S4405 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMUNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4405
BUILDING PROJECT IDEN'TIFICA'TION.
BUILUINGADDRESS: SANITARY N'O. APPLICATION SUBMITTAL DATE
D 4011-165 " Com_
OWNER' Al PHONE: CO 'RA ORS AME: LIC NO:
42Uyz;i /. N/C CONTROL k
AR HI TECI'/ENGINEER: LIC NO: ADJ$I�SS: �V ❑
CONTACT: PHONE (,•�eLY� - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) B D ELECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION QTY - ELECTRIC PERMIT FEEM=z _
I hereby affirm that I em licensed under provisions of Chapter 9(commencing - ( JOB DESCRIPTION
Fw o,t, wim Sectioo9 q0 andofthe Bari JPmfesina,C and my license is RESIDENTIAL'
in lull force PERMIT ISSUANCE.
y,ulF ❑SFDWh ❑KITCHEN
FZa Oatense Cl sa —Con�k" V !!! APPLIANCES-RESIUEM'IAL ❑ADDITION 71 PLUMBING RE-PIPE
Nan' ARCIIITECI'f/C ❑MULTI-UNIT L1 STRUCTURAL
,o so PANELS
Z O y.Z. I understand my plans shall be used as public recur�la4'J11.a an r DWICATION
J����J UP"T021XIAMPS
Q Z'�p [I INTERIOR IIMNEY REPAIR
F t?F-u1 Licenod Professional 201-1000AMPS IMPROVEMENT El SWIMMING POOLS
�r1�; OWNER-BUILDER DECLARATION OVER I000AMP5 ❑BATH REMODEVREPA ❑DEMOLITION
0.C W d I hereby affirm that 1 am exempt from me Contractor's License Law for the
�F following reason,(Station](UI 5,1sponesx and Professions Calc Any clly or coumy SIGNS ELECTRICAL ❑OTHER
m which requires o permit to mswct,aIle,improve,demolish,of repmr any swewrc
F-�-�; pdnnniu issuance.also rcyvires me apPlicam for such permiuo flea signM smmmcm SPECIAL CIRCUITIMISC.
} that he is licensed pursuant R.the provisions of the Ceourucrors License Law(Chapter 9
Conunencing with Section 70(m)of Division 3 ofthe Business and Professions Code)or "TEMP.METER OR POLL'INST, COMMERCIAL:
a ty e C bar he is exempt therefrom nnJ me basis for the alle&cJ exemption.Any violation of ❑NEW BLDG/ADDITION DEMOLITION
X^a Section 703 L5 by any applicant for a permit subjenta the applicant a civil penalty of POWER DEVICES
4:—rte ❑TENANT ❑FOOU SERVICE
not more man five hundred della,(S500).
F Z} IMPROVEMENT
�Q ❑ I,as owner of the propeny.or my employees with wage az meir;.'nle compensation. SWIMMING POOL ELECTRIC
will do the work,and hen...am is not lmondcdomft'emdforsale(See 70U.Bovines. THER
W w and Professions Cdei The Contractor's License Law docs not apply to an owner of OUTLETS-SWITCHES-P ti
0'3— propeny who builds or improves thereon,and who docs such work himmlf or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELE FT. /1
sale.lf,however.the buildingur approve car is sold wi thin one year of complelam.l he SQ.IT.FLOOR AREA $/SQ.FT.
mr builder will have the bumen of proving that he did not(wild or improve for per- '666
yam of Tale,. ryry nr
❑I.as owner of no propeny,am exclusively contracting with licensed contractors to TOTAL: p T In 1
nsuned he J t(Sec AHJ Bd,inr,apal Pr f:: Cod,)Tho C rra Im'Li-
v
i c tzcl d t pp1)t fp pity h b 'Ids p :Ili eonand QTY. PLUMBING PERMIT FP.E
who contractsfor such projects with a contractor(.)licensed pursunn The Common,i
License Law. PERMIT ISSUANCE
1 am exempt tinder Sm. .B&P C for his reason
ALTER-DRAIN&V FNT-WATER(EcO VALUATION
Ounce Dem
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT DEVICE '
I hereby affirm under Penalty of Perjury one of the following declamations 0;010 a S
❑ Ihaveandwlll nmimelnn Cenificoteof Consem asci f-imme for Workers Compact- DRAINS-FLOOR,ROOF,AREA.COND.
