99090130 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL q - VO/W
PERMIT NO R
BUILDING DIVISION APPLICATIONXERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS: SANITARY NO. APPLICATION SUBMITTT
QAL DAE
A-bA L
O R'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO:
' NIC CONTROL#
HITECT/ENGINES LIC NO ADDRESS: `9 ❑
CONTACT: PHONE: BUILDING PERMTTdNFO
❑ Consultant Peas Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
El El JW ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby affirm that I am licensed under provisions of Chapter 9(commencing 70B DESCRIPTION
Da'Z whh Semion9W0)of Division3 ofthe Business and Pn�fessionn Code,and my license is
FOB in full force and PERMIT ISSUANCE RESIDENTIAL:
W y ❑SFDWL ❑KITCHEN REMODEL
�UV License `ss Lic,# PLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPE
W,ul Dete Cnntrac
Gs ARCHITECT'S DECLARATION El MULTI-UNIT El STRUCTURAL
Z p n Z I understand my plans shall be used as public records PANELS MODIFICATION
OZ-Q uPT0200 AMPS ❑INTERIOR [I CHIMNEY REPAIR
Licensed Professional 201-I01OAMPS IMPROVEMENT E]SWIMMING POOLS
eye OWNER-BUILDER DECLARATION aOVER 1000 AMPS BREMODEUREPAIR El DEMOLITION y Q I hereby affirm that I am exempt frofo
m the Corrosion's License Law burns
WP3 F following reason.(Section]03 L5,Business and Professions Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct,alter,improve,demolish,or repair any structure
F 6�. 0 prior o its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUIT/MISC.
G that he is licensed putmort to the pmvlsions ns
of me Contractor's License Low(Chapter 9 ,
(commencing with Section 7000)of Division 3 of the Business suit Professions Code)or TEMP.METER OR POLE INST.
Q,ry�,e a that he is exempt therefor and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
wl' Section 7031,5 by any applicant for n permit subjects the applicant to a civil Penalty of POWER DEVICES 0TENANT ❑FOODSERVICE
y not more than five hundred dollars($500). IMPROVEMENT
Q
L]1,as owner ofthe property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
will do the wmk,mm the nmrnme a not intendedoroffined forode(See 7044,Business ❑OTHER
W 3 and Professions Code:The Contractor's License Law does not apply m an no,of OUTLETS-SWITCHES-FIXTURES
�' .. property who builds in improves there,,.,and who does such work himself or through
his own employees,provided that such improvements are not intended nr offered far NEW RESIDENTIAL ELECTR SQ FT.
sale.If,however the building or improvement is sold within one year idexmplelion.the SQ.IT, -0 AREA IIJSQ.FT.
owner-huilder will have the burden of proving that he did not build or improve fur pur-
pose of sale^)¢
L] l
1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL
construct the project(Sea.9044.Business and Professions Code)The Contractor's Li_ - SEP 2 1 1999h'.
c se Law does not apply tot an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT FEE ,
who contracts for with Project n
with a contractors)licensed pursuano the Contractor's
License law. PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason B
r Dare
ALTER-DRAIN&VENT-WATER(EA)
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE (� 0
f hereby affirm under penalty of perjury one of the fallowing declarulom: z
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
sation,as provided for by Section 37M of the Labor Code,for the performance of the
k for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Workers Compensation Insurance,as required by Section
377 of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I TNG 4 OUTLETS OCC.GROUP QPNi
My We
y�Wny mal sy atria c mer and Policy
Cance a -# ue n'� / Policy No.d`• '� ��e�A GAS-BA,SYSTEM-OVER 4(EA)
CE TIPICAMOFEXEMPTION PROM WORKERS' O
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
BUILDING DIVISION FY&S
('(Tis section treed not be enmplamdiPthepetmit is for one huntlredtlollars($100) GREASE TRAP
or less.) PLANCHECK FEE
I conify that in the performance ofrhe work forwhich this permit is issued,I shall SEWER-SANITARY-STORM EA.200 PT.
not employ any person in any manner so as to become subject to the Workers'Compen- ENERGY FEE
OZ ..tion Law 'a
a. ate WATER HEATER W/VENTMLECTR
O Applicant�(�°(L I+- GRADING FEE
4 NOTICE TO APPLICANT If,after making this Certificate of Exemption,you should WATER SYSTENIGREATING SM
abecome subject to the Workers Compensation provisinns of the Labor Code,yon must SOIL
W forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0. Q
r7z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID are ceipl#
C.1 p (hereby affirm that there isecnnstmetion lending agency fon the performance of
the work for which this permit is issued(Sec 3099,Civ.CJ
C) F" Lattices Name TOTAL: -
V Lender's Address TOTAL:
Po 1 certify that 1 have read this application and state that the above information is BUILDING FEE
rn wrest 1 agree o comply with toll city and county nrdinences and state laws,eluing to QTY. MECHANICAL PERMIT .FEE
UZ building construction,and hereby authorize representatives ofthis city to enter upon the SEISMIC FEE
'—' mance-mentioned property for inspection purposes. PERMIT ISSUANCE
CA)agree to ave,indemnify and keep harmless On City of Cupertino agnimu ELECTRIC FEE
Imbilitie.,judprom coussndexponses which may in anyway accrue against said City ALTER ORADD TO MECH. PLUMBING FEE
in nnsequenceo Sre �n (this Pe - /
APPLICANT .DF�IfAN SAND WII ,CO ALY W iH ALL NON-POINT AIR HANDLING UNIT(TO 10,00CFM) MECHANICAL FEE
SOUR ,T NS.
_ AIR HANDLING UNIT(OVER 10,00)CFM) CONSTRUCTION TAX
STIfIrstim,to ApptlicaUCoutrado Detc EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant sora or handle hazardous metuial HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? HEATING UNIT(OVER 1(0,0(10 BTU)
❑Pes o VENTILATION FAN(SINGLE RESID) PAID
Date Receipt#
Will the applicant or future building occupant use oquipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
emit hazardous air camaminams as defined by the Bay Area Air Quality Management TOTAL:
District' BOILER-COMP(OVER 100,000 BTU)
L]Yes V1 .
AIR CONDITIONER
I have tea he hazardous materials requirement antler Chapter 6.95 of the Cali- ///��� ISSUANCP.DATE
(aria Health afety gQ actionsJ533en)i25534.1understandthatifthe NEW RESIDENTIAL MECH. SQ.PC
be raw yh a am,that' Mtity o notify the occupant -
of th ich m( of a Cenif m of Occupant. m^
o ant mix .gem us - Data TOTAL: ISSUED BY: ( '�
OFFICE