S 4361APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL.
BUILDING PROJECT tDERrIFICAI'[ON
PERMIT NO.
S 4361
IIUILDING ADDRT:Sg: -
SANITARY NO,
APPLICATION SUBMITTAL DAT(
�90 UPL�4�Sa cry 7'
C�Z _pp
OWNERS NA � � , � PHONIi:
RWNER fN!/ Y—
NI'HACTOR:S NAME: �, LIC NO:
N/C
❑
C° R(
ARCHITECT CINEER: LICNO
CPDRESS: _
CON'1'AC . PHONE.
BUILDING PERMIT INFO
(99 (-/(104 7-3
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB ME
c/
LICENSED CONTRACTOR'S DECLARATION
I hereby uain't Thal 1 i Iicenwd ender provi,u of Chapter 9 (conmuncin
y ELECTRIC PERMIT FEE
JOB DESCRIPTI N
with Section 7000) of Division 3 oflhc Business and Prof,,xons CsNe, and my Been:
in full force and eRect
;RMIT ISSUANCE
I 1
1-1 ❑ KITCHEN REMODEL
APPLIANCES- R l iSIDEN'I'I At,
I.inm,c Class Lich
Dale Conleaclar
DITION [I PLUMBING RE -PIPE
[I MULTI -UNIT [I STRUCTURAL
MODIFICATION
ARCHITECTS DECLARATION
I undasend my plans shall be used ax public records
PANELS
UPTO200AMPS
[:1 INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
Licensed Professional
201-1000AMPS
OWNER -BUILDER DECLARATION
I hereby affirm Thal lam exempt (runt the Contractor', Loerse Luw for the
Wilowing reason. (Scans ]1131.5. Business and Profc.csinns Cada Any city or county
El BATH REMODIiDREPAIR ❑ L'MOLITION
❑ OTHE]{
OVLR IIXX)AMI'S
SIGN$ [LIiLTRICAi.
which repairs a permit to construct, alley, improve, demolish, or repair any slinvium
SPECIAL CIRCUI"1'/MISC.
/
pria,lon,iscuanm,ul.Dreyeine, the applicant liasuch penin to fle.6,madvatemenl
thin he ix licenced punuanuo the provisions M the CunOui Lac -e Law (Chapter 9
(commencing with Section 70a)of Division 3 ofthe Business and Professions Cude)or
TEMP. METER OR POLE INST
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
W BLDG/ADDITION ❑ DEMOLITION
Section 903151 .y way applivaul fora pr ti it-mhjwl. the applicant as civil,raltyof
POWER DEVICES
❑TENANT ❑ FOOD SERVICE
outm mothan five hundred dollars (4501).
n L as owner of the property, or my employees with wages as their side compensation,
ucture is no ended omni red lire sale (Set. 7044. Business
will Jo line wink, the strint
and
IMPROVEMENT
❑OTHER
SW Mh POOL ELECIHIC
DU SW fI CI{E, FIXTURES
and Poscoinns Cale:'[he Commolo r', License Law Jaws not apply to an owner of
NEN' RFSIDNTIAL LFi SQ ET
property she builds or improves themam, and who dues such work himself or through
his own employee,, provided that such improvements are not intended or offered for
sale, l: however, the building ar lmpnwumam is sold w) thin one year ufcontplcnan, the
SQ. FT FLOOR AREA
$/SQ. FT.
ininer-builder will have the burden of proving That he did not hold or improve for pur-
pnu n(samJ'
as t or Bre sin eall contracting whin licensed mnbonom e
O
''2�
TOTAL
-
hecr
See 704,
cries, and 11..
a tM1e project (Sec. o Business and Irndessi Code:) The Convenor's
ruse
and
who builds or improves thereon.and
an bu
oWwdcesnet applr loan
La
PLUMBING PERMIT I FEE
act(pnrpeny
who amvaert fnrsuch pmjmlx with a cnnlrumugs) licensed pursuant ar line Commnor'x
who with
a
>icen
ERMI I' ISSUANCE y
Lse law.
❑ [mia.cmplumler Sec. .B&PCforlhisremmi
Owner hale
WORKERS COMPENSATION DECLARATION
I hereby affirm under pcnallyof perjury one of the fallowing Jedars inn,
ALTER - DRAIN & VENT -WATER (EA)
VALUATION
'% / D •/A 0
(
a.•��p l% a1/
BACK FLOW PROTECT. DEVICE.
DRAINS- FLOOR. ROOF A R EA, GOND.
❑ihavetn d tui lltaimaina Cxamicamof Cnnsran in relf-insure for Work,,, Compen.
pnrvi Pcr
,an on, an provided for b Section 37t)(0of the labor Calve, fon see pro ance of the
STORIE,
TYP ION
r
work for which this permit is issued.
