99100054 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY 'O OOS
CITY OF CUPERTINO BUILDING-ELECTRICAi. PERMIT
BUILDING DIVISION APPLICATION/PERMIT PLUMB ING-MECHANICAL
BUILDING PROJECT IDENTIFICATION 50001
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL HATE
too 6 -btAA64, G() 6-R o &A 6° 14-,
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O ER'S ME::: /� P 10 .: N RACTOR'S ME: LIC NO:
6 {i� fi gq) e l 10 ° (� ; N/C CONTROL#
ARCH11" T/ENOINLGR: LIC NO: ADDR SS: ❑ /
11 ?Z3�2 HG An �.R o. 1V
GNTACT; PHONE:
_ I u� (�)6j� I I BUILDING PERMIT INFO
IVIL�J A1• Z -0Q ❑ Consultant Fees Paid by Applicant(initial) LDG ELECT PLUMB h1F.CfI
LICE SED CONTRACTOR'S DECLARATION QTY, ELECTRIC PERMIT FEE
I herehy.Rimm that l vat licensed under powedi ns of Ctmprer,9(cummencivg ]OB DESCRIPTION
�00 with See0on 7")of Division 3 of the Business and Professions Cale,and my license is
in full force and effect. C 's PERMITISSUANCE RESIDENTIAL-
�UZV License Class Lic.# `� �� ❑SFDWL ❑KITCHIiN REMODEL
y64 Date 1. APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
z Oyy ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT L1 STRUCTURAL
❑ I undebound my plans shell he used re public records MODIFICATION
Oz=C GET 0200 AMPS
Fs 4 1a� Licensed Professional ❑INTERIOR El CHIMNEY REPAIR
o- 201-1X01AMPS IMPROVEMENT
E]SWIMMING POOLS
2 OWNER-BUILDER DECLARATION I berme a0inn that 1 um exempt
lme from the Comnim Co License Law for me OVER OfNI AMPS ED BATH REMODEIBEPAI EMOLITION
x 4 U following reason.(Section 9031.5,Business and Profeseinns Code!Any oily or county ❑OTHER
{y a�•F A
TRICAL
F O which requires a pends m confect,alter,improve,dem.11sh,or repair any structure
tnN prior to ire Issuance,also requires theapplicam hellish permit ❑leasigned motemenl RCUIT/MISC.
�y C shot he is licensed punnanuo the pawkionsof the Contractor's License Law(Chapter9
Iv E500 (commencing with Section 9000)of Division 3 of the Business and Professions Code)or ER OR POLE INST.
a ly a CL that he is exempt Therefore and the basis for the alleged exemption.Any violation of ❑DEMOLITION
DWC e�ttoy Section 9031.5 by eby applicant faro permiisub,xv,the applicant too civil penalty of ICES
Fq y
"a
l mom than five hundred dollars S500). ❑FOOD SERVICE
2GEl 1,as owner of the property,or my employees with wages as their sole compensation, POOLE ENT
yy wdl do the work,and the overman isnot imadeduroffered l.rsvle(Sec.]fk4,Business
C7 and Prefessiorts Cade:The Comnetor's License Law does not apply m an owner of SWITCHproperty who builds or improves thereon,and who does such work himselfonhmughhis awn employees,provided that such Improvements ore nm intended or offered for ENTIAL ELEC Ff.
sole.If,however,the building or improvement is sold within one year of completion,the,
.FT.FIAO $/SQ.FT.
owne
r-M1uiWer will have the harden of proving that he did not build.r improve for Aur-
pose of sale.).
