99100086APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
50001
BUILDING PROJECT' IDENTIFICATION
BtJgNGAD RES./
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SANITARY NO.
APPLICATION SUBMITTAL
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CfO�NAME; LIC NO:
OWl//�I S A'E:�� /lI �/ PHONE: IF 'l
NIC
CUNT ROLk
..ff Mt/Ktipj,^."/
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W `�J '� (//IF••/ C�a2
❑
ARCHITEC tENG{NIiER: LIC NO: ADDRES
-ONTACI': PHONE:
BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT 1'L1U�MIy MECH
11 ElCJ ❑
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT' FEE
JOB DESCRIPTION
X00
1 hereby affirm Char 1 am licensed under provisions of Chapter 9 (commencing
Division 3ofrhe
with
wn Y
Btsmax,mal Profn6i... Cade,andm licamois PERMIT ISSUANCE
R IF. 5 pFNTIp
= W r
p
In full tome end dT
❑SFUWL ❑KITCHEN REMODIiI.
ub
<UZU
hQd
LittnsdClvsa Lock
Oam O_ Cnnmacmrf2�•- ( APPLIANCES
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[]ADDITION (3 PLUMBING RIi-PIPE.
❑MUI:1'I-UNIT STRUCTURAL
F,�rn
ARCHITECT'S DECLARATION
C�X
Iunderstand myplans shall be exams public records PANELS
MODIFICATION
Z
UP TD 200 AMPS
❑INTERION [I CHIMNEY REPAIR
`: I"[[�
ndessona
Licensed Pil
,a
201-1000 AMPS
OWNER-BUILDER DECLARATION
IMPROVEMENT (] SWIMMING POOLS
RI
hereby infrm that I am exempt from the Contractor's License Law for the OVER HKOAMPS
CI BATH REMODEL AIR ❑DEMOLITION
following mason. (Smile. 703L5, Business and Profession., Case: Any city or county SIGNS ELECTRICAL
❑ OTHER
LL O Na
which requires a permit to construct, alma improve, demolish, or repair any suncrurt
rnJ
poor it) its issuance, also natuires the applicant for such Permit o file u signed statement SPECIAL CIRCUIT/M1SC.
y
Cp0
Tharhedlicensedpars... to theprovinions of Or Coffiessrs Lieense Inas(Chapter 9
(commencing with Section 7000of Division 3 Business Professions
COMMERCIAL:
ofthe and Code) or TEMP. ME'T'ER OR POLE INST.
a m fu'
'hat he is exempt therefrom and the basis for the alleged exemption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLH'ION
�-y
Seen.. 7031.5 by any applicanrfor a pennon subjects the npplicanuo a civil penaltyof POWER DEVICES❑TENANT
not mine than five hundred dollars (S50p
❑FOOD SERVICE
^£sp
❑1, as owner of the property, err my employccx wish wages av their9ole wmpcnsarion. SWIMMING POOL ELECTRIC
do the intended
IMP VEMENT
ER
y.F
will work. and strvcwreis not oroRertd for tale (Sm. Business
W
and Professions Code: The C.ntm«ors License Low dress not apply rn an owner of OUTLETS-SWITCHES-PIX'TURES
_
property who builds or improves thereon, and who aces such work himself or through
his own employees, provided Ib it such improvements arc not intended or olTmred for NEW RESIDENTIAL ELECTR SQ FL
Sfyfrl'. FLOOR AREA
$ISOs IT.
sale.If. howcvcgrhe building or improvement is sold within one year of completion. the
weer-h tilder will have the burden of proving that he did not build or improve for par-
fLj
pane of sole.).
❑ I, as owner of the property, am exclusively contracting with licensed contractors to TOTAL: 1'
------
confiwa Ibe project (Sas 7014, Business and Profe,.4min Cede) Thr Comfacrors Li.
cense Law does nm apply to an nastier of property who builds or improves Chemon,and QTY. PLUMBING PERMIT FEE
whoconrmetsfor such projects with a corrections) TicenaW pursuant o the Contractors
License Law, PERMIT ISSUANCE
❑lam exempt underSa. ,B&PC for Nis mason
.a
OCT1
ALTER - DRAIN & VENT - WATER (EA) iy
Owner Date I
VALUATION
WOR KEN'S COM PENS ATION DECLARATION BACK FLOW PROTECE DEVICE
I hereby a 'T under penalty of perjury one of the following declarations:
❑ I have enJ will maintain aCertilicnm of Consenuo self-insure for Workeh Cempen- DRAINS -F OOIC ROOF AREA. COND.
