S 4418 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4418
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS SANITARY NO. APPLICATION SUBMITTAL DATE
OWN'R'S NAMIi: NE COMB R'S NAME: LIC NO,
L N/C CONTROL p
ARCH]JEC`lfdfJNG1NhhR: Yl 1Y-kL LIC NO: ADDRESS, ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Foes Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Z wi1h SvnLm W101pof Divixion 3oflhe itusinnsamd Profexsimtts cone,onJ my ucense i, RESIDENTIAL:
F W`O in full force and effect. PERMIT ISSUANCE,
QUI'" License Clens Lica ❑SFDWL [I KITCHEN REMODEL,
hQi Date Courtier., APPLIANCES-RFSIDEM1TIAL ❑ADDITION [I PLUMBING RE-PIPE
F.Dh ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT C1 STRUCTURAL
ZpyZ I undeomnd my plansshall he usedas public records MODIFICATION
OZ1O UPT02MAMPS [_1 INTERIOR ❑CHIMNEY REPAIR
F 4,t',W Licensed Professional 201-1000AMPS IMPROVEMENT
�YE� OWNER-BUILDER DECIARA'1'ION ..,,�� C]SWIMMING PO01.5
Q 1 hereby affirm that 1 am exempt form the Contractors License Law for the OVER HOW AMPS !'?BATH REMODEI/REPAIR C1 DEMOLITION
X 3 a U following rc....(Section]031.5.Business and Profusions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
FU-=LLO ya which mquiw,a permit m efins ,alter,improve demolish,of repair any rmatemre -
h..l
prior it)its issuance,also requires the applicant for such permit to file a.signed statement SPECIAL CIRCUFUMISC
'� y ?but he isliecmcdunsimulmthcProvisionoftheContractor,UrvoeLm,(Chapter 9 lC(j( Z7A
W C) (eommmncing with Section 7000)ofDM,rm3ofthe Business and Profession,Code)., 'TEMP.METER OR POLE INST. COMMERCIAL'
a a c C Nat he is exempt therefrom and the hasis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
�H
Section 701.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES [I TENANT ❑FOOD SERVICE
not more than five hundred dollars(ISM).= IMPROVEMENTOf Pel,as owner of the propcmy.or my employees with wages as their sole compensation. SWIMMING POOL FILE C
F- will do the work..ed the strucwre in not intended or offered mrsale(Sec.904,1.Business ❑OTHER
13 m and Pmfcs,ions Code'.Tho Corinne e,License Law doe,an,apply to an owner of OUTLETS-SWITCHES TIJ ,S
property who builds or improves thereon,and who Nrcs-such work hitnsclf m Nraugb
his own employee,,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR FT
sale.If however,the building or improvement is sold within one year ofcompletimn,the SQ. RAREA PSQ,FT.
owner builderwillhave thbed fp gththeJJ notbuild or inaproveformai- 0D D
mos 1 af )
f th I perry ly l i g -th 1'c d I tors to TOT
my ,fh l Sec.7044 B d Podfisi :C 1 J The Comourlm,L- JUL 1999
seta J tapply f fp pety h hila. p th .n,and QTY, PLUMBING PERMIT FEE
12
whocontracts far such projects ash a loro lders)I cermad pursuant more Contractor's
License La, PERMIT ISSUANCE
❑lam nem er See. ,B&PC for this 3s
0 ALTER-DRAIN&VENT-WATER(EAI 19,30
firm under
of NSA'DON UECLARATIO �7 OOD
BACK PLOW PROTECT DEVICE 3
bn yulfirm under penalty of perjury one of the lullowing dcd sone.
❑ I have and will maintain a Certificate of Canscmm nal-?num for Worker's Camper- DRAINS-FLOOR,ROOF.AREA,COND. STORIES TYPECONSTRUCTION
cation,as provided for by Section 37M of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
1 have and will minimum Wnrket,Compensation Insurance,as required by Section
3900 ofthe Lahor Code.for the performance of the work for which Nis permit is issued. GAS-EA.SYS'I'IiHI-I INC.40U'FhLTti OCC.GROUP APN
My Worker's Cninpen at Insumme carrier and Policy numbmmic.
