S 4224 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL, PF:RMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4224
I BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARYNO. APPLICATION SUBMITTAL DATE
to SCJ2.0'c. 2 r 49
OWNF N E: PHONE: C(y1TR�Cf�, LIC NO:
1166 ��``LLll11 NIC CONTROL#
RCHffHCT/E G NE' EJC NO', RFS : / O k ^ ❑
CONTACT: PHONE: `J BUILDING PERMIT INFO
-3 l3 -4Q 7 Z ❑ Consultant Fees Paid by Applicant(Initial) HLUc ELIiCT PLUMB MICH
� �r ❑� ❑
LICENSED CONTRACnderp DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby 14 that I am licensed ander provisions f Chapter 9(say li c g JOB DESCRIPTION
,�„OZ with Scctinn7a00)af tofmcllusincss and ' tui ion III .ntfinyliryyscix RESIDENTIAL,
�F in full force and disc t7J(NY U7 hl]' FIRMLY ISSUANCE!
y.UF GSFDWL ❑KITCHEN REMODEL
onU License Class LIu# APPLIANCES-RESIDENTIAL
aa Date Contractor []ADDITION ❑PLUMBING RF.PIPE
ARCHITG me DECLAR ❑MUISI-UNIT El STRUCTURAL
Z c' z understand my plans shell be used as public rc s PANELS MODIFICATION
024— WAtkc UP TO 200 AMPS
❑INTHRIOR ❑CH I MNEY RE PAIR
Q�Fqq'W Licensed Professional V 201-I0K10AMPS IMPROVEMENT E]SWIMMING POOLS
Wised
, , OWNER-BUILDER DECLARATION QVI!R 1W0 AMPS [I BATH REMODEIIREPAIR ❑DEMOLITION
C C at I hereby affirm that 1 am exempt from the Contract Lieense law for die
�Lp6U Allnwingreasoa(Section 7031,5,Business and Professions Code:Any city or county SIGNS ELECTRICAL. ❑OTHER
fa O,�F] which requires a permit m construct,alcor,improve,demolish,or repair any structure
prior to its issuance,ala requires lheappliwnt forsuch pend,III a signed statemmn SPECIAL CIRCUIT'/MISC.
ythat he is licensed pursuant to the provisions of the Commerce,License Law(Chapter9
(commencing with Section 7000)of Division 3 afore Business and Professions Code)or TEMP,METER OR POLE INST. COMMERCIAL:
:1 Xn yr that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ElDEMOLITION
1+• Section 70.31.5 by any applicant for a permit subjects the applicant to u civil panahyof POWER DEVICES
aJ^m ❑TENANT ❑FOOD SERVICE
or, .as run fiveh property,
or vyempl.
k�Q � 1,as owner of the progeny,or my employees with wages as their sole cnmpensntion, SWIMMING PO01.ELECTRIC
1MPkOVEMF.N'G-�..-„-,-4��^F
will Jo the oink,and meswcture is not intended or offered for sale(.See 7044,Business ❑OTHERt`
ad 3 and Professions Code:*11w Commumes License Law does not apply to an owner of ONLETS-SWITCHES-FIXTURES p 17 �,L_
property who builds or improves thereon,and who does such work himself or through Ili;
hisor proat s
wn employees, vided thueh Impnme
venta are not trended or offend for NEW RESIDENTIAL HLECTR SQ IT.
