S 4430 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL .S 4430
BUILDING PROJECT IDEN'TIF'ICATION
BUILDING ADDRESS: SANITARY N0. APPLICATION SUBMITTAL DATE
2 A✓ 1,e. lit
VNER'S Melton: PHONE: CONI RACTOR'S NAME: LICNO',
r i SjgA '1 NIC CON'I'ROLa
T
GHTECDENGINEER: LIC NO: 'UD ESS a _I ❑
AdAeii
CONTACT: PHONE: S �S0�Z BUILDING PERMIT INFO
�6-Z3 ❑ Consullnnl Ftts Paid by Applicant(Initial) BLDG ELECT PIAFIB MECH
Y V
LICENSED CONTRa $DECLARATION QTY. ELECTRIC PERMIT FEE1 hereby smith mat 1 am licenslicensedcsed made,pro.iamns or Chapter v(commencing JOB DESCRIPTION
OecZ with section 7000)of Division 3 of the Business and Profession.Cwe,and my license is RESIDENTIAL'
u10 YLRMI'1'ISSUANCE ❑SFDWL ITCHEN REMODEL
F,W Oti in full ik and all (i
aUU Lieen Lic.p APPLIANCES-RESIDENTIAL ❑ADDITION ❑ MBING RF.PIPE
H6aDrsc Cpmrwmr
F,Dr ARCHITECTS DECLARATIM0 PANELS ❑MULTIUNIT [I STRUCTURAL
Z O r Z 1 understand my plans shall he used as public records MODIFICATION
UP TO 2N)AMPS
❑
O Z-+C INTERIOR ❑CHIMNEY REPAIR
1=�E-rW Licensed Profexsinand 201-IIXXIAMKS IMPROVEMENT ❑SWIMMING POOLS
YOWNER-BUILDIiR DECLARATION OVER H100 AMPS O BATH REMODEIIREPAIR 0DEMOLITION
C C Q 1 hereby af0m+mat 1 am exempt from he Cantmcmr's License Law for the
X3 e.U lulka, ing mtouri Sect....7031,5,Business and Proes%inm Code:Any city or county SIGNS ELECTRICAL [I OTHER
F O y which requires it permit u+con.%uuct,alter,improve.demolish,or repair any slmcarc
4 print)its ie,marce.also requires the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
that he is licensed pursuant the provisions of the Contractors License Law(Chapter9
W M0 (Oommencing with Section 7goa)of Division3 ofthe Business and Pmfcssions Csde)m TEMP.ME-ER OR POLE I COMMERCIAL:
a Y C dud he is excnyt lnce,fmnt and the basis Iia the allcgcA cxcmplinn.Any violation of C)NEW BLDGIADIII'TION [_1 DEMOLITION
Xan' Section 7031.5 ny my appliconl for a permit subjects the applicant h+a civil penalty of POWER DEVICES ICES
w t more than five hundred dollam SNOM, ❑TENANT FOOD SERVICE
{-Z Y IMPROVIiMENT
cet: ❑ I,othe wornftne peotracot myemployees wimwages
edforfair
( ec.mmpemenon, SWIMMING POOL,F.LF.CI'RIC OTHER
ce F will Aothe work,Codec he Ca ux,ounot' Ail.... otl does a., pply oOan owner
of
C 3 m and erofe,viuns Code:The C es clumrm L nd w do does oat apply s if owner of (1➢TLISLS-SWITCIIhS-FIXTURES
properly who builds or improves thereon,and who does such wore himself of through
hi,own however,
the provided eat such mentis old w arc not intended or alfercd for NEW RESIDENTIAL IiLECTR SQ FT.
sale.IL however,the building or improvement is sold within one year of cpmpldion.the SQ.FT.FLOOR AR 8 ASQ.fT.
