S 4490 (2) -� APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING.EI,ECFRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4490
s BUILDING PROJECTMENTIFICATION
BUILDINGADDRE SANITARY NO. APPLICAI]ON SUBMITTAL DATE
1\\
' CONTRACTOR'S NAME,: LIC NO:
N/C CONTROI.b
ARCI TECUENG 'ER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO '
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT' P UM
D PG MECH
❑ ❑ E]LICLNSIDCONTRACFORSDFCLARATION QTY. r ELECTRIC PERMIT .'FEE ' ,,,
I bei whom 0 t I T d J p f chapter 9 Rola net sung JOB DESCRIPTION
CM%, wilt Sermon VOOB)ofD' -smn 3.Ohe Business and Professions Code.and my license PERMIT ISSUANCE is RESIDENTIAL:
�Z in full face rude
VF- NCSPOWh CKITCHIiN REMODEL.
aVV License Claes Lick APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
z kc NQ6 Dale Contractor
ARCf11T1iCT'S Il1iCLAkA'TION ❑MULTI-UNIT [I STRUCTURAL
'port PANELS
Z O y Z 1 understand my plans shall be used m public swords MODIFICATION
OZ4O UP TO 200 AMPS El INTERIOR ❑CHIMNEY REPAIR
GW Licutsal Professional 201-IINn1AMl'5 IMPROVEMENT CSWIMMING POOLS
a Q 1 hereby affirm ha N am exempt trnmE he Contin cors License Law for the OVER["AMPS C BATH REMODEUREPAIR C DEMOLITION
O d V following actio n.(Section 911.315,Business mW Pmfosoow Code:Any city or county SIGNS ELEC'T'RICAL C OTHER
l++ O F which requines is permit to construct,alter,improve,demolish,or repair any strumurc
prior I.as issuance,also requires the applicant for such permit to file a signed superman SPECIAL Cl RCUIT/M ISC.
Nthat he islicensed picaare to the provisionsoflhe Convmctm's License Law(Cbaptef9
W r�pOy (commencing with Section 9lKp)of Divisipn3 pf he Businesrend Pro@esions Code)or TEMP.METER OR POLE INST.
COMMERCIAL:
60.i5 c W hoe he is exempt therefrom and the basis far the alleged exemption.Any violation of C NEW BLDG/ADDITION C DEMOLITION
Warn Section 7031.5 by any applicant h
for.permit subjects eapplicaa ❑
nt to civil penalty of POWER DEVICES ❑TENANT FOODSERVICE
F'Zdnot more than five hundred dollars($5007. IMPROVEMENT
I] I,as owner of the property,or my employees with wages Eta their sole mmpemption, SWIMMING POOL ELECTRI
will Jo he work.and he slrucmre is nm intended proffered husar,(Sec.70,14.Business COTHER
3 and Professions Cale:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES XTURIS
property who Im Ids or improves thereon,and who cars such work hi aself or hrough
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL E •C SQ FT.
sale.If,however the building or improvement is sold within one year ofcoeoplesioghe SQ.FL FLOOR AREA ESQ,FT.
wrarbuildw will time the burden of proving that ha did not build or hnpmve for pur-
of sonvio
tW,as s efinfthcprp0exclusively contracting licenThsed contractors to
wntmuu the project(Sc 91W4 R W Prof: :C )Th Contractor,G-
cerise Law does not apply to 1p property h buildsp thereon, d QTY. PLUMBING PERMIT, 'FE
who contracts for such Erojects with a mntr4emgs)licensed pursuant o the Contractors
License Law. PERMIT ISSUANCE
ds B&PCfor this motion JUL 1 .9
. DateALT{?R-DRAIN&VENT-WATER(EA) VAhUA
w WORKER'S C ENSAT -CLARATION BACK FLOW PROTECT.DEVICE By
I hereby affirm under penalty of periary one of the following declarations.
