99080198 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO RUILDIsNG-ELEC7fRICAI. ER Ii NO.
BUILDING DIVISION APPLICATION/PFiRMIT PLUMBING.MECHANICAL.
_ ' ,BUILDING PROJECPIDENTIF[CATION'
iU1LDING ADI3RIiSS: SANITARY NO. APPLICATION SUBMITTAL DATE
7 ,5_0 anAzlnw Place #Z 4
HONE: N'I'R CTOR'S NAME: �G1C NO:
MSI N/C CONTROL.#
CHII'ECT/FNGINEER: LIC NO: AD R/oo
Pj Qq,,-t� y'r s 11
CONTACT: PHONE. ';BUILDING PERMIT INFO
ma�ktr ��_��`q ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1.�.
LICENSED cONTRAc mR9 DECLARATION QTY ; '(,,ELF,CTRLC'PERMIT 1 FEE.
1 hereby a1Brm that 1 am licensed under provisions of Chapter 9(commencing • _ JOB DESCRIPTION
WOO wilt Secdon)000)of Dvismn Sof the Rusmczsand Pmresvmms Caemd my license is RESIDENTIAL
WOO PERMIT ISSUANCE
F=-F in full force and effect. 7 /6'/ DSFDWL [I KITCHEN REMODEL
QUU Livens la Lic.0 r APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
yZ pore TS DEan
y ARCHITECTS DIiCi,ARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
Z O y Z 1 understand my,fma shall he used us public records MODIFICATION
OZ—M UPT02MAMPS [I INTERIOR El CHIMNEY REPAIR
F 4)=W Licensed Professional 201-1000AMPS MPROVEMI':NT GSWIMMING POOLS
ECLARATION
IX C C Q I hereby elRrm OWNER-BUILDER
a N em exdmp rfrnlm the Contractor's License Law for the OVER IDDEAMPS TH REMDDEI/REPAIR D DEMOLITION
L 0.U following reason.(Scotia.]0315,Business and Professions Code:Any city or county SIGNS ELECTRICAL OTHER
3 W F" which requires a permit to construct,aIle,improve,demolish,or repair any structure �]f')ra.��\y�
priarloily isam"Co,alv)requires the applicant lnrsuchpemtit to filetiogned statement SPECIAL CIRCUIT/MISC. `s/• 1
CY thaheisli.ron!Pursuant to the pro,morool the Common's Lieomse Law(Ch,aar9
(commencing with Sca ion 7000)of Division 3 of the Business and Profession,.Cade tar TEMP.METER OR POLE INST. COMMERCIAL:
0.d IY thathc is exempt therefrom and the basis for the alleged exemption Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
u•
Section 7031.5 by any applicant for a permit objects thea applicant u civil alt f POWER DEVICES
—In PF penalty []TENANT ❑FOOD SERVICE
FZY
not more than five hundred dollars(SSW). - IMPROVEMENT
G ❑ Lo are work,the pmperty,r mycmplendes with Bred fostbeirwlecompensation, SWIMMING POOL ELECTRIC
will do the work,and the amcwrc is not intended or offered frnsale(Sec.7044,Nosiness ❑OTHER
ad and Professions Code:The Contractor's License Low does not apply a)an owner of OU'T LF.'TS-SWITCIIliS
6 a^ proper who builds or improves thereon.Emil who does such work In is If or Ihmogh
his own employees,provided that such iinpoo ments are not intended,r offered for NHVI RESIDENTIAL I.F.ESQ FT.
