S 4416 (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 4416
BUILDING PROJECT IDENTIFICATION
BUILDING AVAESS: SANITARY NO. APPLICATION SUBMITTAL DATE
'`1�o£b�t - ►�L'ACW Sore �� .
WNER'S NAMH, PHONE: CON'ikACfOR'S NAME:
^ _-` LIC NO.
— , .k -ii erl�TZ Oxy. Ss(,o(� N/C CONTROI.p
CHETECiENGINEER: LIC NO: ADDRESS: x O r. ❑
SC'�37 MPrLr1a.I�nD �t�• S-.l
CONTACT, PHONE: %S(ay HUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELLE PLUMB ME❑CH
LICENSE)CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that em licenced under provisions of Chapter 9(conmendng JOB DESCRIPTION
0=Z with Section 900(p of Division 3 ofthc Busines.sand Professions Cade.and my license is RECDD
W 00 PERMIT ISSUANCE
CIF o full force and effect. �- $SIo$(1 ❑SFDWL ❑KITCHEN REMODEL
QUV ;-)arei"neClass Contractor
APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N66 Uute ^�-� S Coalman.�O.�t\�f C_!'^.ST
ARCHITECTS DECLARATION ❑MULTIANIT ❑STRUCTURAL
Z O'"Z 1 undboonad my plans shall le used as public records PANELS MODIFICATION
oy�o Oil 10200 AMPS ❑INTERIOR ❑ClHMNEYREPAIR
F.'9 f'LLl Licensed Pmfeasionul 201.1000AMPS IMPROVEMENT E]SWIMMING POOLS
C Y2; OWNER-BUILDER UItC1.ARA'1'ION OVER 1000AMPS El BATH REMODEI EPAIR [I DEMOLITION
C C Q 1 hereby affirm Thal I am exempt from the Contractor's License Law for he
XL U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL El OTHER
4:3 LL y which requires a permit to contortion.xl¢r,improve,demolish,or repair any structure /
I"1=�g Prior to its issuance,also requires Neappliner oumch permiuo fileasigned,moment SPECIAL CIRCUIT/MISC.
E y that he is licensed pursuant to the previsions of the Contractor.License Law(Chapter9
yy (annmencing with SecJon'IaXMp of Uivisiun3nflhe Ousincvc and Po[ensinns Cadu)or TEMP.METER OR POLE.INST.
COMMERCIA
C.4 C thin s e.ecmpi o and he idivert the bass Ibre aagexemp
ithlld etion.Any violation of
c Ll NEW HhDGIADDITION ❑DIiMOLITION
m
X m W Section 7031.5 by any applicant for u pear subjects the applicant to n civil penalty of POWER DEVICES
m of mhundred mom than five dull...(85(10). ❑TENANT [I FOOD SERVICE
FZa ❑I.es owner of Ne propcnY,or my employees wiN wages as Neir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
f0 will dothe ork.aw
ndthc eclureisnol intended mulTcied formle(Ses.7044.Business ❑OTHER
W F.2wand Professions Coo:*Me Contractor s License Law dears not apply m an owner of OU nA 1 s-SWITCHES-puX P_S
property who builds or improves theater,and who does such work himself or through
9
his own employtts,provided that such improvements are not intended or offered for NEW RESIDENTIAL EL SQ ET.
sale.IL however.the building or improvement is sold within one year ofconipletion.the SQ.FT.FLOOR AREA ASQ.FT
pucrhuilder will have the burden of proving thin he did nut build or improve for pur-
so of sale.).
