99080056 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 0
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITN
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
7335i�OLLINC�Ef� R� _q?
OWNER'S NAME: PHONE: CONTRA—rp ;pB'j N'�yIE: L' NR r I N/C CONIIROL#
RCHITECT/ENGINEF,R: LIC NO: ESS El PEAR �0- S 9 ElV
CONTACT: PHONE: '(1- AVEV BUILDING PERMIT INFO
e�lL 9 GL4-4q 3� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ w ❑
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby ry.f drat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
000 with Section]000)ofDivision3 ofNa Business add-�P/ro]fesso sCod�L,end my license is RESIDENTIAL'
OO in full force and off zV PERMIT ISSUANCE
U U License s �� Lic.# J-I ❑SFDWL ❑KITCHEN REMODEL
h z W Uate Cantmcr�. I ��. APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
Z p Nsic1g... ARCHITECT'S DECLARA IO PANELS El MULTI-UNIT El STRUCTURAL
Z I understand my plans shall be used as pantie recurJs MODIFICATION
OZ +q UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
Licensed Pr.f..oral 201-IOWAMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑DEMOLSWIMMING
TIONPOOLS
row,w Q I hereby a1Hrm that I am exempt from the Contractors License Law for the OVER IUBU AMPS 11 BATH REMODEUREPAIR [I DEMOLITION
following reason.(Section 7031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL []OTHER
'3 ps F which requires a permit to construct,alter,improve,demolish,or repair any swuture
0ry prior to its issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
E Y that he is licensed punuam to the provisions of me Contractor's License Use(Chapter 9
W.,Ao (commencing with Section]000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST
4 N�C that he is exempt therefrom and the basis for the alleged exemption.Any violation of - El WBLDG/ADDITION El DEMOLITION
i< W Section70315 by any applicant for a permit subjects Neipplumal no a civil penalty of POWER DEVICES
❑1 ZN m
tom than five hundred dollar,($501q. PRO ❑FOOD SERVICE
VEMENT
51 ❑Las owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F•F will do the work,and the structure is not intended or offered for sale(See.9144,Business OTHER
and Professions Codes The Contractor's 1.1cense Law fires not apply to an owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvemeivs am not intended or offered for NEW RESIDENTIAL ELEMR SQ PT.
sale.If,however the Condoner improvement d ord within..e year.fcrmpledon,the REED' S/SQ.IT
manter-builder will have the burden of proving that he did not build or improve for par- �,� ^�
pose of sale.). _ D /<_1\ I
❑Ly,as owner of the propertam exclusively contracting with licensed contractors to TOTAL' —U
mnswct the projea(Sec.7044,Business and Professions Code:)The Contracture Li-
cense Law does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT FEE /-1UO A I IG I I )
who contracts for such projects with a contractor($)licensed pursuanno the Centimeters
License taw. rePERMIT ISSUANCE 1999
❑I an exempt under Sec. B&P C for this ason
er Data ALTER-DRAIN&VENT-WATER(EA) t/ VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE. J--_��
I hereby anirm under penalty.f perjury ane of the following derlarati.nm
❑I have and will maintain a Cenific re of Convent w self-insure for Workers C.mpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
satlon,as provided for by Section 37W of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
❑I have and will maintain Worker'a Compensation Insurance,as required by Section
37W ofTyrh�e Labor Code I.,the
�upjergfoarrmcaannrasedthe work for which thispermit is issued GAS-EA.SYSTEM- INC.4 OUTLETS sel
OCC GROUP 3Z-7 P`E
CertieA�O�Ncn EUMPIsmic,No.yf�' 174b'1 GAS-EA.SYSTEM-OVER 4(EA) -7 `mac
CERTIFICATE OF EXEMPTION FROM WORKERS' 07r GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(Yids section need not be completed ifthe permit is for onehundreddvllarsBUILDING DIVISION FEES($100) GREASE TRAP
coles'.) PLANCHECK FEE
1 certify[hal in the Performance of the work for wM1lmh this permit is issued,l shall
not employ any person in any manner so as to become subject to the Workers Com _ SEWE -SANITARY-STORM EA.200 F1'.
,Z at..Laws of California.Date Pen ENERGY FEE
zC) Applicant WATER HEATER WNENT/ELECTR GRADING FEE
r/1 NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOCREATING
In ? become subject to the Worker's Compensation Consist...of the Labor Code,you most SOILS FEE
WQ forthwith comply with such precisions or this permit shall be doomed revoked. WATER SERVICE
� z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
V Thereby affirm[hut them is a construction lending agency for the perf.olanee of Data Receipt#
the work for which this Cama is Issued(Sec.3097,Civ,C.)
QU Lenders Name TOTAL:
U Lenders Address TOTAL:
Hy 1 certify Nat 1 have read this application and state that the above information is BUILDING
h correct.I agree to comply with all city and county ordinances and state laws relating m QTY. MECHANICAL PERMIT FEE Travis
C) Z building construction,and hereby authorize representatives of this city m enter upon the SEISMIC
.love-mentioned property Introspection purposes. PERMIT ISSUANCE
(We)agree to save,Indemnify and keep harmless the City of Canadian against ELECTRIC
liabilities,judgments,costs and expenses which may in any way accrue against said City ALTER OR ADD TO MECH.
in cons yuence.f the grunting of this permit ASil
APPLI ANT UNDERS DSS AND
WILL COMPLY WITH'ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CPM) MECHANICAL F
SOU RBGUI.AT D S L 8l
AIR HANDLING UNIT 10,000 CFM) CONSTRUCTION
Sig t sof Apnlican Comramor Data EXHAUST HOOD(W/DUCT7 HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant of future building occupant store or handle hazardous material HEATING UNIT(TO I toy"BTU)
as dented by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code.Section 25532(a)p HEATING UNIT(OVER 14,000 BTU)
L]Yea ❑No VENTILATION FAN(SINGLE RESID) PAID
Will thea applicant or furore building occupant use t or devices which Data Recti t#
pp g pa e.Air Qu BOILER-COME CUP OR 100,000 BTU)
tit hazardous air contaminants as def nod by the Bay Area Air Quality Management TOTAL.
is
District
❑Yes C]N. BOILER-COMP(OVER IW.UU)BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
I
rom.Health&Safety Cade.Sections 25505.25533 and 25534.f understand that if the NEW RESIDENTIAL MECH. SQ.CE n t�
building does not currently have a tenant,that it is my responsibility to notify the occupant
of the requirements which mast be met poor m Issuance of a Cenlfrcate of Occupancy.
Owner or authorized agent Date TOTAL. ISSUED BY:
OFFICE