sale 11,however,the haildir,ainn,ovenient is sold within one year of conmpletimn.the S .FT/FLO(glUREA� �$/SQ
ve
owner-milder will hathe burden of pining that he did not build or improve for par. II J U L, /� 9
you If vale}
0 I,as owner of the prnpen$am exclusively contracting with licensed contractors mm T20
armtmct the project(Seo.7044,Basins.and Professions Code:)'Ue Contractor's Ll- -
naeLaweoesnotupplymvnownornrproPerry who bulldsnrhnpnrves thereon,and QTY. I PLUMBINGPERMIT "FEE .BY
who contracts forsuch Is with a contractors)llceluN tit the Camaaor's I -
prnjee pursuant
License law, PERMIT ISSUANCE 3 1—. Q
0 Icon exempt under Ser. ,B&P C far this reason
Owner Date ALTCR-DRAIN&VES 'F,H(EA) VALUATION
WORKER'S COMP17NSATION DECLARATION BACK PLOW PROI'EC V
I hereby affirm under penalty of perjury one of the following dcclandions: 0 D
I have and will maintain a Cenificamof Conscnna self insure far Worker's Camper- DRAINS-FLOOR.RODE AREA, STO IE TYPE CONSTRUCTION
smion,as provided for by Section 3700 of me Labor Con,for the performance of the /^1
work for which this permit is issued FIXTORES-PERI'RAP V
0 1 novo and will maintain Worker's Compensation h unme a,us ruryiral by Section
3700 of the LaMar Code,for the performance ofthe work for which th�isjj��ccsn�it s.ir�yyll°d GAS-HA.SYSTEM-1 INC. O .;TS OCC.GROUP APN
My Wrak� ncewaieraod Policy GAS-EA.SYSTP.M-OVER,unier: Policy No.: A
CERTIFICATE OF EXEMPTION FROM 1#RjCEIt lI b ( GRF.ASC:/INDUSTRI.WASTE COMPENSA'HON INSURANC. CJ ` a '
(This suction need nm hecrnplmWif thepennit is fonmehandaddollms(SIW) 4, a 'BUILDING DIVISION IsL!HSd s
or less.) GREASE TRAP PLANCH17CK FEE
I century that in the performance ofthe work for which this permit is is.mcd.I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as to become snbjem m the Workers'Crippler. ENERGY FEE
ztuition Luw,of Cali funis.Data WA'I'13R HEATER W/VONT ELP.CTR
Q Applicant GRADING FEE
G7 7 NOTICE'TO APPLICANT.If,after staking this Certificate of Exemption,you should WATER SYSTENUTRFATING
become object m the Woders Compcmaion pnviviuna of the Labor Code,you must SOILS FEE
0 fnnhwim comply with such pmvisiom er this permit shallbedeemed revoked, WATI!R SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL.PLMH. SQ.UL PAID A
U 0 I hercbyaffirm thatm,reit.canswchoo lending ageney fins,pafmmance aI U e Receipt#
use work for which his permit is issued(See 3097,Civ.C.)
Q Lenders Name TOTAL:
Lender's Address TAI
1 certify thathxvc read this applicmion and statethin the shave promotion is BUILDING P
fa/J cortem.l ugrsemenn0ply with su say nm nary onlinunscs and,am lttws relining to QTY. MECHANICALPERMIT PP.E
U z building const tian,and hereby oath res tivesofmis city us enter upon the SEISMIC iE O
above nit I d p ray far in ti ra p
We) nee u. ve.indc ify mJ e a rictus the City of Cupertino against PERMIT ISSUANCE ELECTRIC
iia 'lit s,jud a ts,c sGmad a may way acerae against said City ALTERORADDTOMECH.
in nm .qucncofthcglmtingh' PLUMBING FEE 3 a
AP .CANTO DE 'TAN D' )I I OMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FEE
S IR:ERE(U TI NS 1
q AIR HANDLING UNIT(OVER 10,0000 CFM) CONSTRUCTION TAX
Sig o fAp is
HAZARDOUS
RE Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
IIALARDOUS buildMAIing
recapIAL ISCLOS handle
the
C.cant or fuarebual Co occupant nrandt Health
moand Safety HEATING UNIT(T0 100,(gMI B'I'll)
az 'fi by the Cupcnino Municipal Cmde.Chapter 9.12,and the Health and Safety
Cod, ectian 255320)'1 til?A'fING UNIT(OVER 100,IX10 BTU)
Yes FIN. PAID
VI!NTHATIONFAN(SINGLB RI!SID) Data Receipt#
Will the applicant or future building occupant use equipment or devices which BOLI-F.R-COMI'(3HP OR 100000 BTU)
mit hamrdous w,roman.ana as define by the Bay Area Air Quality Management , TOTAL
District?
0 Yes BOILER-COMP(OVER 100.000 B'TU)
I lave ad theI rsunlou an sre at meats order Chapter 695 of the all- AIR CONDI'1'IONL'It
p ISSUANCE DATE
to mi, iealth afcty odc.5 ti s SB. 2 33 and 25534.1 undersand mar the NEW RESIDENTIAL.MECH. SQ.FT. 1 _ � n
NJ, gdces o caner yh e r n ha ymspmshilitymnmify th occ gam (i 7
of h e¢ hi r m r m mm ante nfa Cetf con spa Z' /—
Ow nr a o ' ed agent ate c TOTAL: �—
ISSUED BY:
OFFICE