S 4404 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
4BUILDINGADDR�S:
ERTINO BUILDING-ELECTRICAL PERMITNO.
IVISION APPLICATION/PERNUT PING PIRNG-MF.CEANIFIC S 4404
IfUI1.DINL`PROJECT'IDENTIhTCAT10N
SS: 11 SANITARY NO. APPLICATION SUBMITTAL DATE
herr Tree ti ate PHO - ' _^� CONTRA 'OR'S NAhip1S J NIC CONTROLIF
R EER: L C NO; ADDR S', ❑
r v%C-
CONTACT: PHONE BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) BLDG ELECT PLU-M�gI MECH
❑ ❑ f! ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECFRICPERMIT FEE
1 hereby iffirm,hm 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
00Z with Section7")ofDivision3ofthe Businessand ProfessionsCode.andmylicenxis RESIDENTIAL'
00 in full force and effect AA PERMITISSUANCE
�UF L.fallt Cl
Lie IF V ❑SFDWL o❑KITCHEN REMODEL
6Z C� APPLIANCES-RESIDENTIAL ❑ADDITION pPLUMBING RE-PIPE
HQ L Date Comrucmr
F'y AL
ARCHITECTS DECLARATI N PANELS [3 MULTI-UNIT MODIFIRUCTCATION
ZOy,Z„ I understand my plans shall be used as public records ❑INTERIOR ❑CHIMNEY REPAIR
oz—, UP TO 200 AMPS
�4 ly Licensed Professional 201-1000AMP$ IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDER DECLARATION
C I hereby affirm,ho,1 um exempt from the Comoretara License Law for the OVER h000AMPS BATH
ATH REMODEL(REPAIR [I DEMOLITION
X 3 6 V following mmam.(Section 7031.5,Business and Rofessions Cade:Any city or county SIGNS ELECTRICAL '
O
W fc which requires a Permit to construct,alter,improve,demolish,or repair any structure
0 ormints its sua
isnce,also requiresthe applicant fnrsuchpmit
etm fileasignad statement SPECIAL CIRCUITNIISC.
so
A that he is licensed pursuanno the provoomw of the Contractors License Law lChapter9 COMMERCIAL,
<� (commencing with Section 7")of Division 3ofthe Business and ProfessionsCode)or TEMP.METER ORPOL T.
d y no t that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of [I NEW BLDG/ADDITION ❑DEMOLITION
Y. Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEV( []TENANT [I FOOD SERVICE
y not mom Nan five hundred dollars(S50d.
IMPROVEMENT
wi L as owner oRhe progeny,ser my employees with wages as their Sole compensation, SWIMMING POOL E C
will do the w.rk,enJ,heswmurc isnm immndedor m)ireJ far sale(gec.7044,Business 11 OTHER
3 and Professions Code:The Contmc,ors License Law dews not apply to an owner of OUTLETS-SWITCHES- U
property who builds or improves thereon,and who does such work himself,,through
his own employees,provided that such improvements am not intended or offered for NEW RFSIDBNTIAL EF BCTR Q ET.
sale.IL however,the buddimgor improvement is cold within oneycmof completion.the SQ' REA D Q.n.
