S 4352 (2) APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL 5 4352
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY IN APPLICATION SUBMITTAALL DATE
OW ER'SNAME: PHONE ONI'RACTOR'. NAME: LIC NO:
ROK r �--�q I e NIC CONTROL p
CHI FCVI3NGNF.HR: LIC NO: ADDRESS. ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ COnSultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El 1:1 1:1r
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby uf0tm that I..licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
WOO with Scaion'l0W)of Division 3 of the Rminevsand Prow"inns Cnde,ml my license is RESIDENTIAL:
Or in full lmatind fca PERMIT ISSl1ANCF. ❑SFDWL ❑KITCHEN REMODEL
QUV Licence Class LiC.O APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
y st S Da¢ ComDECL
•>� A CHITBCTS DECLAR TION ❑MULTI-UNIT ❑STRUCTURAL
Z O t2z I understand my plans shall he used as public records PANELS MODIFICATION
OZ-, UPT0200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
ar/41LM Licensed Professional 2014000AMPS IMPROVEMENT SWIMMING POOLS
�J OWNER-BUILDER DECLARATION OVER IOW AMPS ❑BATH REMODELIREPAIR ❑D• OLMON
Q I hereby ef0rm that 1 am exempt from the Contractor's License Law for the
gyp(,O L U following reason.(Section 9031 5,13usiness and Profession.,Code:Any city or county SIGNS ELECTRICAL ❑OTHER
41 a LL N which requires a permit m emmor ch alter,improve,demolish,or repair any atumure
F�Oe pdonoits issuance,also requircslhe upplicam(.,such permilmfleesignW slasemcm SPECIAL CIRCUITIMISC.
that he is licensed pursuant to the provisions ofthe ContmmofsLicense Law(Chapter 9
OO (cnmmencing with Section?o0(0of Dosium 3of the Business and Pafevinns Code)or 'FZMR MET ER OR POLE INST. COMMERCIAL:
d e oC Nm he is exempt therefrom and the basis for Ne allegM exemption,Any vidatinn of ❑NEW BLDGIADDITION ❑DEMOLITION
liSection 11131.5 byany applicantfor.permitsubjtt¢Ne applicant m.civil penalty of POWER DEVICES
sty []TENANT ❑FOODSERVICE
t mom than five hundred dollars(5500). PROVFMENT
6 01.ns owner of the pr.peny.nmy employees winb wages xs their sola cnmpcnsaioq SWIMMING POOL ELECTRIC
C will do the work,and the-_sb.mum iv not inuenled,nuffaed far sale(Sec.?044,Business OTHER
and Professions Code:The Contractor's License Law does not apply to m owner of OUTLETS-SWITCHES-FIXTURES
6 3 primary who builds or improves thereon,add who does such work himself or though
his own employees,provided that such improvements am not intended or ofFeleJ for NEW RESIDENTIAL F.LECfR SQ FT.
sale If,however,the building or iniprovement is.sold within one yearof completion,the SQ.FT.FLOOR AREA USQ.Pn
ner-builder will have the burden of paving than he did nn,hold.,improve for In,
pose of aale
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
oc
construct the project(Sec.7044,Business and Professions Gine:)The Cmustal is L-
cense l.nw doer am apply 1.unuwnerofProperty wino huild..r improves thereon,and QTY. PLUMBING PERMIT FEE
who contracts for such projects with accountants)hcensedpuxuml to the Contractors
License Ln, PERMIT ISSUANCE D
C]Iam exempt under Sa. .B&P C for this reason �!