IIJCI'URIiS -P[R TRAP
1 hoveve and willTi.fmaintain Worker's tsalion Reese,, by Seclinn
h this
thye�pe¢ryrtinwmc dti t�`he work lisr which this pemail is issed,
7700of tiny, lsa/Mryr�Cpordye, cne-
GAS -I?A. SYS 'I'IiM-I INC. 4OUTLETS
OCC 1P
AVN
{fol
M wnrk.�Vp✓��f/n3 u`,nox Te Policy m r
No:
3
' GAS -I SA. SYSTEM OVER 4( EA)
GREASUINDUS'I RL WASTE IN'1'IiRCEI"TUR
C iTll 'All? OF IiREMPDOFI FROM WORNERS'
COMPENSATION INSURANCE
(This section nmdnotbemmpleund ifthe permit is for one hundred dol lars(SIW)
or less.)
GREASE TRAY
PLANCHECK FEE S' V
r
1 oemn, )hal in the performance of the work for which this permit ix Issunl. I shall
o as to subject be Workers'Compen-
not employ any Person in any manner. sbecomet t
SEWER -SANITARY -STORM ISA. 2001-1'.
ENERGY Et Q Q
WATER HEATER WNENT/ELECI R
Co Lnws of Califonein. Date
s pplicma
GRADIN(da
fl
ICE TO APPLICAND If, after making this Cenifcate of Exemption, you should
becomesubject to the Worker's Compensation provisions of the Labor Code, you most
WATIiR SYSTEMI TREATING
SOI
runhwn comply with such pfnvinion, o thN permit shell he deened ic—oci
WAI 17R S12RVICI:
CONSTRUCTION LENDING AGENCY
I hereby affirm thin there is a eomwvctlon lending agency for the performance of
NEW RESIDENTIAL PLMB. SQ, ET.
PAID
am Receipts
Me work fm which this pon til is issued (Sea 3099, Co. C.)O
Lender's Name
'1'A
BUILDING FEE Op•
TOTAL.
Lender's Address
I ccnify that 1 have read this application ani state that the above information is
erect. l agree to comply with all city and county ordinances and stale laws reining to
building construction. and hereby authorize representatives ofthis city teener upon l
MECHANICAL PERMIT FEE
SEISMIC FEE Z•4
FI.EC(RIC FEE
abovwocntionN property bur inspcclion purposes.
agree m,ave, indemnify send keep harmines, the Cily of Cupcninu a rot
5RMI'I' ISSUANCE(We)
ALTER OR ADD TO MECH.
PLUMBING HE
liabilities.judgments. costs andexpenes which may in any way accrue against sa' 'try
at comcyuence of the granting of this pcoun.
AIR IIANDLI NG UNG (10 I0,000 CFM)
MIiCHANICAL FEE
APPLICANT UNDERSTANDS ND WILT. COMPLY WITH ALL NON -POI N
SOURCE RE ATIO 5.
HANDLING UNIT IO.O OCFM)
CONSTRUCTION TAX /..
9 ��AIR
,V
Signamrt of AP ctor Dat
NAL MA . fIA1S DISCLOSURE
11
EXHAUST GOOD(W/DUCT} Ts
HOUSING MITIGATION EtiE
HEATING UNIT (TO 100,000, BTU)
IUZS
WIIIt plicarn or future building occupant store or handle hazardous material
as ddincJ h e Cupertino Municipal Code. Chapter V. 12, and line HcahM1 nnJ Solely
Code, Sectio 2553200?
HEATING UNIT (OVER IIM).g10 BTU)
VENT] LATION FANS INGLE REMD)
[-1 Vic, F7 No
PAID Dam Reeeiptp
BOILER- COMP GHP OR I00,M) BTU)
I Will the applicant or future building occupant um equip rem or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
Dorm?
E] yes E] No
TOTAL
HOILI[R-COMP (OVIik IOU,gNI B'IU7
AIR CONDITIONER
1 have read the haunlous nwerials requirements under Chapter 1495 of the Cali.
foram IbzI h & Safety Code, Sections 25505. 25533 and 25534. 1 undeolaml thus it the
t g y rtsrymw y Y pa^
In
'n J of currtntl eamnanh that it is -bilis tr nofif )M1e accu 1
I UANCE DATE
S
•,w - , ��
'✓✓ W
NEW RESIDEN'T'IAL MIiCIi. SQ. FI'.
nnner pee pilar a (.biby r aepancy.
-
TOTAL:
Owner rimJ agent Dae
ISSUED RY: -
OFFICE