99100036 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
K 10OU a to
CITY OF CUPERTINO PLUMBING-ELECTRICALMECHANICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIMERMIT DINGPLUP OJE(C EDHANIFIC g
1t ,PLUMBING PROJF.CT;NENTIFICATIUN FIFA
SANITARY NO, APPLICATION SUBMITTAL DATE
BUILDING ADDRESS: '
t - (2/� p
O BR'S NAME: PHONE CONTRACTORS NAME: LIC NO:
NE f i aTlTmNIC CONTROL It
ARCHITECT NEIN.: LIC N(T. d- AD R.L ❑ y�
( J
CONTACT. PHONE BUILDING PERMIT INFO
❑ COneUltant Fees Paid by Applicant(Initial) RLDO ELECT PLUMB MECH
3� 1 ram . ❑ ❑ ❑
LICENSED CONTRAC TORS DECLARATION QTY. ELECTRICPERMN` FEE
1 hereby annular that I am licensed under provisions of Chapter 9 Cannoundraing t JOB DESCRIPTION
nWZith Sedan 71)(YoofDvson 3nf the Bus' IW fessions Coda and ny license is RESIDENTIAL
TIAL
WOO wPERMIT ISSUANCE
FW= in full force and effect _ ❑SFI3WI. ElKITCHEN REMODEL
0Ut, License Class—Li..# APPLIANCES-RESIDENTIAL El ADDITION C:1 PLUMBING RE-PIPE
F Z W Data Contractor-
in Qm ❑MULTI-UNIT ❑STRUCTURAL
F D an ARCHITECT'S DECLARATION PANELS
Z O y 7se
J. 1 understand my plans shall he mad as public records UP TO 2W AMPS MODIFICATION
0Z ❑IN'fF:RIOR El REPAIR
('^W Licensed Professional 201-IOfN1AMP5 IMPROVEMENT E3SWIM MI NG POOLS
q�a, .,OWNER-BUILDER DECLARATION uu]] OVER III(1(IAMPS El BATH REMODELII2EPAIR ❑DEMDLTfIGN
P a 1 herehy aftinn that I um exempt from the Contractor's License Low for the
iWWiy5 O C U following reason.(Section 7031.5,Business and Pruni sions Code:Any city or county SIGNS ELECTRICAL OTHER
w'3 W y which requires a permit to construct,alter,Improve,demolish,or repair say Slmawrc
��OQ p,lot to its famance-also regaims meapplicant for such permit to File.signed swmmem SPECIAL CIRCUIT/MISC. '
}"t that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
(commencing with Section 9111Xgof Division 3oftlm Businessund Poidseime,Coda)... T13MR METER OR POLE INST. COMMERCIAL'
Edo Thal he Is exempt therefromand the basis fur the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
Who, Section 7031.5 by any applicant fora permit subjects(be appllmnt to it civil Penalty of POWER DEVICES "-_—1 ❑TENANT' ❑FOOD SERVICE
t more than Five hundred dollary($500), - IMPROVEMENT
�0 ❑La,owner of the properly,arm to ars with wa theirsolecnm Jon, SWIMMING POOL ELIiCTRIC '
2222 y amp y gas as pensa v
ME do thewa,k,and the dnadaro is a.[intended nroffered for auto(Sea.7o44,Beside. ❑OTHER
43 m and Pmroolons Gude:Dow Contractor's Li,dr,a Law dace not apply to as owner of OUTLETS-SWI'I'CHE9-PIXY E
property who hudd,or improves thereon,and who does such work himself or through
his own employees,provided that such improverneuls are not intended or offered for NEW RESIDENTIAL ELEC'1'It
solo.If,h�wever.Ihe M1uilding orimpravemenl is sold within one year of completion,the SQ.Fr.FLOOR AREA $/SQ.FT.
nu-builder will have the bundcn of proving that he did not huild nr improve for per-
psoof sale.).