Owner Date ALDER-DRAIN&VENT-WATER(IIA) A Ag999
WORKER'S COMPENSATION DECLARATION BACK FLOW PROT=DEVICE fJUJUJY %
I h,m y afthm under Penalty of perjury one of the following declarations:
❑I have and will maintain a Cenifcme of Consent to self-insure for Workers Camper- DRAINS-FLOOR,ROOF AREA,CONK t5V STORIES TYPE CONST RUCTION
sation,as provided for by Sealant 37N)of the Labor Cade,for the pm andence of the o f ij
work for which this permit is issued. FIXTURES-PER TRAP
❑ I have and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor Code.for the pvomnnmce of the work for which this pcomi is issued. GAS-EA.SYSTEM-I INC.4 OUTLHIS OCC,GROUP APN
My Worker's Cnmpcmminn Inaunmce carrier and Policy man o,are: -
Carrier Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEBNDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION PEGS
(0fiis section nerd cut boannplued iftha poral.is Cnr cone hundred dollars lbl(q) GREASL TRAP
or les,.) PLANCHECK FEE
Iccrifyahmin the Nrfmiromecof the work(.,which this permit is issued,Ishill SEWER-SANITARY-STORM EA.2W FT.
not employ any Nuo n t in any imnnap. as a.become subLL«nL aha Workers'Compen. ENERGY FEE
Z cation Laws of ate ` 2(n—9 9
O Amplicuul �---�� WATER HEATER WNGNTIHLECTR GRADING FEE
NOTICIi TO AN'f:IL cher star is CmiOca¢of Exemption,you should WATER SYSTCMNREATING SOILS FEE
become subject to the Worker's Compensation provisions of the labor Code,you muse
foMwiN comply with such provisions or this permit shall be deemrd revoked. WATER SERVICE
0
Uz CONSTRUCTION LENDINGAGBNCY NEW RESIDENTIAL PLMII. SQ.PT. PAID
V 0 Ihereby which'hi that
ennanii.vaed(Scconstruction lendmg agency for the MHormance of Date R eiplM
U. F theLe work for which Nis permi.is inued ISm.3119?.Lay.C.)
O Lender's Name TOTAL:
Lender's Address TOTAL:
1 certify that I have read this lity=it coup y ordinances state that the above iws relating is BUILDING FF.E
fr Z building agreemmmand wird y utyond cnunOvesof thus sure lower upon the
Qry, MECHANICAL PERMIT FEE
C.) s� above mentioned
hereby tmhnnmrepreumativex of this city to enter upon the SEISMIC FEE
oll
aMwe (We)
agree 1.wryawe.for inspection ad keepha PERMIT ISSUANCE
(Wel agree m save,indemnify aW keep harmless the City of Cupenlno against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in my way accmwgainst said City ALTER OR ADD TO MECH.
in consequence of the granting of this permit. PLUMPING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOJ3R�I�GULATIONS. /''- MECHANICAL THE
( ✓ r is / .Lq� /!� AIH HANDLING UNIT(OVER IB,IXNI CFM) CONSTRUCTION TA
f Sii...ImemfA�-pppllica� risCmdrusamr� `1___ �(ODate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE 1 '^
Will the applicant or future building occupant store or handle hamadous material HRAHNG ON['I'(TO UXLO )BTU)
as defined by the Cupenlno Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532ta)? HEATING UNIT(OVER Ifla"BTU)
❑Yes No
VENTILATION PAN(SINGLE NF.SID) PAID -
Will the applicant or future building occumin use equipment or devices which Dale Receipt N
mail hmadous air contaminants as defined by the Bay Area Air Quality Mawgeplent ROLLER-COMP(3HP OR 100,000 BTU)
DiNict? T AL:
❑Yew No BOILER-COMP(OVER 100.000 BTU)
I have read the hazardous materials requirements under Chapter fi.950(N<Cali- NR CONDITIONER ISSUANCE DATE
heads Heilth&Safety Cade,Sections 25505,8533 and 25534.1 understand that if the NEW RESIDEM'IAL MECH. SQ.FT. / 7 Z// -7-
building does nommmmly haveatcmm,that is May responsibiliayto notify Ne eecupunt C/%n 2 -(
yams tan whioh the....
,ono lssmnca oft Conillmte of Occupant,
Ownft or authorized agent Date I TO L: ISSUED BY:
OFFICE