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,CONE. 59'ORI 'FYPF.CO SR'RUCTION
,lion,as provided for by Section 3900 of he Llmr Cade,for the performance of he
work for which this permit is issued. FIXTURES-PER TRAP
❑ 1 have and will maintain Workers Compensation Insurance,as regnired by Section
3900 ofthe labor Code,for he performance work for which his pemtit is issued. GAS-EA.SYSTEM-I INC.40I1TLET5 OCC.GROUP APN
My Worker's Compensation Insurance confer vad Policy number are:
Carrier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCEGRP.ASE/INDUSTRI,WASTE INTERCEPTOR p BUILDING DIVISION�EHB^'
(This wecdnn n«d oatbensmpined iflhepelmit iafmonehundreddollars(S100) GREASETRAP o v
or Icss) I PLANCHECK HE
I cemily that in the performance ofthe work for which this permit is issued,I shall SEWIiR-SANITAkY-STORM EA.2001T.
not employ any person in any insurer so as to become subject to he Workers'Co.,.- ENERGY FEE
ZZ saliun Laws of California.Dae WATER HEATER WNENT/ELECTR
2 Applicant GRADING FEE
(n NOTICE TO APPLICANT.If,after making this Certificate of Exmnption,you should WATER SYSTEWMEATING
a
became object to the Worker',Compcnswi.n provislons of the Labor Code,you mull SOILS FEE
mrshwih comply with such provisions or this permit shall he deemed revoked WATER SERVICE
0
UZ CONSTRUCTION LENDING AGENCY NEW RESIDIiNT1Al.PLMB, SQ.Ff. PAID
V 0 I forwhichithi lhemt i isamnstme.3 len ding agency forthe performance of Dem Receiptp
W.C) t-+ 'he work for which this permit is issued(See.JU91,Cie CJ
Q L.enea's Name T(YTAL,
IsndcrI Address fyt
cenily than 1 have read Nis application and same hoe the above information is BUILDING FEE
Z? correct.l agree to comply with all city and county ordinances and time laws rclmint to 'QTY MECHANICAL PERMIT FEF.
V Z building esme ucdint.and hereby sabodze representatives of this city to came upon the SEISMIC FEE
wevve-mentioned property for inspection purposes PERMIT ISSUANCE
(We)agree to save,indammify and keep harmless the City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way areae against said City ALTER OR ADD TO MECH.
prearc of the grmaing.f Els permit. PLUMBING FEE
m use'ANTiR SAND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I(1,tA1fICPM) MECHANICAL FEE
SG TE'U /T NS.
AIR HANDLING UNIT(OVER IQ11fd1 CFM) CONSTRUCTION TAX
aware OTAp 'can mr Dale EXIIAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or fulure nuildingnccup.1 ware or handle hazaduus maledal HEATING ON]F t]'0100.000 BTU)
as defined by the Cupertino Municipal Code Chapter 9.12,and the Health and Safety
Code,Section 25532(u)'1 HEATING UNIT UVE,R 100,000 B'I'U)
❑Yes [I No PAID
VF.NI'ILATION FAN(SINGER RPSIU) Date Receipt b
Will the applicant Or Idhrc huildled by me B use ea Air u or devises which
emit hvardoos air contaminants as JehneJ by he Ray Area Air Quality Management BOILER-COMP(3HP OR IfN).nIXl PTU)
Disvim^ TOTAL:
71'ew CNo BOILER-COMP(GVER III0,000 BTI])
I tepefwd the hoar loo,mamrisRreryiremcnts under Chapter 6.95 of the Call- AIR CONDITIONER ISSUANCE DATE
Austria Health we Safety Cade,Sections 25505,25533 and 25534.I understand that if the NEW R[SIDLNTIAh MECH. SQ.FT.
builJ'n not 0 1...L al itismy responsibility'.ramify he occupant
t req ems Or it wl nn n, t 's .CwtiFlenm of Occupancy.
n s rat Date TOTAL: ISSUED BY:
OFFICE