99100007 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 9q 10
(� CITY
w- CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPIICATION/PERMIT elumswG-MECHANICAL
:BULDNG; RUJEGCIDR
U � , P
1001
BUR.DINGADPR.SS; SANITARY NO. APPLICATION SUBMITTAL DATE
/966J' v �rw ,Or le- �r/
hNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
r/r ,r `` L•/� 3)+.� N/C CONTROI.K
ARC�H/ITECT/ENGINEER, LIC NO: ADDRESS: G [! J i ❑
7 i Ae`
CONTACT: PHONE: ".(; ';'r BUILDING PERMIT INFO
❑ Consultant Pce6 Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ 9 ❑
LICENSED CONTRACTORS DECLARATION t- i t„ /
(hereby affnn lh t l licensed d p f Chapter 9(eommen QTY ELE' RIC PERMITx {''r 'IEEE' a;"
s JOB DESCRIPTION
WOO with Section]000)ofDvs as inspire Ba,dec and Project Codeatdmylieen RESIDENTIAL
i-W�y O In full force and sacra q PERM]I ISSUANCE
C Uz F License Class 3�i Lic.# /� zL_ ❑SPDWI. El KITCHEN REMODEL
Date CnnlrvMr APPLIANCES-RESIDENTIAL ❑ADDITION $(PLUMBING RE-PIPE
0d
ARCHITECT'S DECLARATION PANELS El MULTI-UNIT El STRUCTURAL
Z HO'/O/Z I understand my plans uhall be melt as public aecoMs MODIFICATION
UP T0200 AMPS
El INTERIOR El CHIMNEY REPAIR
W.1 Licensed Professional
OWNER-BUILDER DECLARATION 2lll_IIXNIAMPS IMPROVEMENT SWIMMING POOLS
I hereby affirm that I am exempt from the Contractor's Liceme Law for the OVER I000AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
3 a.U following reLvrn.(Section 70315,Business and Professions Code:Any city or county SIGNS ELECTRI ❑OTHER
G y which wdpr mr a permit to consumer,alter,improve,demolish,or repair any structure
�� Postal.as is........ho requires the applicant for such permit to file a signed andanent SPECIAL CI UIT/MISC.
that he is licenced pursuant m the provisions at the Contractors License Law
(Chapter9
(commecers,,th Section 9M10)rf Dlv...an audit,Bustaround Professions Code)m TEMP. .TER OR POLE INST.
Ft o rL rhea he Is mempr manage.and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
4• Section 7031.5 by anyappliwnl for a penah,adjeen he applic..I lou civil ppretty of PO •R DEVICES
t mrrethen Eve lmndred dollars t$500),
TENANT ❑FOODSERVICE
FO ❑1,as owner of the property.or my employees with wages as their sole compensation, WIMMING POOL ELECTRIC IMPROVEMENTpar will do thework,and the sttucmrc is notinlendul nrofferW fmsule(Set.7014,Business
am and Professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves rhemon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECTR SQ PC
side.If,however the building or i carevemenr is sold within one year ofcompletion,rhe SQ.FT.FLOOR AREA VSQ.FT.
owner-buildc,will have the burden of proving that he did not build Or ImpreVefor p
pmt I. le}
❑cense I d l apply t f property h bu Id. inanition;there+
p,and
,
MINES 1, f the property. exclusively I f g 't d contractors to
constructth project(Sec 7044 B dP f.. Cod )ThC t r I UOF
who e r ca for inch projects with a cornrnggs)licensed pursuant the Contractors LIr
License Law, PERMIT ISSUANCE
❑ saIiiiiii
I amexumpt under Sec ,B&PCfor this moron
r 4 Is
Dam ALTER-DRAIN&VENT-WATER(EA) L ..
