S 4431 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PHRMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4431
t` i' IIUILDINGPRGJEcT,IDENTIFICATION,
BUILDIN U RESS>� — v\ I / C/ m es 1 J`N Y / SANITARY NO. APPLICATION SUBMITTAL DATE
1 ` I 1
OW r A E: PHONE CONTRACT OR'S NAME: T NO:
_ co) 6—D if NIC CON RDI1
l
t.WW ARCHIT[Cf/IiNGINEER: LIC NO. ADDRESS: - El
CONTACT: PHONE: BUILDING PERMIT INFO"
❑ Consultant Fees Paid by Applicant(Initial) HIM ELECT PLUMB MUCH
Ei— ❑— C1'
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
Q=z1 hereby affirm that 1 um licensed under provisions of Chapter 9 fconmencing _ _ - JOB DESCRIPTION
Poo with Section 7axpnf Divisioo Sof Ne Business and Professions Code.and my license is
FO- in hill forceind effect. PERMIT ISSUANCE S-S� RESIDENTIAL
-
wuF Litnnm Class Lie. USPDWL Ll KITCHEN REMODEL
F_W Dae Cnahah., I APPLIANCES-RESIDENTIAL C�O C1 ADDITION El PLUMBING RP.PIPE
ARCIUTECCS DECLARATION UMULTI-UNIT El STRUCTURAL
z p H.z. I understood my p un,shall be asal m public records PANELS MODIFICATION
OZ- m ❑P9U 200AMPS [IINTERIOR UCHIMNEYREPAIR
F�.F.W Licensed Professional 201-1000AMPS _ IMPROVEMENT
Wy OWNER-BUILDER DECLARATION E]SWIMMING POOLS
4K u7 a 1 thereby x[lirm Nm I am exempt from the Contractor License law for the OVER 1000AMPS El BATH REMODFUREPAIR U DEMOLITION
f WO W U following reason.(Section 7031.5.Business and P Feature,Cale:Any city or county SIGNS ELECTRICAL U OTHER
y which requires a peril to conewn,alter,improve,demolish,or repair any absence �rjfJQlyh-
to primmiu ismanex,absorcquires Neapplicant foramen perminr fleusignedsmmnrcm SPECIAL CIRCUIT/MISC.
that he is licensed pursuant to the provisions ofthe Contractors license Law(Chapter 9
fttmtmencing whh s.ainn 7(N111)o[Oivlsinn3 ofthn Raciness and Pndessiom Chad,)or 'f EMP METER OR POLE INST COMMERCIAL:
0.a C C that he is exempt therefrom and the iasis for the alleged exemption.Any violation of U NEW BLDG/ADDITION U DEMOLITION
u• Section LS by anyapplican for a Permit subjects Ne applicant to a civil penalty of POWER DEVICIiS
} not more than Eve hundred dollars D5W), ❑TENANT [I FOOD SERVICE
O ❑ 1,m�wner nl'the prolxny.nr my employeeswiN wages nn Ncir sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will dome work,andthemouram isnm lnardealonlbereal mrsu1e(See.0044,Business UOTHER
6 3 m and Rofessions Code:The Cnnlmcerr's License Law rices not apply m en owner of OIJTLITS-SWITCHES-FlX'NRES s
property situations or improves thereon,and who dues such work himself or through go
his own employees,provided that such improvements am not intended or offered far NEW RESIDENTIAL ELECTR
sale If,however.the baildlug.,mu,nowemenl ovoid wi Ninoneyew.fcompletion,the SQ.IT,FLOOR AREA $/SQ.Ff.
owreobullder will have the burden of proving that he did not build or improve for pur-
Fam of salej.