owner-builder will have the burden of Proving that he did not Wild or improve for for-
pi
o r-
❑C 1,as owns TOTAL. J U L 1 2 1999
Las owner of me progeny,am exclusively contracting with licensed contractors to
construct the project(Sec.7614.Business and Professions Code:)The Contractor's Li- -
cerise Law does not apply manowner ofproperty who builds orimpawnthereen.and QTY. PLUMBING PERMIT FEE
who contracts for such projects with a wmmcloos)licensed pursmnnn Ne Canaaaors
License Law. PERMIT ISSUANCE V By
❑I am exempt under Sec. B&P C for this reason
ALTER-DRAIN&VENT-WATER(G) VALUATION
Owner Dote
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DD•VICE
I hereby affirm under Penalty of perjury one of Ne following dedrartiom:
❑I have and will maintain a Certificate ofComen,to self-insure for Workcrs Compem DRAINS-FLOOR.ROOF.AREA,COND. STORIES TYPE CONSTRUCTION
nation,as provided for by Sation 37M of the Labor Code.for the Performance of the
work for which this Permit is issued jr FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as acquired by accord
37M of the Labor Code.forte Performance of the work for which this Permit is issued. GAS-FA.SYSTEM-IINCAOUTLETS tJCC.GROUp APN
My Wor sed n carie Poli y NoPol.;n
my swCarric �_ Policy No.: a GAS-EA.SYSTEM-OVER4(FA)
CERTIFICATE OF EEEEEEXXNEMPI'ION(ROM WORKERS'
COMPENSATION INSURANCE GREASS NDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section read not be completed if the permit is for one hundred dollar,P$1 W) GREASE TRAP
.......
r IessJ PLANCHECK FEE
I certify Not in the performance of he work for which this permit is issued,l shall SEWER-SANITARY-STORM EA.200 FT. ENERGY FEE
notemploy nny persons an man a he s Tenn the Workers'Campcn- /
Z satin.Laws of C m WATER HEATER WNENTIELECTR
O GRADING FEB
z Applicant
y NOTICE TO L AN .I,a tern a enificate of Exemption,you should WATER SYSTEM/TREATING SOILS FEE
L� L^ beer, c object the Workers Comps ion Provisions of the Labor Code,you must
LkI i� fonhwidi comply with such provisions or this permit shall W dimmed revoked WATER SERVICE
7z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIALPLMI3. SQ.FT. PAID Date ReceiptM
L) ❑ Ihereby whuRrmthin
arena i ixsued(See3lending
v.agencyfor thelserformonce of
theLe work for which Nis permit is issued(Sec.l09],Civ.C)
Lenders Name TOTAL. TOTAL:
L) Leaders Address
�.S _ BUILDING FEE
1 certify that 1 have rend this application and state that the above information is
V) correct.I agree to comply with all city and county ordinances and slate laws reining to QTY MECHANICAL PERMIT FEE.
U Z building construction,and hereby tallithim representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Wc)agree m cove,Indemnify and keep harmless the City of CoNvino against ELECTRIC HE
liabili,ies.jud,nosid costs dexpenus which may in ony way accrue against said City ALTER OR ADD TO MECH.
PLUMBING FEE
Incsmsequenc E NDSNis perm
APPLICA UF. TANDSA LL COMPLY WITH ALL NON POINT AIR HANDLING UNIT(TO IU,Igq CENT) MECHANICAL FEE
SOU P t NS.
AIR HANDLING UNIT(OVER 11.001 CFM) CONSTRUCTIONTAX
mm of Applicant C.ntmc r Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUSMA ,DISCLOSURE
WIINeapplicantorfumm Wilding« pvntsmmorhandlemmadousawle al HEATING UNI'r(To 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health tad Safety
Code.Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yes sRNo VENTILATION FAN(SINGLE RESIU) PAID Date Receipt is
Will the applicant or future building occupant use equipment or devices which gQILER-COMP(3HP OR 100.000 BTU)
emit hazardous sir contaminants as Defined by the Bay Area Aa Quality Management TOTAL:
District^ BOILER-COMP(OVER 100,000 B'I'U)
El Yet, YNNo
I have mu Neyyyazardauso tcdnls acq.irtmmxdadet CWpbr6.95.d Ne Cm- AIR CONDITIONER ISSUANCE DATE
fomite Heal, A' fir✓Coda. ns 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FT.
Wildi Ste nIt arant,thlhl+tismyresponsibilitymnodfy,he.ceupant
of t p hI issuance of a Cerollofore ancy.
oriuda m (� Date TOTAL: ISSUED BY:
OFFICE