S 4331 (2) APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.MECHANICAL. S 4331
BUILDING PROJECT IDENTIFICATION
BUI 1 G ADI)RLSS: ��� uT SANITARY NO. APPLICATION SUBMITTAL DAT
3 !TONE: CONTRACTOR'S NAME: ( LIC NO:
• NIC CONTROLX
ARCHH'ECI'l1iNGINEiik: LIC NU: ADDRESS: ❑
� O
CONTACT': PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by APPRizant(Initial) BLDG ELECT PLUMB MECH
� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm hoe 1 nm licensed Bu tender and
Prnf sz of Chapter 9 into cumc,g JOB DESCRIPTION
��Z win,SmlrceandgBof Divisini0 of the Business and Prnfesxions Cole.wa my lleeroa:n RESIDENTIAL:
F 'nfull e Class and effect. PERMIT ISSUANCE
REMODEL
UU Liccnsc Class Lic.p 0ADWL ElKITCHEN
RE-PIPE
HQL DateContractor AIRhIANCFS-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
ARC)HTECI'S DECLARATION PANELS El MULTI-UNIT ❑STRUCTURAL
Z O y? I understand my plana shall be used as public records MODIFICATION
UP T0200 AMPS ❑INTERIOR I-]CHIMNEY REPAIR
a4 L; Liunced Professional 201-1000AMPS IMPROVF,MENT OSWIMMING POOLS
C C C 6 1 hereby affirm h��am exempt from DECLARATION
he Contractor's License Law for he OVER["AMPS 0 BATH REMODEIJ EPAIR D DEMOLITION
3 G U following maO.n.(Section 1031.5,Business and Professions Coda:Any city or county SIGNS ELECTRICAL 0 CTRE
W LL y which myuires a permit to construct,alter,improve,demolish,or repair any xlrmcome
E"LLwOg' Ile-
prior to its Issuance,also requires the applicam for such permit to file a xigned statement SPECIAL CIRCUIONII$C /Q O
EWY that are is llcnucd pursuant to the provisions of he Contractors License Law(Chapter 9 — 10
W n00 (commencing with Sccllon]B(X)of Division 3 of,he Fusirms,and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
d K c c hat he is exempt therefrom and the bsic for the alleged exemption.Any violation 0f 0 NEW BLDG/ADDITION 0 DEMOLITION
_N Section 1031.5 by anyapplicant far a permit.subjects he applicant to a civil penalty of POWER DEVICES ❑TENANT 0FOOD SERVICE
Mnot more than five hundred dollars($500).
01,aowneTofhepropeny,ormyemployeenwiihwagcsastheirsnlecompensaiion, SWIMMING POOL,EI.E RIC IMPROVEMENT
Fwill Jo the work,ww
dthescture is oat intendedoroffereJ for sale(Sec.]OW,Business 00THERs`._"
3 w and Professions Code:The Cnntmclor's License Low Jas not apply to an owner of OUTLETS-SWITCH -FIXTURES
properly who builds or improves thereon,and who does such work himself o Ihmugh
his own employes,provided that such improvements-not intended or offered for NEW RESIDENT ELECfR SQ PT.
w1c.If.however the omidingor intprrvernunliscold within ane yearofcompl¢cion,the 5 �LI'FLOOR AREA $/S
er-bui)der will have he burden of proving that he did not Food or improve for pur-
JUn.r rl the pmryrlY,air exclusively contracting with licensed cunmactors to AL' - 2 1 99
tinct hexprtjca)Sec.]M4,Besinecs and Pndcdona cede:)TM1e Cnnlmnor's hi-
censclawdoesnotapplytoanownerof properly who builds orimpmv,,themon,and QTY PLUMBINGPERMIT PEE
who 6nnvms 1"or such projects with a contortionist licensed pursuant the Contractor's [T V
Lice.-law, PERMIT ISSUANCE L
l am e t under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATF,R(EA) VALUATION
Owner Date
WORKERS"COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE
1 hereby alliumunder Penalty ofperjury one
t) he self insum following deductions:
Olhave aro provill ded
intation i7M of ConsentIt)Code.foteforworkeh Compere- DRAINS-FLOOR,ROOF,AREA,GOND. STORIES TYPE CONSTRUCT)O.