Currier: Policy No: GAS-BA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEJNDUS'PRE WASTE INTERCEPTOR
(This section need not hecompined if the permit is fnro n,hundred dollars(SIM) BUILDING DIVISION LEES
or]...I GREASE TRAP PLANCHECK FEE
our emplo an aryin, become Iccnifyflimivthe nn oOhework! whichthis permitisissued.I shall
r h
NOTICE Ldw, APPLICANT:If. making
suhject to the Workerv'Cnmpem SEWER-SANITARY-STORM GA.200 FT.
zENERGY FEE
O A ];cant WATER HEATER WNENT/ELECI'R GRADING FEE
ng this Cenifiar,of Exemption,you should WATER SYSTENUTREATING
C ; become subject m the Worker's Compensammn previsions of the labor Cede,you must SOILS FEE
fonnvult comply with such provisions or this Permit shall M deemed revoked, WATER SERVICE
6 0
� z CONS'1'RUCIION LENDINGAGENCY NEW RESIDENFIAL PLMB. SQ,FT. PAID
V Q I hereby affirm that here is a construction lending agency for Performance of Date Receipt
lL F-' the work for which this perm]is issued(Sec.3099.Co.C.)
Lenders Name
U TOTAL:
Fr"
96 1<ndcr'1 Atify t TOTAL:0. 1 certify thc,,i have read this application and stove finance,
the,Mme information i, BUILDING PEELi7l /a
Z mvem.logreemcomply
and with hemby cityandcranny malivec A and atom law,entr upon
nthe QTY. MECHANICAL PL•RMIT FEE
U ,Z Inildingconmedp opedd for
ua,4aarcr,owe,nwtivm nl this city to enter span the SIiISMIC FEE
,Mme-mentioned propene tint emniftian purposes.
(We)a PERMIT ISSUANCE
( ) green save.indemnify and keep harmless the City of Cupcnino agvnst ELECTRIC FEE
Iiabilidu,juJgnmms.c nJ<xpenso which may in any way accme egainsuaid City ALTER OR ADD TO MECH.
count,in Caned oft ting of this permh. PLUMBING FEE
APPLICANT . STANDS AND COMPLY WI L1,NON-POI AIR HANDLING UNIT(TO 10,000 CPM)
SOURCER ATIONS. MI
?CI IANICAL FEE
G AIR HANDLING UNIT(OVER 0,0,X)CFM) CONSTRUCTION TAX
n APp'a Conhsctor - U/
EXHAUST HOOD OVIDUCT)
UC
HAZARDOUS MATERIALS DISCLOSUKE HOUSING MITIGATION FEE
Will supplicant or future building occupant sore or handle haiufilms material HEATING UNIT(TO 100,000 BTU)
as defined by the CuPerfno Municipal Ode,Chapter 9.12,and the Health and Safety
Coda Section 25532(a)7HEATING UNIT OVER 100,000 B'FU)
[:1 Vex
VENTILATION FAN(SINGLE RESIDE PAID
Will the applicant or future building occupant use equipment or devices which Data Receipt a
emit hreardouaair eonmmmanl,as defined by the Bay Area Air Qual fry Management BOILER-COMP DHP OR 100,000 BTT
District? /' TOTAL:
❑Yes BOILER-COMP(OVER 1000g)BTU)
1 have read uiallous ntmeriuls requireem! np¢r 6S5 nl the Cdi- AIR CONDITIONER
4' ISSUANCE DATE
Inmiu Heald&;me Cafe,Section 05.255 M' 34.1 umlersunJ that if the NEN'RESIDENTIAL MECH. SQ.FT.
buildingJsq Imndy haven ,that it
y flAdayt.madythe cupanl
ifthe ism,. -Imus,, ,,Pried CcHifc f0ccseat,or a w
ved gent Ondc TOTAL: ISSUEDBY:
OFFICE