99100067 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 'I OO O to
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING,DIVISION APPLICATIONMERMIT PLUMBING"MECHANICAL
BUILDING PROJECT IDENTIFICATION
BU14DING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
LL_t GfA P140
OWNERS N MG: PHONE: COIL JAMRACroR'S NAME: LIC NO:
NAC CONTROL#
HITECT/13NGINEER: LIC O: ADDRESS:
17roY "f(Q
JMVA_)"0,
CONTACT. PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION ❑ ❑ ❑
herehy aRtm mal I am licensed under provisions of Chapter 9 ournmencin QTY ELECTRIC PERMIT FE8
P g JOB DESCRIPTION
{y�OZ wirdll force
901Mp of Diviaion9afthe Husinexs and Protenaians Code,and mylicence is RESIDENTIAL:
F 9
in (arse and PERMIT ISSUANCE
aC�F ❑SFDWL EI KITCHEN REMODEL
Q U V Licen! Qyiss Loc.#
y<i Dete J-LJ_ Contra APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
1„ ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT El STRUCTURAL
Z O n Z 1 understand my plans,hull be used as public records MODIFICATION
OZ— UPI'0200 AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FaC4-1n Licensed Prafessinnnl 20LIW0AMPS IMPROVEMENT E)SWIMMING POOLS
C Y J OWNER-BUILDER DECLARATION OVER 1000 AMPS BATH REMODEL/REPAIR DEMOLITION
Q 1 hereby affirm that 1 am exempt from the Contractor's License Law for the �s
X 3 i U following mason(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑ 1ER/,JA�#9 ` R
E LL O m which requires a Permit to construct,alter improve,demolish,or repair any structure R'feNC,•'eiff 1
Puerto its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUR/MISC.
G�, that he is licensed pomuam to the pmvlaoons of me Contractor's License Law(Chapter 9
LV�GO (commencing with Section 70fffiof Division 3ofthe Business and Rofessions Code)0, IEMP.METER OR MILE INST, COMMERCIAL:
6 p, es that he os exempt Iherefmm and the basis for the ulleged exemption.Any vi.Inkm of ❑NEW BLDG/ADDITION ❑DEMOLITION
4X1 m Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of POWER DEVICES []TENANT ❑FOODSERVICE
~
of more than Ione hundred dollars($500). TENANT MENT SC ❑1,as owner of the progeny,or my empinytts wird wages ns their sole cmnpcnsmion, SWIMMING POOLELECI'RIC
F. will do the work,and the structure is not intended or offered forsale(Sex.7044,BusinessME
[]OTHER
4 3$ and professions Code:The Contractors License Law does not apply to an owner of OUTLETS-SWITCHES-
pmpeny who builds or Improves tberron,and who does such work himself or through
his own employees,provided that such improvements are not intended m offered for NEW RESIDEN'HAL FitC 1A
sale.If.howeverthe building or improvement is sold within one year of completion,NeQ .FLO REA $/$Q.FT.ner-builder will have the burden of proving that he did not build or improe far pur-
poae.fsowne am I ❑ 1,asownerof ct Seeproperty.,Bexclusively crou%sing wird,)The Ccnnactors to ej ���.nse La Nc project(Sec.oan Business and rty whoon Code:)The Comrerion, nd f) nse Lawd«an,tub yroan aw netu,o(psom(,w,coseddsorimpmvice Cmuracand QTY PLUMBINGx�who canwms frsuch Projects wuh aenmrucmr(s)Ilecnaed pursuanno the Conwumr'sLicenseLaw. PERMIT ISSUANCE
❑I am exempt under See ,B&P C for this reasonALTER-DRAIN&VENT-Owner DateWORKER'S COMPENSATION DECLARATION BACK FLOW PRCTE(7'.D9
I hominy uMr.under penaltyof perjmyono of the following declarmions: 4 QQ
l have and will maonlaou a Cenifcaleof Consent losclf.i.,me for Work,,,Compen- DRAINS-FLOOR,ROOF,AREA,COND.
,an..,as Provided for by Section 37M of the Labor Code,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3700oflhe labor Cale,fertile Performance oflhe work forwhich Nis permit is homes. GAS-EA.SYSTEM-I INCA OUTLETS OCC.GROUP APN
My Works' C m u and Policy
Carrier: Y`SMUe Policy Na: ir"Ca(618 GAS-EA.SYSTEM-OVER 4(EA) ;3rQ9- t9-��I
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRF.ASFJINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not be completed ifinepemtit is foranehundred dollars($100) GREASE TRAP
or less.) PLANCHECK FEE
Loy any that in in Perany manner va m,t becomeent
It to perthe W lixel"ed,[shall
n- SEWER-SANITARY-STORM EA.2W FT.
not employ any Aaron in any manner m a m become subjcd to the Workeri Compen- ENERGY FRE
Sae..Law]�.,ff,,CC &Date
O C A loema JJC "r WATER HEATER W/VMT/ELECfR
pp (• GRADING FEE
y NOTICE TO APPLICANT:If,eller making this visio s of of Exemption, ,you should WATER SYSTEMOREATING
U ; become subject m the Workers Com s or thin pmvisions of the Iabar Cale,you mum SOILS PEE
foMwith comply with such provisions or Ni.permit shell he deemed rooked. WATER SERVICE
0
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PCMB. SQ.FL PAID
V 0 Ifohereby whichaffirm that there isaconmec.30lending agency for the performance of Date Receipt#
� the work for which Nis permit is Issued(Sec.309].Clv,Cd
Q
U Lender's Name TOTAL:
V Lender's Address TOTAL:
Fy I comfy that 1 have read this application and state that the above information os BUILDING FEE
(A c.necl.l agree to comply with all city and county ordinances and mate laws relating to QTY MECHANICAL PERMIT FEE
C.) Z building construction.and hereby amhorize represemarives of this city to enter upon the SEISMIC FEE
above-mentioned pmpeny for inspection purposes. PERMIT ISSUANCE.
(We)agree to save,indemnity and keep monic,s the City of Cupemno against ELECTRIC FEE
Ioahiliuc,,judgmems,costs and expenses which may on any wayaccrue against said City ALTER OR ADD TO MECH.
in consequence of the granting of Nis permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT AIR HANDLING UNIT(TO 10,000 CFM)
SOURCE REGULATIONS. MECHANICAL FEE
AIR HANDLING UNIT(OVER FLOW CFM) CONSTRUCTION TAX
Signature of APphcanl/Commntar Dote EXHAUST HOOD(WiDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant more or handle hazardous material HEATING UNIT(TO 100J001)BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade.Section 2553260? HEATING UNIT(OVER 100,000 BTU)
❑Yes tNo PAID
VENTILATION PAN(SINGLE RESID) Dam Rtteipt#
Wit I thedmus it contaminapplicant Or nts
building by the rt use Bay Ane Air ualint tdManaement BOILER-COMP QHP OR IW,IXq BTU)
oil hazardous air cnnwminams ua dclined by the Bey Area Air Quality Management TOTAL:
Wct?
C]Yes XNo BOILER-COMP(OVER IOO.IX)O BTU)
AIR CONDITIONER
1 have read t mzarduus rw¢eals requirements under Chapter 6.95 of the Cali- ISSUANC
amoa Heahh& et ections 25505 25537 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ,EL
builmo t By eemt mibility m notify the smo pool
of c c•11 hie ncl m' resit soft a hIc resole Canlficane.f .
or or amountedagent DoTOTAL: ISSUED BY:
OFFICE