S4399 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PES ITNO. 4 3 9 9
BUILDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PR(1JECT IDENTIFICATION -r - '
BUILDINGADDRESS: - SANITARY NU. APPLICATION SUBMITTALDATE
Aj
OWN sR'S NAME Gv PH NE s CONT'RACTOR'S NAME LIC NO:
NIC CONTROLp
1`» ARCHITECDENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: - - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
2 3 ZS 7 1 tw g--
LICENSED CONTRAC'TOR'S DECIARATION QTY ELECTRIC PERMIT FEE
I hereby athm rthat 1 em licenced under pmviuintts of Chapter 9 hurnmencing JOB DESCRIPTION
'OEgZ with Section 7000)of Division 3 of the Business and Professions Code,and my license L:
is RESIDENTIA
W O p PERMIT ISSUANCE
H in full force and c0n'I. El SFDWL L1 KITCHEN REMODEL
C
UF` Liansc Class Lic,p
¢ UANCGS-RLSIDIiNT1Al ❑AUDITION ❑PLUMBING REPIPE
y a a nate cnaEmem,
F.7h ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Ill I undmalard my plane shall bn coed ie,a blic records MODIFICATION
OZ--, UPT0200AMPS El INTERIOR ❑CHIMNEY REPAIR
FyLicensed Professional 201-I000AMPS IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1000 AMPS [I RATE REMODEUREPAIR L1 DEMOLITION
ppy..C C Q 1 hereby offittn[ha[1 um exempt tram[he Comment',Licence Law for[M1<
jy 3�U following mason.(Section]031.5,Bush....call Pmfio,,iuna Code:Any city or mumY SIGNS ELECTRICAL ❑OTHER
y which requires a permit movement,.Ilea imp rme,demolish,or repair any mmcmrc
C,al)
prior to its macenee.also requires the applicant for such permit m file a signed sutemetn SPECIALCIRCUUMIS
f }� that he is licensed pursuant o the provisions of the Centel Licenx Law(Chapter 9
hennreencing with Section 70go of Division 3of the Buslacesand Protcssions Cook)or TEMP.METER OR COMMERCIAL:
a a p C that he is exempt them@ons and Elie basis lot the alleged cxemplion.Any vinheion of ❑NI?W BLDG/ADDITION ❑DEMOLITIONS
k^` Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of POWER DEVICE
not mom than five hundred dollars(5500). ❑TENANT ❑FOOD SERVICE
H Z T IMPROVEb1ENT
_¢ Las owner of the property,nr my employees with rages ns their.nle rompenwtiun, SWIMMING POOL ELECT
�F� will do Ebe work.andthe structure is ool intended onliucd Elastic(See 7014,Business ❑OTHER
W t m and Profession Code:The Contimemr's License Law dtes nm apply to an owner of OUTLETS-SWITCHES-FIXTURE D
a'3 propl rho builds or improves thereon,and who docs such work himself.,through
h:town employees.provided th t such improvement., on,not intended or offered for NEW RESIDENTIAL ELECIR SQ FT.
I If,h thb ild'ng p o em m Id within met yelonfecon,icrion.the r, Q.FIT
FLOOR,ARA "` .FT.
M1'IJ '111 hb l fp ghth dl bid p f Par-
„I
ar
po a Hyde)
( f the p peny IContracting with licensed c m trato A-r•
I t the project(STF14.BusinessandPr[ :Code:)ThContractor's Li - 1
w Live J t applyE of property who bei d-ono,ove,there.,and QTY. PLUMBING PERMITFEE �j+ JUL - 8199
C.
ho,ornicol,felt...bp 1 t Ill a cement 0)licensed pu anno the Contractor. 1
License Law, PERMIT ISSUANCE
❑1 am exempt male,Sec. .B&P C for this meann
Owner Dam
ALTER-DRAIN&VENT-WATER(EA) __VALUATION
.-.�..�.-..,.�-
WORKde,p COMPENSATIONofperjyvm DECLARATION BACK FLOW PROTECT.DEVICE.