nw ie-nuildar will have the nurdea of pm.ing the he Aid not build tar Improve far put- 661
puscof"a). 1�� VA
0 1,as owner of the properly,am exclusively contracting with licemed contaeters to T
construct the project(Sec.1011,Business and professions Gras the Contractors Li- I
u c law does notapply m an ownerof property who builds or improves detour, ad QTY. PLUMBING PERMIT
who cummnts lorxuch pr j„its with uanfoo, s)flescd pursunm mthe Can nractax a
I'ven,a law% PERMIT ISSUANCE
0 I am exempt under Sec. .B&I'C for this reason
ALTER-GRAIN&VENT-WATER EA) TION
Data �® �
to WORndiR'SCOM of opo',[ONor UIfCLARAI'[ON BACK PLOW PROI'EC'I'.UEVICIi
1 hereby al mai under penalg of perjury one of the following d Worker's
io Conniver-
,t lhave andwi,maintains Cion 37eof comethroCode,surefer WnrkehscofhDRAINS-FLOOR.POOR AREA,COND. STORIES 'TYPE CONSTRUCTION
stenos,tax prsrvi dti fpr by Ss i... 37N)of the LoMn Crxl=,for the performuncc of me
wore for which this pem)it is issncd. FIXTURES-PER LRAV
Xhave and will maintain Worker's Cnnnp,nsatina]a...once.ax required by Section
ofthe laMa Code,fonha perfomonc=ofrhe.,,,it far which this permit is isvued. GAS-ICA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
My Wurky._ pt _yon lnyu+ c ar ahaY rynam ram J GAS-EA.SYSTEM-OVER4UiA)
Carrier. �J*C) r F Y rt q 7 'L
CIiRTIFICAI'H OF EXIiMITION FROM WORKIiR:'OtO 13 I GREASUINDUSI'RL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FL'ES
(This section need not he completed Ron,path+it is forma hundred dollars 06100) GREASE'IRAP
or less.)(This
FEE
leerily dual in the pe,It nnn.ntotal the work tut whiclvhis panni,is iaucd.I rliall SEWER-SAN[I'ARY-STORM IIA.200 FT.
out employ any parson in any manner sJ us m ba'omcsubjea to the Workers'Coope.- ENERGY FEE
Z satins taws of Califamia.Data WATER HEATER WNENT6iLECTR GRADING FEE
Z O Applicant
NGI'ICE TO AI-PLICAN'l':IL after making this Ccrtiti,ac of Excmpuon,Ynu should WATER SYSTEMOREATING SOILS FIJI
a become subject to the Workers Comput,alu n prnvt ora of the Lalxa Code,you mutt
forthwith comply with such provi.%ims tot his permit shall be deemed revoked. WATER S12RVICE
Q
U O CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
I hverb,afOrm m.,,h,re is a conxlmou a loading agency Bathe ped....umccuf Dote Racipt
F' the work for which this permit is issued Noce.uPG.Civ.CJ
O U Isnders Name TOTAL:
I ceders Address
W
BUILDINGFEE r�
1 ccaily that I naw read thI upplicaem and setae mat that above mformnIinn is
Z com•ct.1 more, ,,comply with all city and county ordinances and state laws relating m QI'Y. MECHANICAL PERMIT FEE
V Z buildingconsauaion.and herebyaatlmr.representatives afthis city facade,qvm the SIiISMiC I'Efi
mbove-memioned properly for inspection putfivar, PERMIT ISSUANCE
ELECTRIC
(We)agree to use,indemnify ad kccpfrontlet,et,no,Chy of Cupertino again”
frontlet, I�
I'whiliiies,)udgnnents,costs and expense,whalinmy in any way ax,rue"or"said City ALI FIR OR ADD'IO MHCH.
1'LUMUING ITHi
in APPLICANT
of thegrantingof thisposit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 1O,0Ul)CPM) MECHANICAL 'E
fSOURC EGUL.ATIONS.004 AIR HANDLING UNIT(OVER 10,000CPM) CONSTRUCT NTAX
imon. Appliado o mcmrDam EXHUST HOOD(WIDUCf) HOUSINGM ON FEE
AZARUOU. MATERIALS DISCLOSUREWilltheupplicom pr fumre buildagace...ntsuvc or handle Imeard sarmedal HEATING UNIT T 0 Half 0BTU)
de.Septby the Ca,,,lu o Manicfpul Coo.Chapnv 972,and the Healthand Safety
doom A
inn 25532(a)I HHA'I'INC,UNIT(OVER H)O,1X)0 BI'U)
❑Yes FIN,, VENTILATION FAN(S INGLE RESID) PAID
Dam ueiptM '
Will the appheant m'Intro=building oceupsnt um equipment or devices which
ou naamdous air cmantro ams as dellued by it,limy Arca Air Quality Moura,ment BOILER-COMP @IIP OR I(X),O(X)BTU)
d., I' L:
1n,D BOILRR-COMP(OVER 10(oft)BTU)
❑Yes L]No
ILav=redtlmm
ahaNm
onsmetiuls rcquimnents under Cbapmr 9.95ul the Cali AIR CONDITIONER ISSUA CF,DATE
Tamm.Health&Safety Code.Section,3505,25533 and 25534.1 understand that if the NEW RESIDENTIAL.MECH. S0.PT. ( )
building does not currently have a tenant,that it is my responsibility to notify the occupant
ofrhe tectum em,whichmust be met prior to issuance pf to Certificate of(kn+pamy.
Owner or authmiaed agent Doe ISSUED BY:
OFFICE