99090027 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING F.LF.CTRICAL PERMIT NO. p�p
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL �PITT'l�
BUILDING PROJECT IDENTIFICATION Ir
BUILDINGADDRESS. SANITARY NO. APPLICATION SUBMITTAL DATE
l- -3 -4
OWNEONTRA
CTOR:S NAME LIC O NIC CONTROL#
I ECT/HNGINEER: PLIC NO: A SS: ❑
AM
TACT: PHONE:
BUILDING PERMIT ITJFO
f� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLU SUCH
❑ ❑ M ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby aft m thin 1 am licensed ander....einns of chapter 9(commencing JOB DESCRIPTION
❑aZ with Section]B0B)of Division 3oDhe Baaimesaimed Professions code,and my license is SIDENTI
in full force and effect PERMIT ISSUANCE L.
aUU License Claes Lic.# SFDWL C1 KITCHEN REMODEL
y Z w Date Connector APPLIANCES-RESIDENTIAL ADDITION ❑PLUMBING RE-PIPE
F5z
ARCHITECT'S DECLARATION PANELS ❑MULTI-UNIT L3 STRUCTURAL
'z p m I understand my pints shall be used as public mrinfs
__- UP TO 200 AMPS MODIFICATION
i`WA ❑INTERIOR El CHIMNEY POOL
ai Id Licensed Professional 201-IoW AMPS IMPROVEMENT
C �; C]SWIMMING POOLS
OWNER-BUILDER m the Carmen OVER 1000AMP5 ❑BATH REMODEVREPAIR El DEMOLITION
W 6 I hereby affirm that 1 am exempt from the Co1inces o License Law macho
{?LS O es U following reason(Sermon]03 L5,Business antl Professions Code.Any city nr,aunty SIGNS ELECTRICAL. HER
W 31i y which requires a Permit to construct,alter,improve,demolish,or repair any stmctum
�ol.Q] prior to totsissuance,also requires the applicam for such pormlOo fileasi dusearom
gne
y Nat he is licensed pursuant o the provisions of the Contractors License Law(Chapter 9 SPECIAL CIRCUIT/MISC.
W 6C) (commencing with Section]WG)ol'Division 3.f the Bluinessand Professions Code)., TEMP.METER OR POLE INST. COMMERCIAL:
d ry,pa 2r that he is exmpt etherefmm and the basis far the alleged exemption.Any vi durimi of ❑NEW BLDGIADDITION ❑DEMOLITION
t� try Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE.
0 not more than five hundred dollars(8500).
❑I,as nwnernRhe progeny,ormyemployees with wages as lheirsnle compensmioq SWIMMING POOL ELECTRIC IMPROVEMENT
,X willilotht work,andthesomam is not intended oroffered forsale(Sec.]0TU Business El OTHER
tr13 and Professions Code:The ComnmmrI License Law does oat apply to or owner of OUTLETS-SWITCHES-FIXTU
CFL property who builds ar improves Ihereun,inti who does such .,it himself or through
his awn employees,provided That such improvements ale counteract m uffered for NEW RESIDENTIAL ELECTR
sale.If.however,the building or imprdmicaut is sold within one year of completion.the SQ.FT FLOOR AREA SISQ.FT.
causublarlder will have the burden of proving that he did not build or imPmve for pur-
pow of side.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL:
construct the prompt(Seo.](44,Business and Professions Cotler)The Cone.crors Li-
nse Law does for apply to an owner of property who builds or improve.,thereon,and QTY, PLUMBING PERMIT FEE
who contracts for such projects with a comracmt(s)licensed pursuant o the Contractor s
License Law. PERMIT ISSUANCE
❑ I.m,x,.ptandersec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
,our Date
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT DEVICE
I hereby affirm under penalty of perm ry one of the following deelamtions:
I tropical will maintain a Cenifcme of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOF.AREA,COND.
G n,as provided for by Section 3700 of the Lahr Code,for the performance of the STORIES
rhave
TYPE CONSTRUCf10N
rwhich Ihispefi ilisissued. FIXTURES-PER TRAP
h ve and will maintain Workers Compensation Insurance,as required by Section
(Ill of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC,4 OUTLETS OCC.GROUP
y Wnr - I prone,and Policy
Ctioner�l [e m Pniicy No_ GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICA'I E OF EXEMPTION FROM WORKERS' GRUSEINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE. EBBS
(This section food not he completed if the pencil is forome hundred dollars(%100) BUILDING DIVISION
or less') GREASE TRAP
1 sonify that in theperformance of the work for which this permit is issued,Isbell PLANCHECK HE
not employ any person in any manner so as to become subject to the Workers'Comper- SEWER-SANITARY-STORM EA.200 FT
Z satiml Laws of California.Date of ENERGY FEE �1
z O Applicant + R HEATER WNENT/ELECTR q
Pp GRADING FEE ^ 1
y NOTICE TO APPLICANT:If,after pensati thins Cenifcme of Exemption,you should WATER SYSTENUTREATINC 1
become subject to the Workers Compensation permit
sh al of the Labor Code.you mull 1 `\)t
Qforthwith comply with such Provisions or this permit shall he deemed revoked WATER SERVICE. tI lil
;Dz CONSTRUCTION L ENDING AGENCY NEWRESIDENTIALPLMIL SQ.FT. PAID A 1O .1 14,
I;) p Ihereby affirm that there is a construction lending agency for the performance of `Date dle,elpt# J
the work for which this permit is Issued(Seo.309],Civ.0)
OF Lender's Name TOTAL_ i
Lender's Address TOTAL:
LU I comfy that I have resinous application and state that the above information is BUILDIV8HE
Fr W correct.I agree to comply withal]city and county ordinances and state laws relatingm QTY. MECHANICAL PERMIT PEE y
V Z building construction,and hereby authorize representatives of this city to enter open the SEISMIC
tabove-mentioned property for inspection purposes. PERMIT ISSUANCE
(We).91.to save,indemnify and keep to miless the City of Cupemno against ELECTRIC FEE
liabilidet.,tal ments,coats and expenses which may in any way demeagonal said City
in consequence of the granting of this permit. ALTER OR ADD TO MECH. PLUMBING FEE
APPLICANT 11 )ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM)
SOURC. NS. /�/�� MECHANICAL FEE
//n AIR HANDLING UNIT 10,000 CPM)
�yp/t— CONSTRUCTION TAX
Signature ofAPPlincy mumetar Tole EXHAUST HOLD(WIDUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicnnt or future building odupamume or handl,hazmdeas material HEATING UNIT(TO IW,OIHI BTU)
as d,fned by the Capemmrm Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)'I HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGER RESID) PAID Will the applicant or furore building t use equipment or device which Date Receipt p
goccupan quipme BOILER-COMPDHPOR 100,0008TU)
mit hmarduus air contaminants as defined by the Buy Area Air Quality Management TOTAL
strict?
❑Yea Fl No BOILER-COMP(OVER 100.00)BTU
1 hove read the h yeardove anaterm,requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCEDATE
ramie Health&Safe ride.Sections 25505,25533 and 25534.1 undersmnd that if the NEW RESIDENTIAL MUCH, SQ.UT.
building doe m n eamnont,that it is my responsibility to notify the occupant
of mem ui w them t prior m issuance of aCnifibateo y
o�zuthoriz d egcll lige c�TO AL ISSUE BY:
OFFICE