S4433 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMITNO.
BUILDING DIVISION APPLICATIONTERMIT PLUMB NG-MECHANICAL S 4433
BUILDING PROJECT IDENTIFICATION -
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7 7 4Ci
OWN NAME PHONE: CONT A 'Ok'S NAh LIFO:
NIC CONTROL#
ad I
�ARCIIITF.Cf/IiNGINEGR, LIC NO: AI D ESS
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1
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG EJECT PLUMB MEECC,H
L��I LJ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby alarm that I am licensed under provisions of chapter 9 bummenrmg JOB DESCRIPTION
aZ w'uh Section7000afD.,kion 3ofEm Business and Prufessimo Code.and my license is O RESIDENTIAL:
FOO ' fallforr ,ndc PERMIT ISSUANCIi
xUU to j ,ZQ ❑SFDWL ❑PLUMBINREMODRI.
azU Date lQgsz F(.«Lic.N APPLIANCES—RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
N Q L UutP
F
ARCHITECT'S DFCLARA" ON ❑MULTI-UNIT ❑STRUCTURAL
/
PANELS
ZOr4Z Iundervand my plans shall be used as public records MODIFICATION
OZr—nn UP 10 200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-1000AMPS IMPROVEMENT 0SWIMMINGPOOIS
OWNER-BUILDERDECLARATIONOVER1000AMPS ❑BATH UREPAIR ADEM LITION
C C Q 1 hereby affirm that 1 am exempt torn the Cn auseim'z License Law Gtr the
X O a U following re,mn.(Section]031.5,Radars,and Professions Codd:Any city car county SIGNS ELECTRICAL
Ill:k
4:3 tL h which requires a permit to construct,alter,improve,demolish,or repair any sauctom
oo poort t c alsoequ th ppl
ca
hat
such tt flsignedLtfemem SPECIAL CIRCUIT/MISC
y.] h th 1 : 1p nu It t p oldieC t t Lc la (Chapter9 71.
aCIC, Iexamor ang with Section 7000)of Diviscan3oldie Business unJladeccions Cmmdc)or TEMP.MBI'ER OR I'OLF. S' COMMERCIAL
—CO
Q.C o Z that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of ❑NEW BLDG/ADDIT UEMOI. ION
Xm cr Section by any applicant for a permit subjects the applicant a civil Penalty of POWER DEVICES
W.,y Ll TENANT ❑FOOD SERVICE
moI mom than fi,e handeed dollars($50f)1.
,=QIMPROVEMENT
Q [,as owner of the property.or my employees with wages as their sole compensation, SWIMMING POOI_yUECTRIC
b. willdmhework.and thesnanurers to
not lnndediamfund «9W4Bu
for mle(S , siness ❑OTf1ER
3^ and Professions Cade:The Contractor's License law due s nm apply to an owner of r OUTLET'S—SW ITCHES FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such impoommcun are not intended or Merrill for NEW RESIDENTIAL ELECTR SQ ET.
-Jr.IL however.the building compmwemem n oAd within cane y,drof cUmpleu.n.tbe FhOf�RJ1 SIS
ncr-builder will have the burden of proving that he did not build or improve for par-
paxe s 1 ). TOTAL 'I A
QI rfthe
t(Sc, rya sandcontinuingewid:)MeeComtmdnzu, JUL l `2 1 99
construct the project apply
2Hw,Business and Pr f4:' ns Codec Tho Commctors!A-
nselawdeconotchp1r mean ownerof property who buildsorimproves me.).,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a connactor(s)licensed pursuant to the Contractor's
Cuero,Law. PERMIT ISSUANCE By
Iota exempt under Sec. .B 6 P C for An,mi son "J
Owner Dae ALTER—DRAIN d VENT—WATER IFA) VALUATION
WORrde, COMPENSATION yon DECLARATION tefollmem, BACK FLOW PROTECT DEVICE
Iherehy nf0rm under Penalty nflwrjury one of the following dedarolinre
I have and will maintain a Cenificamof Comm to self-insure lir Workers Compen- DRAINS—FLOOR.ROOF,AREA,GOND. STORIES TYPE S RUCTION
cation,as provided for by Section 3]W of the tabor Code,for the performance of the
w rk fee which this permit is issued FIXTURES—PER TRAP
1 hate and will main aia Worker's Compensation h m en«,ere required by Section
901afthrl Co Imo the per.fmdnre ofrhe work far which this pemmil is isoed GAS—EA.SYS'I'IiM-I INC.4 OUTLETS OC GROUP APN
My War■r p 1 ns dPnl¢y
Cartier:! u c is Policy N7�6I/�W/—W�N b� GTS—EA.SYSTLh1-OVER 4HEA)
//
CER FICATE OF EX17M PTION FROM WORKERS' �(
COMPENSATION INSURANCE GRI.ASFJINDUSTRL WASTE.INTERCEPTOR
(Ther seminaneed not b,completed ifthe permit is intone hundred dollars(8100) _ BUILDING DIVISION FRES
lir less.) GREASE TRAP PLANCHECK FEE
I remify that mite pedormencr ofthe work for which this permit is issued,Ishan SEWER—SANITARY—STORM EA.200 ET.
