S 4420 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CU PERTINO - BUILDING-ELECTRICAL PERMITNO.
BUILDING DIffI VISION APPLICATIONIPERMIT PLUMBING
BUILDING
S 4420
BUILDING PROJECT IDENTIFICATION
IiNLUiNGOA�L $ �I n r ` �� �� SANITARY NO. APPLICATION SUBMITTAL DATE
O ER'SN E: 'Y•\C 'PI`HONE: CONTRACTOR'S NAME: LIC NO �^
Q `Che S/a �n 'LO NIC CONTROL as
ARCHITECT GINGER: 1U7 LIC NQ ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG LECT PLUMB ECN
LICENSED CONTRACTOR'S DECLARATIONZWz QTY ELECTRIC PERMIT FEE
1 hereby aRirm that I am limned under provisions of Chapter 9(commencing JOB DESCRIPTI
w0c) with Section 7")of Division 3 aftne Businessund Prdessions Code,anJ my limnseia
t'100 / PERMIT ISSUANCE RESIDENTIAL:
F=WF in full time and effect. ❑SFDWL ITCHEN REMODEL
U License Cltxa L10.#
I- W 3 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
tial Date Contractor
Fly ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
O m Z I understand my pians shall be used as public rereminds MODIFICATION
O� UPTO 200 AMPS
P y t:W Licensed Professional ❑INTERIOR ❑SWIMMING
POOLS
J
OWNER-BUILDER DECLARATION 201-IIKKIAMPS IMPROVEMENT E]]SWIMLITION IS
w< /hereby omrm that 1 am exempt tram the Contractors License Law for the OVER IM)AMPS
El BATH REMODEUREPAIR ❑DEMOLITION
y0.yee,,�LU following reason, Smdon 90315,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
lal3fi F which requires a permit re cnnswet,alter improve,Demolish,or repair any aw
Fqq�O
prior issuance.also requires (m such peminr rile statement SPECIAL CIRCUIT/MISC.
n
2 u(� that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
TO 0C (commencing with Section 7")of Division 3 of the Business and Professions Cade)or TEMP.METER OR POLE COMMERCIAL,
that he is exempt therefrom and the basis for the alleged exemption.Any violation of all ❑NEW BLDG/ADDITION D DEMOLITION
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES 0 TENANT ❑FOOD SERVICE
not more than rive hundred dollets($5f1o). IMPR V', r'I
pi,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOLE [.r
will do the work,and the suucmre is not intended or offered for sale(SecAM4,Busine.cs 40 DOTH
W and Professions Cade: ontm
Tic Ccmrs License law dne
olives not apply to an owr of OUTLETS-S W ITCHES-FI a S
0.3 property who builds or improves thereon,and who does such work himself or through V
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL ELGCTR S
sale.)Lhrwever.the building or improvement is sold within one year afciandetion,the .
mer-builder will have the burden of proving that he did not build or improve for pur-
pose six
sale J.
co 1,us owner of the property,,Business si and Protracting with licensed cohuadov to TOTAL: QQ
onsc La the project(Sec.o an wneoand property
who
Cade:i Theuv threon,Li- L�(
Genufawdcesnot
uchapply r rota with
aofpropcny whosedporimproves thereon,end QTY. PLUMBING PERMIT FEE
who Dammers for anon projects with a conmador(s)licensed punuxnt to the Commnurs
License law. PERMIT ISSUANCE op
❑ I am exempt under Sec. .B&P C for this reason
Date ALTER
ALTER-DRAIN&VENT-WAI'ER(EAT VALUATION
• WORKE 'S COMPENSATI N DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby eBim under penalty of perjury one of the following dedmetions: /
E] I have and will maintain u Ceriticate of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF,AREA,COND.
STORIES TYPECONS
workas provided for by Section 39011 of the tabor Cade,far the performance of the
for which this permit Is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compensation Insurance,as required by Section
3100ofthe Labor Code for the petforomex.fthe work for whieh,hi,permit is issued. GAS-EA.SYSTEM-1 INC.4 OUT OCC.GROUP
My Workers Compensation Insurance carrier and Policy number are: 3 /6 os'j.]ss7�s
Cartier: Pnl icy No.: I GAS-EA.SYSTEM OVER 4(;P-/
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WAS INTERCEPTOR BUILDING bMOSION FEES
Oris section need not IN completed ifthe Permit is for one hundred dollars($I W) '
m lesxJ GREASETRAP PLANCHECK FEE
I certify that in the perfmmance of the work far which this permit isoaued,lxhall SEWER-SAN)' Y-STORM FA.200 I`C
not employ any person in any manner so as to become subject to the Workers'Camper- ENERGY FEE
Z satian Lawsofcalifsrnia.Date WATERH' ERWIVENT/ELECTR
2 Applicant GRADING FEE
VI NOTICE TO APPLICANT.If,atter making this CediOcme of Exemption,you should WA'f SYSTEMiTRFATING
(~ became subject to the Workers Compensation provisions of the labor Cork,you must SOILS FEE
Lat1 ti forthwith comply with such provisions of thin permit shall be deemed revoked. TER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY
NEW RCSIDENTIALPLMB. SQ,IT PAID Recci tp
C-)Q Thereby affirm that there iso construction lending agency,for the perfomuntt of
took P
the k for which this pmmh ed tvis IsxuW ISec.31199,Civ.CJ
Lenders Name TOTAL:
AWL Lender's Address TOTAL:
1 certify that I have mind this application and sum that the ebwY information is BUILDING PEE a
t�A comer.l agree to comply with all city and county ordinances and state lawn relating to QTY. MECHANICAL PERMIT FEE
L)Z building ronsvection,and hereby ammaim representatives of this city to enter upon me an, SEISMIC FEE �Z 7
above-mentioned property for inspection purposes. PERMIT ISSUANCE 'w
(We)agree to save,indemnify and keep harmless the City of Cupertino eguinst ELECTRIC FEE a sed
liabilities,judgments.costa and expenses which may in anyway aceme against said City ALTER OR ADD TO MECH.
in consequence of the granting of Nis pcnot. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO la(IW CFM) i MECHANICAL FEE
S E REGULATIONS.
_ I l t CSTR
p AIR HANDLING UNIT 10,000 CFM) CONSTRUCTION TAX
Signaturol'AppnicaRYContmcror l Date_l EXHAUST HOOD(WMUCI') 30 HOUSING MITIGATION FEE
HAZARDOUS MATERIAL'DISCLOSURE
Will the applicant or future Wilding occupant store machine hazardous material HEATING UNIT fTO VK,00(i BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Cede,Section 25532(x)^ / HEATING UNIT(OVER 100,00il BTU)
❑Yes (IN's VENTILATION FAN(SINGLE RESID) PAID "-
Date Receipt#
.� Will the applicant or future building occupant use equipment or devices which infusions BOILER-COMP(3I{p OR 100.000O BTU)
emit hnmons air conumias defined by the Bay Area Air Quality Management
TOTAL:
Di.nricf!0 Yes Z"NBOILER-COMP(OVER 100,001)BTU)
o.
I have read the haznfslous matenals amaimments under Chapter 6.95 of the Cali- AIR CONDITIONER A DATE
fomia Health&Safety Gds,Sections 25505,25533 and 25534.1 undrisund that if the NEW RESIDENTIAL MECH. SQ.FT.
but an a not current y have x return.that it is my responsibility to notify the occupant
at't miner.which must �pct r m issuance nl a Cenificxt of Occupanty.
yoOwmarrnm arizedagen ¢ TOTAL: ISSUED BY:
OFFICE