnntAPPLIANCES-RESIDENTIAL []ADDITION EI PLUMBING RI:PIPE
F�[Y memr
FOti I I ARCHITECT'S UIiCLAR (1NN. PANELS ❑MULTI-UNIT El STRUCTURAL
Z Oy? Iunderaandmyplarm shall be used n.public mcuMODIFICATION
OZ—O UPT0200AMPS El INTERIOR EI CHIMNEY REPAIR
I-�f'u: LieemN Ptofcxeional 201.10I0AMPS IMPROVEMENT E)SWIMMING POOLS
Y
OWNER-RUILUI:H OECLARA'1'[ON OVER 1008 AMPS El BATH REMODEURF,PAIR El DEMOLITION
C a I hereby anon mat 1 am exempt Hon the Comracmr's I.ivence Law ror he
o following reason.(Section 1(131.5,Business and Professions Calc:Any city or county SIGNS ELECTRICAL E:1 OTHER
Y13 a U.N ch require,a Penni(to conafnet.alter,Ruffner,JCauall,h,or repair any stmctute
1"'1=' whi
C) prior to its issuance,also raquims He applicant for such permit to file a signed statement / SPECIAL CIRCUIT/MISC.
Out he is Iicen,ed national to the provieior—I the Conmemd,Lamm Law(Chapter9 Le
0 (commencing with Section 7000)of Division 3 of The Business and Profc%omis Cade)m TEMP.M ETER OR POLE INS'F.
a c that he is exempt therefrom and the basis for the alleged exemption.Any violation of E DG/ADDITION [IDEMOLITION
LX
W l� Suction 7031.5 by any applicant for u permit ours",the ap,hrout m u civil pcnulty of POWER DEVICES ❑FOOD SERVICE
not mom than Eve hundred dollars 1$51107.
I,u,owner of the mann Ince%with wager,us their sole compensation, SWIMMING POOL ELECTRIC IM 1LNT
_ property, Y aaID Y b penia
1- will do the work.and the structure is not intended or offered for sale(See1HN,Business OTHIiH
G;m and Professions Code:The Connacunex License Law does not apply to oc owner ofOUTLETS-SWITCHES-FIXTURES
property who build,or bnprme,Ihercon,and who dues such work himself or through
his own employees,provided that such improvements am not intended or offered lot NEW RESIDENTIAL 12LEC'FR SQ FT.
_sale.If,haw r.me bouldingormpro ant(,odd withiumne y,orof,orme inn,the .FLOOR AREA HSQ,FT.
Fiervbuilaer will have the burden of proving that he did not build or improve lot put.
ve m sole). —l��
1,m"owner of Nm t
e property,auselosivuly contracting with licemed contractors to TA 1
enmwauhe project(Sm.H6 .Business and Professions Cade:)The Contmemr,Li- 1 r
cruse Law does not apply m;m owner of property who builds orhop rovesmnrcoa and QTY. PLUMBING PERMIT
who commas for such pmjccts with a contrxmgs)licenmd pursuant to the Con/Itmcmr, 't '
Lian,CLaw. A PERMIT ISSUANCE UG 1 7 11M
l am exempt under Sec. .It&PC rot N' reas,a. -3 i
iY A R-DRAIN&VEE WATER EA) VALILATION
Dam
WORKER'S COMPENSATION DECLARA 11 ka,frACV ,PROTECT.DEVICE '7 �/ Q ,rte O
I hereby affirm under penalty of perjury one of the following de utinns" 1 �i L• _ lJ
have and will maintain uCeNticecor Consent tosell'-insure far Compel- UR S-Fr0 0 EA,COND. Sl OR I ES
'1'Y PE CONST RUCTION
n,as provided for by Section 37M of the Labor Cade,for the'do f
ork far whlclnhis permit i,hsuud. I -I' It
Alf
I have and rill a tam W'otkce Cumnemation Innummb,ac required by Section
1100o m p mareaf Ne work for whi<b than Far In is d. AS-EA.S E� S OCC GROUP APN
My Wo v Policand y
Nic o
3 ,3 GAS-G. S "OVE 1
Came a Policy No.M W
1 'll7 R_: i iMP110N FROM W'O R.'