I; ONSTRUCTION
main, m provided for by Sation 3]W of rbc Labor Cale, fur the p do mwce or thr
_.�.,.
ark far which This permit is issued. FIXTURES -PER TRAP
I have and will maintain Worker's Compensation Insurance, as imitated by Sation
37W of the Labor Code.forrhe performance oTthe work for which this permit is issued. GAS -EA. SYSTEM-1 INC. Y OUTLET'S
My Workers CPq�g sg1 n Insurance carrier and Policy numbsyn�,,
OCC. GROUP q PN-3
CUMer:—ie rVf4'J'o Policy 1 f%i��� GAS-FA. SYSTEM -OVER 4 (EA)
/ .i
CERTIFICATE OF EXEMPTION FROM WORKERS'
0/7
COMPENSATION INSURANCE GREASEIINDUSI'RL WASTE INTERCEPTOR
BUILDING DIVISION FENS
(This 6adnn need not be completed if the permit Mar one hundreddollars T$10)
PLANCHECK FEE
or las) GNEASETRAP
I certify that in the perfurmanceoflhe work for which His penniC is is.aued.l shall $EWER-SANITARY-STORM F.A. 21q F1'.
ENERGY FEE
fit
mol employ any person in any Ilunn<r w av beco bj a the Warken' Compen-
Z
sation Lawsaf o acam.,mc �' a T
if WATER HEATER WNENT/ELECfR
Applicata s`+.
GRADING FEE
O
z
V]
NOTICE TO APPLICANT: If, onto aressirron, Certificate of Exemption, you should WATER SYSTEM/ REATING
SOILS FEE
a;
became subject n the Workers Compo motion provisions of rhe Labor Code, you must
0
fnnM1with comply with such provisions nr this permit vM1allhdeemed revoked. WATER SERVICE
jz
CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ. Pf.
PAID
UP
lending agency forth. performance of
Thor
Nero issued(See.
Date Receipt k
Lils L�
whiclrmthat
the War{', (a! WM1ICh Ih19 pCfrII11616tLCd (See. 3B9), CIV. C.)
3
TOTAL:
0 Li
Lender's Name
1-c der9 Address 'fOTAI.:
W
y
I certify that I have read this application and state that O..bove information is
BUILDING FEF,
h
mrrml. 1 agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
SEISMIC FEE
V z
building ca®madon, amt hereby suNoriu representatives of this city to enter upon the
above-mcnfoned property for inspeninn purposes. PERMIT ISSUANCE
(We) rigrre to save, indemnify and keep hmmlcss the City of Cupertino against
ELECTRIC FEE
Iiahilities,judgmems, cmtx and expenses which may in any way accme against said City ALTER ORADDTO MECH.
as run ..... of rhe granting of this pen nit.
PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT CTO 10,0011 CFM)
SOUC REGULAT
MECHANICAL FEE
�- a ' LL AIR HANDLING UNIT (OVER to." CFM)
CONSTRUCTION TAX
Signmurt nfA,pli..nVConrmcmr Dan EXHAUST HOOD (WMUC)
HOUSING MITIGATION FGF.
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future buildingoccupant store or handle hamrdous material HEATING UNIT (TO 10T.XI0 BTU)
as defined by the Cupertino Municipal Cale, Chapter 9.12, and the Health and Safety
Code, Sation 25532(01 HEATING UNIT (OVER 1011100 Brut
1]Yea ��
VENTILATION FAN (SINGLE H[SID)
PAID
W II the applicant nr fu� Onaver touse equipment or devices which
emit haxallonv air comamit.nt6 asefned by the Bey Area Air Quality Management BOILER-COMP IJHP OR 100.00) BTU)
Dme Rra
District BOILER - COMP (OVER IW(W HTU)
❑Yes
• I have and the haesNous mammals IY uin<mmnla under Chu lar 6,95 of rhe Cali- AIR CONDITIONER
4 P
ISSUANCE DATE
rma Health mtefca Code,earoom25505, is my als25534.1 undersfy B thatif Ne NEW RESIDENTIAL MECH. SQ. F1'.
uilding nut torten hweumnwl, ma it is my responsibility to notify Ne occupant
7amerminifficinced
(j
V ^ 1 (J
te tb rmi to issuame ofa Ccnifcanni; cu an
w
7
." (1..0 r_ f,g
ISSUEDBY.
agent --'- tae TOTAL:
OFFICE