❑ 1,.,.,,,.are of the pmpeoy,an,exclusively contrudin,with lean sol amnactors to
minuet the pmject(Sec.7044,Business and Professions Cudc:)The Contructoh Li- /
se law does not apply to an owner of pfopery who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who resonances for such pmjecns with a contmemgs)licensed pursuant o the Contractor's
License law. PERMITISSUANCE
❑1 am exempt under Sec. .B&P C for this reason L/-11
ALTER-DRAIN&VENT-WATER(EA) VALUATION
inner Dana
WORKER S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE JUL 12 1999
I hpe
ereby offinn under nally of perjuryone ol'the following declarations,
IM1ave and will mainainx Cenifirate..f Conxenno ndf-inwrcfor Workcr'x Compcn- 11
DRAINS-FLOOR.POOR,AREA.COND. STORIES TYU(( STRUCTION
sari...,as provided for by Section 37W of the Lawn Cade,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
Q(1 have and will maintain Worker's Compensation Insurance,as required by Section
3700 of rhe tabor Cade.for the Performance of the work for which this perit is issued. GAS-EA.SYSTEM-1 INC.J OUTLETS pPN
My Workch Com tloZncunNZI, crPaMyN,, her
Carrier: STlat I--OO yNn.:Q F�! a1-�'l� CPS-13A SYSTEM-OVF.RG(CA)
CERTIFICATE OF EXEMPTION FROM WORKERS'1j1.Q( GRI3ASIJINUUSTRI.WAS'I'Ii IN'CERCF.I'TOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(Thivsection need not becomplerod it nhepernait is foram hundred Jnllars($10(b CREASE*1 RAP
nr kms.) PLANCHI[CK ITE
I cenify that in the performance of the work for which this permov,isword.]shall SEWER-SANITARY-STORM F.A.200 FU
not employ any person in any manner so as to become subjesuo the Workers Compen- ENERGY FEE
O Z srtion Laws of California.Dole WATER HEATER WNENVELECfR GRADING PEE
z C) Applicant
NOTICE TO APPLICANT:If,after making thin Certificate of Exemption,you should WAl'ER SYSTEMoTREATING SOILS PEE
F-'
became ems,m the Wnrkors Compensation provisions of the col Cute,you matt
QIhnhwllh comply with such pnrvisnns or his Aconic shall be deemed revoked. WATIik SERV ICL'
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL ELME SQ.FT. PAID
L)O thereby affirm that there is a construction lending agency tonne perfnrmanceof Uma Receipts
the work for which this permit is Issued(Sec.3097.Civ.C.)
TOTAL:
ldmdcfs Name
W I1mbd,Address TOTAL: BUILDING FEE
1. 1 eentfy that I have mad this application and state that the above infirvnanan is
iii. ,i u mod.1 aures a,comply with all day and canary o..to.....and state laws relating to QTY. MECHANICAL PERMIT FEE
U buildingcemorwlon,and Tachy a-dantle.cprcncnlans,of nhisciry m enar risen the SEISMIC FEE
aMncmemioned property ler inspection pupwses, PERMIT'ISSUANCE
(We)agree m save,indemnify and keep monies,the City of Cupertino against ELECTRIC hili
habiluiecjudgments,costs and expenses which may in any way accrue against said City AC1ERORADDTOMECH.
PLUMBING FEE
moonwrouctAPPLICANT
of Nc tininfiRSTA gof thisD mir
WILL
APPI-ICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO IO.WO CPM)
MECfiANICAI.FEE
SOURCE.REGULATIONS.
n��`•a`+ �a•S-�� AIR HANDLING UNIT(OVER I0.001 CPM) CONSTRUCTION TAX
ss (� N
Signnarc of AppLc:ml/Catnmamr Duca 13XIIAUS'I'I{COD(WIDUCC) HOUSING MITIGATION FEE
IIA%Alt DOUS MATERIALS DISCLOSURE
Will the epplicum ar future building meupam score or handle hamNnus material 1113A'I'ING UNIT(TO 100,000 H'1'U)
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health send Safety
Cada Scaion 255326x1' HEATING UNIT(OVER 100.000 BTU)
[I Yes RN. PAID
VENTILATION FAN(SINGLE!RP_SIU) Done Recciptp
Will the applicant or future building occupant use equipment or devices which
snit hausMonc sir confaminunu sec defined by the Huy Arca Air Quality Management ROIhHft-COMP(3HP OR 100,000 BTU)
TOTAL'.
District! ���✓/// HUILER-COMP(OVER 00,M)13'1'U)
Yes I Nn
I have read the hamohns' a
mterials reqm
uircenu under Chapter 6.95 of the Cult- AIR CONDITIONER ISSUANCE DATE
remain Hwlth&Safety Cade.Sections 25505.25533 and 25534.1 understand that if she NEW RELSIDENTIAL MECH. SQ.FT.
building does not currently have.coram set is my responsibility to notify the occupant
of
the
requirements hi hmust bean
I" f a Certificate of Occupancy.
7 el, , �4 y A-s5
Owner a onalmnazod agent Date TOTAL'I ISSUED HY:
OFFICE