❑ Las owner of the prnpeny,am exolusivdy wn0aaing w1W licensed comrucwrs m
nnswct the project(Sac.9044,Business and Pr.fssinns Cada:)The C.mncmr's Li-
censeLtrolsfrsuapplyman with
co'pmperts whored Thorimpro the Contactors QTY. PLUMB + +
who controls for such projects wirh a ammmcrogs)licensed pursuanno the Conwaov's
License Law. PERMIT ISSUANCE
❑ 1 am exempt under Sec. ,B&P C for this reason
Owner Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE O_
I hereby affirm under penalty of perjury one of the following declanticame -
IhespladwillmaintainaCc firsheof Consems.self-in.vure for Worker's Compen- DRAINS-FLOOR.ROOF,AREA, SI'OkICS TYPE CONSTRUCTION
tion,ons provided for by Section 3]W of the Labor Code,for the performance of she
weak for which this permit is issued. FIXTURES-PER TRAP �v
❑1 have and will maintain Worker's Compensation Insurance,as inquired by Section
3700 ofthe Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4OUTLE OCC.GROUP My WsPke' C on .tion Ins 'er nd Policy n m
Gricv� �ofiryNo.: GAS-EA,SYSTEM-OVER 4EEA)
CERTIFICATED EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFANDUSTRL WASTE INTERC
Obis section need not be completed if the permit is for one hundred dollars1$I(XE IL NGDIVISIO FEES
or less) GREASE TRAP
Icerlfy that in the pati'ormunceofthowvrkforwhich thlspermit isissueq,lshall STORM EA.2IXI FT, tt
not employ any person in any manner so as to becomem
subject the Workers'Compen- SEWER-SANITARY- P
,m2,' ration Laws of California,Dam
Applicant WATER HEATER WNENTELECTRz2
In BE
rA NOTICE TO APPLICANT:If,atter making this Certificate of Exemption,you should WATER SYSTEM/I'IiGTING
abecome subjem m the Worker's Cnmpcervil.n provisions of the laor bCode,you most :t"• p.E 1 t T.
Qforthwith comply with such provisions or this permit shall he deemed revoked WATER SERVICE i 1
.7z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB, SQ,IT. PAI
U0 l hereby affirm that there is a construction lending agency for performance of Data Biaccipil
". P the work for which this permit is issued(Sec.3099.Civ.C)
0 Gil
V Lender's Name
Lender's Address TOTAL: TOTAL:
� as I certify that 1 have rend this application and state that the above information is BUILDI FEE
i h correct.l agree to comply with all city and county ordinances and state laws relating t. QTY MECHANICAL PERMIT FEE
U 7� nnimins.onswmn,n.arta b.reny amhodz..repre.enwlivea. or
nhis lily to nterup.n the SEISMIC FE
ab.v.-mentioned property Introspection purposes. PERML'I'ISSUANCE
TWO agree to save,indentvify and keep harmless Ne City of Cupertino against ELECTRIC PEE
liabilities,judgments,costs and expenses which may in any way vcmme against said City ALTER OR ADD TO MECH.
In...struevco of the ,manager thls permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO,fAO CAM)SOURCE REGULATIONS. MECHANICAL FE.
�-1 tQ ` i Q CONSTRUC'f10N TA
AIR HANDLING UNIT 10,M)CFM)
Signatum o[ApplicanUComraclo ata EXHAUST HOOD(W/IIUCT) HOUSING MITI ATIO
HAZARDO S MATERIALS DISCLOSURE FEE
Willtheapplicamorte. nilding a.cnpatsnsre nr bundle hozordovvmmerial HEATING UNIT CTO I ddzdr BIG)
as defined by the Cupertino Muni tpal Cade,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)9 HEATING UNIT(OVER 101L(IW BTU)
F7 Yes ON.
VENTILATION PAN(SINGLE kESID) PAID
Will the applicant or future building rrocup.nl use equipment or devices which Uvte R
alt h...hims accommodations as defined M1y the Bay Are.Air Quality Management BOILER-COMP QHPOR 1OO.OW BTU)
Istrict9 BOILER-COME(OVER 100.000 BT O) T AI:
Dyes ON.
I have read the hazardous materials requimmenu under Chapter 6.95 of she Cal i- AIR CONDITIONER ISSUANCE DATE
fnmia Health&Safety Code,Sections 25505,25533 and 25514.1 undersand that if the NEW RESIDF,NTIAL MECH. SQ.FT
buildingdoes nos lurtomly have amou t,Natunmy nesparriblllty tonotifythe occupam
of the fequiremems which must Fz met prig m issuance of a Certifetne of 0ccuponcy.
Owner vr.uthormd agent Date TOTAL: ISSUED BY:
OFFICE