hereby affirm under pewfic of Perjury one of the following declarations:
❑I a.a,and
o,id,lIll by Socum 37A ofCe Labor Codeasure for WookmecCompaq-the DRAINS-FLOOR.ROOF AREA,GOND. STORIES TYPE CONSTRUCTION
moon,as hick this
for ad Section 3703 of the Labor Code,for EM1e performance of the
C,ork]Ihor,and this paintai le Worker's
I+1%TURES-PER'TRAP
1 have and or maintain Worker's Com,pmmoccefdo n hourance,lkfo,which
as requiredd i Section
3703 of the Who Codaforim Im,comwe ame,and P.nrk(nmberaEhispnmit is towed. GAS-EA.SYSTEM-I INC 30I1TLET5 OCC.GROUP APN
holyCa W'nrkers Compensmion Inwmnce carrier mol Policy number arc:
Carrico Policy No: GAS-EA.SYSTEM-OVER 1(EA)
CERTIEl I,OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This seclionneed nut becomeletobiftlio,emit is fnrone M1undreddollars(SIIU) GREASETRAP
or I.,)(This
FEE
I certify that in the perlbnnunm at(110 work fan which this permit is i—ad,l shall SEWER-SANITARY-S'I'ORM EA.2F)FT.
nm employ any person in any manner m as to h weree wbPar to the Worker,'Civilian- FEE
OZ whoa Wwsof Califomia.Dem WATER HEATER WNENT/ELECTR GRADING FEE
Z Applicant `
M NOTICE TO APPLICANT:If,after making[[iis Certificate of Exemption,you should WATER SYS TEWFRFAI'ING SOILS FEE
become subject to the Wootens Competaanon pmvioon.of the Labor Code,you mum
IZ Wfonhwith comply with such provisions or this Permit shall be deemed revoked. WATER SERVICE
a �
Z) z CON$'TRULTION LENDING AGENCY NEW RLSIDENTIAI.PCMB. SQ.Ff. PAID Dam Receipt a
U 0 Iherebye irmthan harcis U CORNITUCtose lcndingagency for the perhnmance of
E” the work for whwhthi:Permit is i,vadl(SIC.3097.Co.C.)
TOTAL:
C) Lenders Name
0 U t<ndce,Address TOTAL:
Pi1 certify that I have ,ad his ,d E d late that 0, h _ f of nit BUILDING
V) correct,I agree ill comply wth all City arel Comm,lamean,o,and o t law,r,loon,to QTY. MECHANICAL PERMIT - .FEE
U Z building tairomuctialsoundhereby conar e reperwoolds.,ofth,Caym cats—,mthe SEISMIC FEE
above-mentioned property for inspection per uses. 11I2RN11T ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupni
cnu agaimt ELC:CTRIC FET:
Iiabiiiuez,judgmcus,mas.:md expenses which may in any wary accrue against said City A ITER OR ADD TOM ECIL
PLUMBING HE
in APPLICANT
<c of the minfino,UNDERSTANDS
pc WILL
APVLICANT UNDERSTANDS AND WILL COMPLY WITH ACI.NON-POINT AIR HANDLING UNIT LTO 10.000 CIiM) MECHANICAL.FEE
SOURCE REGULATIONS.
D ^ '+ AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCT ION TAX
Y mreafA,Iicaolle.InorI Date FAHAUS'T HOOD(W/DUCT HOUSING MI'1'IGATION TER
HAZARDOUS NAE ERIAIS DISCLOSURE.
Will the applicant or future building occupant store orhandle hoaardom material HEATING UNIT(TO 1011.03)BTU)
as defined by the Cupertino Municipal Code,Chapter 912,and the Health and Safety
Code,Section ZS532(a)9 HEATING UNIT(OVER 103,all)B U)
❑Yes EINo PAID
VENT11.A1'ION FAN ISINGLERESID) Date Receipt#
Will the applicant or future building occupant use equipment or devices which
cant huzardcus air Emla niaants arc definCJ by the Be,Area Air Quality Management BOILER-COMP CHP OR 100,003 BTU) TOTAL:
District, BOILER-COMP(OVFR 100,IX0 BTU) O
❑Yes C]No
AIR CONDITIONER
1 h 'J tM1 M1 I reacted,'cels y E:underCh'p4 6.95 t he Caii- ISSUANCE DATE
formal Boath&S f p Call,Section,25505 25533 and 25534.1 modensland hand the NEW RESIDENTIAL.MECH. SQ.Fit ) g
building dors not currently have a mmol.that it my morensbility,m notify the occupant (/ r
of r ems which mus[be met m issuance fit Certificate ofEkcuryncy.
Ow r mlh if agent Dore TOTAL: ISSUEDBY:
OFFICE