sale.If,however.the building orimprovemem is sold within one year of completion,the �1ZE S/SQ.FT
cr-builder will have the burden of proving that he did not build or improve for pur- -
0 1,as ales _
e L ru t r of the Sec. 0y.,E exclusively Cly c tract g Coithde)
licensed c haat t CIA L:
D
nse La the protect apply
to a Business d Prof Cod )It C 1 t L - - r 2
cense Law does not apply to un owner ail pn puny h builds in pr :Ih re and QTY,t t PIAtMBING;PERMIT ^ I. UU 7 1999
It,,contracts far such,.rivers with a cmmmemos)I cursed purxtoat is the Cant, s V
License Law. PERMIT ISSUANCE
D 1 am exempt under Sec. B A 1'C for this reason
be, Dae ALTER—DRAIN do VENT—WATER(RAI VALUATI \
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE W
I hereby aifirrn under,moll, f,drar,ore ofthe fallowing declinations:
I have a"dwiil maintain aCertificateofCommon)self-i"wm for Worker's Comped- DRAINS—FLOOR,RWE AREA,COND. STORIES TYPE CONSTRUCTION
cation,as provided far by Section 37M of the Labor Cade,for the performance of the
work fnf which this,armit Is issued, FIXTURES—PER TRAP
❑I have and will ntainmin Worker's Compensation Insurance,its required by Section
37W ofthe Labor Code,for the perfammince of the work for which this permit is issued, GAS—EA.SYSTEM-1 INC.4 OUTLETS OCC.GROUP APN
My Work p r/n�t and Policy yWhD �p
Carrier�7bi/FCo Policy No.: l a /z GAS—EA.SYSTEMOVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR 1
(This seclinm need notbocamplaeJ if lhcpennit is fornne hundrtd dollas(EI W) r �'bx ,„ FIUILINNgfJvVl9f0N FT1P5,; A err#k
GREASE
or less.) 'IT3AP
PLANCHECK FEE
leartifylhot lntheperferrnaaeeoitarlakbrwhlehthlspennil is issued,[dedl SEWER—SANITARY—STORM EA.200 Irl
not emplay say person i"any manner so Es m hccome subjecno the Workcrk Comped- ENERGY FEE
ZZ mum,Laws of California.Data WATER HEATER W/VIiNT/ELECTR
O Applicant GRADING FEE
.N. NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should WATER SYSTEN/TREATING
ahccome subject m the Worker's Compensation provisions of the Labor Code,you in SOILS FEE
[II forthwith comply witbsuch provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION alNG AGENCY NEW RESIDENTIAL PLMB. SQ.IT PAID
U0 Iherety ufOrm that there isaaw,ion
mslnn lending agency far he parfarmana of ])ete Recelpl# '
FI' the work for which this permit is issued(See.3097,Cie C.)
O U Lenders Name TOTAL:
Lenders Address TOTAL:
I certify that I have read this application and site that the above information is BUILDING PEE
LLiI coned.I agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT 1 r' FEE';
UZ building codsauetion,and hereby commve representatives of this city to enter upontha SEISMIC FEE
above-mentioned Properly for ioapecdon purposes. PHRMIT ISSUANCE
(We)agree a,rive,iodadudfy and keep tardlleas the City o1'Cupertino against ELECTRIC FEE
Iiabililies,judgmenls,co.(,.ad expenses which may in any way orma.,clact,sid City ALTER OR ADD TO MECH.
in consequence of the grunting of this permit. PLUMBING FEL'
APPLIC P UN RSTA S AND W COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEF.
SOUR EG TIO /)
d��7�y AIR HANDLING UNIT(OVER 10,(810 CFM) CONSTRUCTION TAX
Si nature of AppllcmnVCnmractor ((((//// Dae/ EXHAUST GOOD(W/DUCT) HOUSING MITIGATION FFE
IIAPARDOUS MATERIALS DISCLOSURE
Will theapplicuntor future hdfialmg occulmm stare.,handle hnmrdous mmeriil HEATING UNIT(101(b,000 BTU)
m defined by the Cupertino Municipal Code,Chapter 9.12,and the Health said Safety
Code,Section 25532(a)'7 I ELATING UNIT(OVER 100,000 BTU)
DYes DNo VENTILATION FAN(SINGLE RESID) PAID
llWill the applicant or furore building occupant use equipment or devices which Data Receipt#
trt't,hadmagons air contaminants as derided by the Bay Area Air Quality Management BOILER-COMP(3HI'Ok 100.000BID)
yi
nrict"
TOT
❑Yes E]No - ROIhER-COM P(OVER IW,00p BTU]
I have read the hamrdous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomia Heals k Safe y C Scetions 25505,25533 ail M534.1 understand that if the NEW RESIDENTIAL.MECH. SQ,Fr.
buildin srac t amnam t n is my resporlsibilhym notify the occupant
of the a who or to issuance of a Ceoal Occupa0cy
'ner or authovirad a,end LL�Dmee TOTAL: 11^'}
E ISSUED BY:
OFFICE
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