1,as.wtier of the pr.pert um exclusively contracting with licensed contrac(crs m TOTAL:y ,,D
remmmellbeeser apply.han watBovrofmc,pry who ns
o.:J"Ihr Comma.,Ll- f - .t "
wo contracts
does me suchplri vial,
ofpmpeny who sed pursuant
to
lhemm,and QTY t, PLUMBING PGRMIT FEE
who compere for such pmjema with a romractods)licensed purauam m the Contractors
Licenve Law, PERMIT ISSUANCE • 5'
CI nmexeptunder Sw. ,H&P C farkhisremon
Owner
ALTER-DRAIN&VENT-WATER MA) VALUATION
DatC
WORKER'S COM1IPEN TION DECLARATION BACK FLOW PROTECT.DEVICE
I herchynifrm under penally ofpequry one oflfie following declarations: 5 17V5J '-�-
Ihave and will mairtoin.Cenificicol'Come.uoself-imure,lav Wmke,'s Compen- DRAINS-FLOOR,ROOF,AREA,COND. - STORIES I'YI'BCONS(RUCTION
cation,as provided for by Section 37M of the Labor Glc,for the performance of the
work for which this .it is issued. 3 FIXTURES-PER TRAP gq n
1 have and will maintain Worker's C.mpensaion Insurance,as required by Section f- V
9700 of the l ahor Cole,lin Ne perfornanceof the work for w hich phis pe nn ills issued. GAS-EA.SYSTEM-1 INC.4 OUTLETS DEC GROUP APN
My Worker's Compensation Insurance carrier and Policy numberme:
Cartier. Policy No.: t GAS-EA.SYSTEM-OVER 4(EA) �5`
CERTIIICATEOFEXEMPfION FROMWORKERS' OREASE/INDUS'I'RL WAST[s INTERCEPTOR
P_ 3
COMPENSA'1'IUN INSURANCE BUILDING DIVISION FEES
(This action need nm he compimal if NeFcrmil is fonmehundred Jollary(Sled) GREASETRAP
or less) PLANCHECK IIiE
(certify that.the Perany notanceofsIn ork beetorwhich jectlo thePermitkco,'issued, SEWER-SANITARY-STORM EA.200 PT.
not employ any Cerner in any manner xn as to hrnmc subject In the Worker'Compero ENERGY FEE
Z amino Luws of Califamia.Dom
z Q Applicant WATERfIEAT1312 WNEN'1'/CLGCTR GRADING FEE
sV)
. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMITREATING
a , hcome subject home Worker's Compensation provisions of the labor Code,you mea
U Ibohwith comply with wch motooionsor this ,.an shill he deemed revoked. WAI'IiR SERVICE
Q
CONSTRUCTIONLENDING AGENCY NEW RESIDENTIAL PLMN. S PAID
U Q Ihercby uRr Nunhere is a construction lending agency for the performance ofDate Reeciplk
W dm work for which this Iamot is isvucd(Sec.3097,Civ.C.)
0 Lenders Num. TUML:
Lenders Address
C. 1 certify Na 1 have read this application and state Na the above Information's - I - - Os 4Z UIL G FE 97•VQ
rr (A erect.l agree to comply whh all city and county ordinances and state laws mlating In QTY MECfIANICAI.PERMIT - E
huiiiagconwmnion,and hereby authorize representatives.f Nis city(center upon the _i ICEEE
above crctom edproperty I'm inspection purposes. PERMIT ISSUANCE
(We)agree(c save,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE y s
liabilities,judgments,costs and expenses which may in any way scram against said City ALTER OR ADD*10 MECH.
In amsequencc of hive groping of This peril. PLUMBING FEE
APPL NT JNDERSTA!DS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(M 10,000 CFM)
MECHANICAL FEE s
SOUR T�tE LAT NS. �r
azQ AIR HANDLING UNIT(OVER 10,0010 CPM)
I CONSTRUCTION TAX
Slgnamre el'Applicant/Cnmmmor Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS AIA IAL S DISCLOSURE
Will the applicant or future building mempant store or handle hazardous material HEATING UNIT(TO 100,000 HTU)
ev defined by the Cupenino Municipal Cale,Chapter 9.12.and the Health said Safety
Code,Section 25532(a)'fHEATING UNIT(OVER 11111,000 HTIJ)
❑Yes No VENTILATION I-AN(SINGLE RESLD) 6s I(7 PAID _
I Dara Recmpt N
Will the applicant orfurore tui fired occupant Be,seco Airleptofdevicaswhich BOILER-COMP(3HPOR 111(1,1)00RTI))
"mit hazanlnus air conmpinan@ aydof incl by the RArea Air Quality Management TOTAL /J/us�j-6
Uiaricd BOILER-COME(OVER 100,000 BTU) 7
❑Yes Y'
I hmcread the In...Mines materials r uinnrems under Chapter of the Calm AIR CONDITIONER
9 I ISSUANCE DATE n
Lantra He &Snfery Gde.Sectio 3505,25533 and 25534,L understand that if the NEW RESIDENTIAL MECH. SQ.FT. �{s
huikfi & fety ly he atenamtel�l l my rtspocoldlitymnaifylh.occopaat d
of Ne ref eme uwhiTm xt be meter/1 `>ua eefaC• ' ue�fc (,/ �(� y�
Owner or unionize agent VVV�� /I Date TOTAL: /Is6Z ISSULDBY: Me NN7�C'F
OFFICE