WORKER'S COMPENSATION DECLARATION RACK FLOW PROTECT.DEVICE
1 hereby affrm under penally of perjury one of the pallowing declarations:
❑I have and will maintain aCenificateof Consenv.self nsare for Worker's Compe.- DRAINS-FLOOR,ROOF,AREA,C i NSTRUCTION
sound,as provided for by Section 3900 of the Labor Code,for he performance of the
woo
k loo which this permit is issued.- FIXTURES-PBR TRAP
d(have and will maintain Workererroranteof
Compensation Insurance, h required t i Section
3700 of the huhur Code.for performance of the work for which this permit is issued. CAS-EA.SYSTPN-I INC 40UTLET$ OCC.GROUP APN
My Worker[s Cyylpensalion carica and Policy northern
Certicc df/?Tylr � Polwy No: GAS-EA.SYSTEM-OVER 4 CA) /
CERTIFICATE OF EXEMPTION FROM WORKERS' o
COMPENSATION INSURANCE GREASEdNDUSTRL WASTE INTERCEPTORD{NG IQ :FIBER»�$����
O'h'usecti it need not bemmpleted lithe proms,is friend hundred dnllars(SI00) GREASE TRAP
or Ivc.) PLANCHECK FEE
I cenlfy drat in the peffomhance of the work fm which this permit is issued,Talent i'
not em le an SEWER-SANITARY-STORM EA.200 FT 9
p y any in any manna so as in become aubjwn.the Workers' �BNERGY Fl3E
',Z an..Lawaof Calilbmia.Data� O Applicant WATER HEATERW/VENT/ELECTR GRADINOFF,
Ij NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should WATER SYSTE.M/fREATfNG
become subject to the Worker's Compens.him provisions of the Leon,Cade,you tomop SOILS PEE
fortor forthwith comply with such provisions ohls permit shall be deemed revoked. WATER SERVICE By
ao
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.fT. PAID
I hereby option that there is a construction lending agency for the performance of Data Receipt#
L)
U the work for which this pormil is issued(See.3097,Civ.C)
Lender's Name TOTAL:
C) (U Lender,Address TOTAL
r� Ps I andyffir,1 have d h ppl' stn and stale that the b f.mar o "y /_ t BUILDING PEE
soar 51 a ren I g t comply th.11 it, d county ordinance,and since 1 renting I 0,7 Y. ) MECHANICAL PERMIT '1 FBP
G za.
building construction,and hereby authorize representatives of Ibis city to enter upon the I a SEISMIC FEE
above-menhoned property for inspersion purposes.
(We)agree to save,indemnify and keep harmlecc the Cil,of Cupertino against PERMIT ISSUANCE 117ELECTRIC FEE
liabilities,]uillarb .costs and expenses which may in any way.cemt against said City ALTER OR ADD TO MBCH.
nnseyuenw of the granting of this pwmil. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURC� GULATIONS. / /�/!�� MECHANICAL FEE
�� /D_T' '.7 AIR HANDLING UNIT 10.0 1 CONSTRUCTION TAX
Shgnamretf Applicant/Curcrzmor °r
Data EXHAUSTHOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
- Willthe applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 10 BIITU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Code,Suction 25532(x)? �/ HEATING UNIT HR 100,090 BTU)
FI Yes L7N VHNTIL IN(SINGLE RF.SID) PAID ..
Dam Receipt#
Will the appusrr tofu a,befireg bmhe Bayon ecyuiir pant on Quality
Moces untain,
gOIL -COMP(iHPOR 100.000 BTU)
emit hazardous air comaminants as delineA by the Bay Arca Air Quslity Managemem TOTAL: k
DlstnoC
10
I]Yes No ILER-COMP(OVER 100,000 BTU)
1 brae read the hxeard.us nationals requih'unems ruder Chapter 695 of the Cali- AIR CONDI'T'IONER ISS ANCE DATE
form.Health&Safety Cold,Sections 25505.25533 and 25534.1 undersrand that If the NEW RESIDENTIAL MECH. SQ.FT.
hadding does nut currently have.lemma,that it is to,re,porability to notify thewtioca nl
M1a I.Certificate
lcat—e or Oe....ray¢wageffd nfhDa ' �fe
TOTAL w
ISSUED B
OFFICE