not employ any pmson in any manner nn zero,become subli
jaon the Wmkxrs'Camper- ENERGY FEE
oZ cation Lawsat Califend. Unto WA'1'I7R HEATER W/VENT/ELFCTR GRADING FEF.
Z C) Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should WATER SYST MGI ktEATING SOILS FEE
a become subject to the Worker's Compensation pretions of the Labor Code,you must
forthwith mply with such pmv':' ru ,this penal shall bedecnmd revoked WATER SERVICE
7 Z CONSTRUCTION LENDING AGENCY NEW RESIDENT PLMB. SQ.FL PAID Date Roppip,0
V O I hereby affirm that them is a construction lending agency for the perfutmunce of
he work for whis pn'ndt is issued(So,3097.Co.CJ
C) ich thIamdxes Name 'TOTAL',
C.1 Lenders Address TOTAL:
} I certify that 1 have mad this application and state that the above information is BUILDING FEE
Fi h correct.1 agree m comply with all city and carry ordinances and state laws relating to QTY MECHANICAL PERMIT FEE
Z buildingcUr,micun,and hereby ambmite repmomtivasuf(biscity to enter alavide SEISMIC PER.
shave-mentioned property for inspection pimpairs. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
habil ides,judgments,costs and expenses which may In any way acave against said City ALTERORADDTOMECH.
PLUMBING FEE
in rma,c iarnca of fa,gfanfn,of his permit.
APPLICANT UNEtjlggMcDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0110 CF,M)
SOURCE D ION . CONSTRUCTION
FEB
AIR HANDLING UNIT(OVER Ig00o CEM) CONSTRUCTION TAX
Signammaf AppIm VConwctor Dwe EXHAUST HOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MAMMALS DISCLOSURE
Will the applicant or future building occupanutom or handle hamrdoax material HEATING UNI p(TO 1010011 BTU)
as defined by the Cupeninn Municipal Cade,Chapter 9.12,and the Health and Safety
Lode,Section 25532(a)° HEATING UNIT(OVER 101,00 BTU)
❑Yes Elfin VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building use equipment or devices which
ftO1LLRCOMP(3HP OR 11(00( BTU) Receipt#
mir bezardunxair Cmtominnnz as defined by the Bay Area Ar Quality Management'
Diuricr! TOTAL:
❑Ye. ❑Nn BOILf?R—COMP(OVER)MAX)BTU)
I have adtheEarurdons materials requirements under Chapter 695 of the Cali- AIR CONDITIONER
re / (SSU SCE DATE
Earn,Health de Safety Gula,Sections 25505,25539 and 25534.1 understand that d the NEW RESIDENTIAL MECIL SQ.ET.
haildingdoeso lyhavesten mAhatltismymeponsibilityumnof ythcteso,cm
of the red n,wIt hmust ha -t prior t0 isuu«c ofa Ccnificge fo'n ve
of c
Ownu or naahor'�A agent I Dae TOTAL: SSUL'D BY:
OFFICE