❑ 1,as owner of the property,ten exclusively contracting with lice I TOTAL
onstruct the project(Sec 7044,Businr,a and Professions Code:) treLawdoesnotapplytoanownerofpmpertywhobuildsortrop FEE
who contracts for such Taiwan,with a commands)licensed pursuant t
License Law. MIT'ISSUA CEI am exempt under Sec. .P@PCfo isOwner Date VALUATION
WORKER'S COMPENSATION DF.CIARATION rj OI herehyaffirm under penaltyor perjury one of the following declamtmn �J❑Ihave andwle for by ection 3700 ofCorkent to
Laor relhinsmG ^ A . STO STYPE CONSTRUC'f10N
sedan,it,ve provided for by Section ficate of the Ietbar Codc,fir Ih owork far winadmis permit is issued. RE. P R
1 have and will maintain Worker's Compensation Insurance,as
37M orthe Labor Code,fimtheperkamanceoftheworkfnr which this pemit is"are S- Y IN S OCC GROUP �� I'h ��
My Workers Compensation Insurance carrier and Policy re:nantherad-
Cartier:- PolicyNa.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASEIINDUSTRL WASTF.INTF.RCEI'IYIR
COMPENSATION INSURANCE BUILDING DIVISION FEES
ffhissectioa meed nal ba complated fthe permit is farone hundred dollars($100) GREASETRAP
noires.) PLANCHECK PEE
I acidly that in the porfennonmofthe work l'orishichmisperand is issued,Island SEWER-SANITARY-STORM EA.200 FT.
not employ any puavn in any manner so as to become subject to the Worker.,Cooper- ENERGY PCC
Z solum Livasof California.Data WATER HEATER WNENT/ELECUR
Z Applicant - GRADING 17EE
Z y NOTICE TO APPLICANT:11,after making this Certificate of exemption,you should WAI HR SYSTEM/TREATING
become subject to the Workers Compensation provisions of the Labor Cale,you must 'S'ILS PEE I I
ai fnnhwithcomply wimsuch provisionsnrthispannit shall M1edeemedoevoked. WATER SERVICE Ll
UJ
Ir
7 x. CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMP. SQ.Irl'. 'IPAID D. moi t#
1 hereby affirm that them Is a constmdion lending agancy for the performance of
U 0 the work for which this permit i,issued(Sea 3097,Civ,C.) li
W Lender's Name TO A
OLender's Address TOTAL'.
W 'I artily that l have read this application and state mat the ahnve information ix - . ... r IBUILDINC PHC
V) correct.l agree to comply with a0 city and county ordinances and state laws relating to QTy„ MECHANICAL PERMIT FEE
'SP.ISMIC.FEE
C-) ,`7a. hin attract, ,and hereby authorize rvpaawntalives ofthis city to enter alsm the
- on Perry for in
pure PERMIT ISSUANCP.
a)agnee m save,indmnnify and er armlets Iho Chy of Cupertino against ELECTRIC PEE
liahila s,judgmon cosec xnd expenses may in uny way accrue against vtiJ City AL'fGR OR ADD TO MECH.
In tenquenw of the granting of this PLUMBING PCC -
APPL ,ANTUNDP.RSTANDSA ami LL COMPLY WITH ALL NON-POINT AI R HANDLING UNIT(TO 10.WO CFM)
MHCIIANICAI.PEC
SOURI +R TIONS.
AIR HANDLING ON]](OVER 10,000 CPM) CONSTRUCTION TAX
Signalureof APPli,m Contra Dote EXHAUST HOOD(W/DUCT) ROUSING MITIGATION FEE
HAZARD MA'1'BR 'S DISCLOSURIi
Will theapplicanlm(a , mil ' mupunlsmre orhamdlc hnamdnm mutcriul IIIIA'lINO UNIT TO IOU,000 BTU)
as defined by the Cupertino Mum al Code,Chapter 9.12,and the Health and Safely
Cade,Section 25532(a)7 HEATING UNIT(OVER 10(d000 PTU)
❑Yea . ❑No VHNTILATION FAN(SINGLE RESID) PAID
Data Receipt p
Will rd the air c mut or dowse building by the B use ea Air Qu or devices Management
�emit hazardous air wnwminanls s defined by the Boy Area Air Quality Managammt BOILER-COMP(3HP OR 100,00013
'fU)
painful? ❑Nu BOILER-COMP(OVER 10(1,W0 6'fU) -
❑Yes
AIR CONDITIONER
wA the huzardoas male rielarcyoi eundor Chapter 695 of the Cab- ISSUANCE DATE
1 Hea¢h&Safety Cade,Sections 25505. 53 and 25534.1 andetstaod that if the NEW RESIDENTIAL MECH. SQ.ET.
bu i d� atcmmnlly have a m ant,th tis responsibility to notify the occupant (J /
off, which rest No at On vanceefu Cenifiencof Occapsncy. /,
out rte agent' - Date TOTAL: ISSUED BY: yI
OFFICE ��