when,as provided for by Section 31(0 of the Labor Crede,for the performance oldie
work av and his permit is issued. FlXTURES-PF.R TRAP
1 brae and will oR.fmaintain Worker's Compensation work
f.. ce,h required by Section
MyWrthe kcf'vCorCodc On hoommucmanmofd work number am: permitsissued. GAS-En_Sys'fEM-I INC.40lITLETS
OCC GROUP APE
fL
My Wmrkch Compensation Inaunnce carrier and Policy number am: 7V
Cartier; Policy No.: GAS-EA.SYSTEM-OVER i IFA)
C13Ri'IFlC TF COMPENSATION
WORKERS' 2 �
COMPENSATI ufffie INSURANCE GRF.ASFIINDUSTRI,WASTE INTERCEPTOR
(TM1Is section need nm be completed if the Mnmit is Toren¢hundred dollars(SIM) BUILDING DIVISION TEES
Or It,,.) GREASE TRAP PLANCHECK FEE
Toy any person
inthe(arfmarrimeofthexmfmore,k for whichthisiO he osirs Game.- SEWER-SANITARY-STORM EA,208 FT.
not employ any person In any manner m as m become subject m the Workers Cmmpcn-
Z cation Laws of California.Doc ENERGY FEE
O O Applicant NATER 1{EATER WNENT/IP,ISCIR
GRADING FEE
N NOTICE TOAPPLICANT:If,after making this Certificateof Labor Code.
you should WAT ER SYSTEMl1'REAI'WG
become cuomp y hoe Waders Compenmmon provisions of the need r Coke,you must SOILS FF
fonhw'ith comply withsuch provisions or!lis permit nhnll he)tented revoked. WATER SERVICE
a �
z CONS"THUC'TION LENDING AGENCY NEW RESIDT:NTIAI.TIME, SQ.FT. PAID
V 0 Iherebyaf&mhanhcrc ica mmlmnnon lending agency fin the performance Ol' D e Receipt#
Phe work for which his permit is issue l(Sec.3097,Civ.C)
Lender's Name
O V lender's Addrexs TOTAL: TOTAL:
y1 certify that I have read his application and state hal he shove infommtinn is BUILDIN E 17
tZ) sever.l agree to comply with all city and county onlinances and state laws relating to QTY. MECHANICAL PERMIT' FEE
L) Z building constrtuana,and hereby rellmn,empm,eutuuva ofth,,uil,lm emunpan the SEISMIC E
alone-mentioned prnpeny for inspeankm mmeAca. PERMIT'ISSUANCE(we)agree to save,indemnify and keep harmless he City of CupeNno against ELEC'fRl EE
IiabilitiesTudgnncros,encs and expenses which may in any way accrue against said City ALTER 012 ADD To MF,CfI.
in xmsuyuence nfhc granting of This
form... PLUMBING IN
APPLICANT UNDER SS A"V"'� LL COMPLY WITH ALL NON-POINT
50 L iREGULATAIR HANDLING UNI T(T0 10,MCFM)I� MECHANICAL Il
AI R HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Sngnmme of Applucanl/Cmancon Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATEEIALS DISCLOSURE HOUSING MITIGATION FEE
Will lheapplieanum future buildingmmcupamusnu nr handle bmandomnimerial HEATING UNIT(TO 100.008 BTU)
as Defined by the Cupenino Municipal Code,Chapter 9.12,and the Health card Safety
Cn fe.Suction 25532(a)^ HEATING UNIT(OVER 100,000 BTU)
Fl Y,, No
VENTILATION FAN(SINGLE.RESID) PAID t p
c Ume Receipt Will the applicant Or furore building Occupant use equipment Or devices which P
mit bmardoos air contammuntsas defined by the Say Arca Air Quality Management BOILER OR 01.000 BTU)
Distrix^ 'TOTAL:
O Ycs 0 N BOILER-COMP(OVER 100.000 BTI))
I have read the ha�ous material,requirements under Chapter(195 of hoe Cali- AIR CONDI DONEE
ISSUANCE DATE
Inmia Health&Safety Gale.Stenion¢255115.25533 and 2553).I understand that hilt, NEW RESIDENT IAL MECH. SQ.FT.
huildingA siml curcntly al win hoe it is my resporoibility to notify the,occupant �—
of rents whit imnanee ofd Cenificamot Ox,riancy. / -
scummed agent Date TOTAL:
ISSUEDr!ncr or BY:
OFFICE