COh1MNSATLON INSURANCE GRE W E 'ERCHI'i' BUILDING DIVISION FEES
(I ed not be cu....elcd it permit is for nnc hundred dollars($100) GRE,kSE TRAP
m lca,.l PL iCX
Fl.1.
I certify that In the Perfmrmanceuf Fc work for which Nis Fermis is issued,l shall SEWER-SANITARY-STORM EA.2IX1
optemploy any Personrin a nymunne,x.a,mbecomembjem to the Worker.,Cumpien- Erucly FEE
inion Laws dCalifornia.Data WATER HEATIiI W/VENT/ELEC R
,zZ A,,Uimo I GFEE
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should WATER SYSTEMOREATING
F ? hero..s0j,o ,,the Worker,Compensation Provisions of the Lahr Code,you roust SOI FEE
hard ith comply with such owisinn,or this permit mall he decmedrevoked. WATER SERVICE
Q
7 z CONS"TRUC1ION LENDING AGENCY NEW RESIDENTIAL PI,MB. SQ.Cr PAL [)am Rcccipt a
V OIherebyaRnn thin heme i>amnstmaion lendingugency fomite pefformeacem
f' The work for which This permit is u,uod(Set.31191,Civ.C.) AL:
OU Ignder,Name
�.t W lenders AJdre,s TOTa
0. 1 certify that 1 have read this application and state that the above information i,. BUILDING FEE
F� � comm Lagme mcomply with allciryand county otdinuncesand sutelaws mmtingm QTY. MECHANICAL PERMIT I FEE n
bwldlig mar
nuctiun.and hereby uutbarive reprewntativr%of this city to enter upon the SEISMIC PE Zr 2-0
above-mentioned property for inspection puryoses. PERMIT ISSUANCE Z91
(We)agree m save,indemnify and kap M1urmlexs the City of Cupertino against ELECTRIC
liebdaie,,judgmenu,cnsts and expcn,es which may in any wary accrue against said City ALT ER OR ADD T(1 MECi 1. PLUMBIN 7 'L
APImcg cofthc tingor Nllperant. it
LIC iRS N SA DWILLCOMPLYWIT LL NON-POINT AIR HANDLING UNIT(TO Miss)CFM) MECIIII A IEE 'l
501 ,ER000LATI
e' _ AIR HANDLING UNIT(OVER 10.001)CFM) CONSTRU IONTAX
aammofAppli a mmemr ateIle' EXHAUST HOOD(W/DUC) HOUSING ITIGATION FEE
ZARD . MATERIALS DISCLOSURE
WBltbeapphcamot future building cremprat nom or handle M1arardous maacrial ' HEATING UNIT IT 1100.01(a)BE 2 O
us defined by the Copetino Municipal Code,Chapter 9.12,and the Healon and Safety
Cade,Seaiun 25532(d! 1IEATING UNIT(OVER 100,M)NTU)
Dyes ❑No VENTILATION FAN(SINGLE RESIDE PAID
Uatc Receipt
Will the applicant or future Wilding occupant use eyuinmcnt or devices which
It
marmot mr aontumi ants ns defined by the Bay Aran Air Quality Manugemem BOILER-COMP(3HP OR IW.IXIO BTU) TOTAL:
mat^ BOILER-COMP(OVER IIXkUUd BTU)
❑yes F7 No
F 1veteaathe naiardetumriak,tqui¢mcm,uakr CTapmr h95 of the Cali- AIRCONDI'I'IONER ISSUE CE DATE
for',1 Int&S:dety Calc.Sechans 25505,25533 and 25534,1 understand thus If me NEW RESIDENT[Al.MECH. SQ.FT. e� / 7
/ docanot�' po,:rtt.
myrcsrym,ihilitymnuOfyOeoccupent 6 /
rewirenaenran«ora mrat orf up c.otho. TJITA ISSUED BY:
OFFICE