sntio ,as provided for by Section 3900 of the Labor Code,for the lVdarreance of the ST< IES TYPE.CONSTRUCTION
for wbich this permit is issud. FIXTURES-PER TRAP
w 1 and rill maintain Worker's Compensation Insurance,as required by Section
ofxme LosrC'ale,fonheyltgr6rfinmyant�deynfthe w�1kkk far which w�hiicch this ^J9J�� d GAS-EA.SYSTEM-I INC.J OUTLETS OCC.GROUP
GICe WnrIIQ i�1l 'lt�n / { RIB'-cY �y (1 issue
Caviar / CAS-17A.SYSTEM-OVER 4(EA) ITS yy
CERTIFICA'TF.OF E%ENUTION FROM WORKERS' S�7
COMPENSATION INSURANCE GREAS W NDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
Chis section need not heatmplead i[theµmnit is for M1unJrcd dollars($IINI) GREASE'I'RAP
in less.) YLANCHF,CK FEE c
Icrnifythetintbeperfermanerefthe wnrkfn a,beedmispermit izlssaed.Ishan SEWER-SANITARY-STORM P.A.200 FT.
not employ any person in any manner w as m become subject a the Wm1w,Co.,.- ENERGY FEE
C) Z x pion Laws of Califar in.Dare WATER HEATER W/VENT(ELECTR GRADING FTE
Z Q Applicant
^ NOTICE TO APPLICANT:IL after ranking this Cenificate of Exemption,you should WATIiR SYS]EMITREA'IING
F > hecm
oe zabjym a the Workers Cn,scra dao provisions of the Livor Code,you must SOILS FEC
Wbmhwith comply with such Previsions or this permit shall be deetnpd revoked. WATER SERVICE
aQ
CONS'TRUCT'ION LIiNDING AGERCY NEW ItT:SIDENTIAh PhMB. SQ�i"I', PAID
U z Uma Remiptk
U 0 I hereby omrm than thorn is..ed(Ser.30 len Jing agency[onh<pedormunec of
the work for which mis permit is issued(Sec.JIN].Civ.C.)
� F" Isnders Name TOTAL:
U Lender's Addar, TOTAL:
1 cenify that I have read in,,application and ,am than IM1e aMwe mammonist is BUILDING FEE
F tai) cored.1 agree a comply with all city sad county ordinances and soup laws relating to QTY. MECHANICAL PERMIT FEE i
V SEISMIC PEE
Z building construction.and hereby artmorm representatives of this city to court upon me
aMrvo-mentioned propeny is),inspection pprposez. PERMIT ISSUANCE
(We)agme to free,indemnify and keep taintless he Guy nfC,scmro a,mr,11 ELECTRIC FTP,
hidilities,tal,ments,costaem expenses which may many way active agaitnlsaid City ALTER OR ADD TO MECH. PLUMBING FEF,
in came, e of me grannin .nnhis permit.
APP, A T UNDERST DS AND WILL COMPLY WITH ALL NO -POINT AIR HANDLING UNIT(TO 10,000CFM)
�,.- z MECHANICAL FEE
S RC
r AIR HANDLING UNIT(OVER I0df00 CFM)
CONSTRUCTION TAX
. ,aino,of App nUCon caq r a Date EXHAUST HOOD(W/DUC
HAZ DOUS MATERIALS DISCLOSURE HGUSING MITIGATION FEE
Will he applicant or Idiomhuilding occupamsnce or hadlc humclimsnnmcrial HEATING UNIT(TO B'rU)
as deff by the Cupertino Municipal Code.Chapter 9.12.and he Health and Safety
Code,Section 25532(a)? HEATING UNIT(OVER IM.W0 BTU)
❑Yes Ne PAID —
VENTILATION FAN(SINGLE RESID) Date KermitM
• Will Nt aPplicam fumre bullJing ruatpant ucc equipmcnl or Joiccs which
emit hnmMoux air conn Tanta as J�ned by me Bay Ar ca Air Quality Management BOILIER-COMP(311Y OR 1W.IXIO BTU) TOTAL:
Dema? BOILER-COME(OVER Egy"BTU)
El Yet
I have the hm� uu serials mquiremcnts un der Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Health&S sty Ede 5 r n ns 25505,25513 and 25531.I understand that if me NEW RESIDENTIAL MECH. SQ.FT.
in RR
xn o o ant itis sop mibilitymnodfy theacupant
of rho' aPriomoissuunre f a Certificate of Occupancy.
OnWrinauthonsidda,li Dam TOTAL: ISSUED BY: Is
OFFICE