S 4448 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL S 4448
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: 1, SANITARY NO. APPLICATION SUBMITTAL DATE
/m o (3 i3 R Q- <'k. P�✓�P�/ e 7./5--99
OWNER'S NAME: PHONE: CONTRACT'OR'S NAME: . LICNO: CONTROL#
✓H11 C �+� Y�V�Z67o NIC v
CHITECf GINEER: LIC NO: ADDRESS: ❑
�LlC/ L L #9G S
CONrACP. PHONE: BUILDWG PF,RMIT INFO
p
l f;e^2e7v ❑ Consultant Fem Paid by Applicant(Initial) BLDG LECT PLUMB MECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATIONQTy FLECTRIC PERMIT FEE
I hereby e�nn that I am licensed under provisions of Chapter 9(commencing JOB D CRIPTION
CCz it Serious 7000)of Division 3 of the Business and Professions Code,and my license is RESIDENTIAL'
FOO n full force and effect. PERMIT ISSUANCE
aU� Licrna Clnss I Li<# G9 12 Q ❑SFDWL ❑KITCHEN REMODEL
6FZU a Age APPLIANCES-RESIDENTIAL ION ❑PLUMBING RE-PIPE
NF.Q i Dme — ' Camranor
20 sn A dUTECTsS DECLARATION PANELS ❑MULTIUNIT ❑STRUCTURAL
s�Z I understand my pens sh Mused as blit r ands MODIFICATION
OZ-0 UP T02 PS ❑INTERIOR El CHIMNEY REPAIR
a4[- Licensed Professional I-Ig1IlAMPS IMPROVEMENT SWIMMING POOLS
WNER-BUILDER DECLARATION
C� OVER 1000AMPS BATE"ODE �P IR OGCRION
tL' 1 heresy affirm That 1 1 5 exempt from the Contractor's License Lew for the
O y V following reason permit
t ]comm gusines and Professions h,or Any city or county SIGNS ELLCENICAI. ER
311{- which requires o permit m<onswa,ghee improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit o file a signed statement SPECIAL CIRCUITIMISC.
u
that he is licensed purmano the provisions ofthe Contractors License Law(Chapter 9
ly ly�0 (commencing with Section 7")of Division J of the Business and Professions Code)or TEMP.METER OR POL ST COMMERCIAL: a
d cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of El NEW BLDG/ADDITION [I DEMOLITION
WAN Section703 L5 by an,.p,lic.t fora pemdl subjectsmeapplicanno a civil penally of POWER DEVICES []TENANT [3 FOOD SERVICE
f-Zy, not more than live hundred dollars(8500). IMPROVEMENT
p56Q I] I.as owner of the property,or my employers with wages as their sole compensation, SWIMMING P LELECTRIC []OTHERd will do the work,and the structure is not intended or oBetcd for sale(Sec.]044,Business
u�l m and Professions Code:The Contractor's License Law does nos apply in an owner of OUTLETS SWITCHES-FIXTURES
6 3^ property who build.or improves thereon,end who dice.,such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW IDENTIA ELECTR SQ PT.
sale.If.however,Ne buildingm improvement is sold within one year of completion,the 5 .FT.FLOOR AREA ESQ.FT.
pweer-builder will have the harden of proving tbm he did not build nr improve for par
ose of sale J. D / \
as owner of property,am exclusively convecting emvurs to
ecting with licensed cmTOTAL
FJ h
construct the project(Sec.7044,Business and Professions Code:)The Contmos,Li- D
cepa Law dos not apply m an owner of properly who builds or improve thereon,and QTY. PLUMBINGoft FEF
who convects tar such projects with a comtaJUL dor(s)licensed pursuant to the Contractors IL 5 1 99
License Law. PERMIT ISSUANCE
❑Iantcxemplundef Ser. ,B&PCtorthisrea.,on
Owner Dom ALTER-DRAIN&VENT- EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK MEOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain u Certificate of Consent n self-insure for Workers Compen- DRAINS-FLOOR,ROOF,,AREA,COND. STORIES TYPECONSTRUCION
.,tion,as provided for by Section 37W of the Lahr Code,for the Performance of the
is k for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
.] olthe latwr Code,for rhe performance of the work for which this pemdl is issued. OAS-EA.SYS TEM-I INC.4 OMLETS ICC.GROUP AYN
My Worker's Compensation Insurance carrier and Policy number am:
Cannot: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEINDUSTRL WAS TE IN RCEPI'OR BUILDING DIVISION FEES
(Thissection neednol Mma,iried ifthe permit is mallow hundred dollars($On GREASETRAP
nr les.) PLANCHECK FEE
I certify that in the pertormancemme work forwhich this permit is isomd.Tshall SEWER-SANITARY- RM F.A.200 Ff.
not employ any person In any murine so a,to M�hjecn m the Wmlons Compen- ENERGY FEE
Z ,Z sation laws of Califie.m.Oa _ WATER HEATER Ns NT' LEM
Q Applicant r r GRADING FEE
► N(TfICE T If,after making this Certificate of Exemption,you should WATER SYSTEM REATING SOILS FEE
abecome sobject to the Workers Compensation provisions of the Labor Code,you mull
I^ forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERV E
Q
5z CONSTHUCI']ON LENDING AGFiNCY NEW RFS FiNTIAL PLM H. SQ.FT. PAID Ua Receipt#
V Qk c,which tat thaubert isacn (Sive.onlendis.agency fanM performance of
IM work for which this permit is issued(Sec.JIn],Civ.C.)
W lender',Name TOTAL:
[ULl Lenders Address TOTAL: BUILDING FEE
tl I certify that I have read this application and,tate that the above information is
rF.I N coma.T agreem comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE Ca
V Z building construeion.and hereby authoriserepresentatives of this city savior,up nn the
SEISMIC FEE
ubnve.memioned property for inspection mrpnas. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless Ne City of Cupertino against ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way accme against said City ALTER OR ADD TO MECH. ZI
in consequence of the granting of this Farm.in FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT AIR HANDLING UNIT(To Iff"CFM) MECHANICAL FEE
Soil N A
AIR HANDLING UNIT(OVER 10.000 CPM) CONSTRUCTION TAX
Sig m n pgl¢an Date EX I MUST HOOD(WMUCT) HOUSING MITIGATION FEE
11A AST. MATERIALS DISCLOSURE
Will the applicant or to,..building a,voinn emir.,handle haasrdms material HEATING UNIT(TO 100,001 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 255320)? `' HEATING UNIT(OVER IIP, TU)
❑Vas No VF.NTILATIONFAN(SIN ERESID) PAIU� .(� Rercipl#
Will the applicant or future building wcuWmma,uequipment or devices which gO1LER-COM1/P(3 OH 100.1X#PTU)
mit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL:
Iatric,? ,,gy�pp BOILER-CO (OVER 100,0110 BTU)
❑Yes tNn
I have read the harardof,undcnaryuire
ls B under Cmprtrfi95 of the Cali- AIR CON TONER ISSUANCE DATE
Runic Health&Solely Cede,Sections 25505,25577 and 25531.I understand.hal if the NE T:SIDENTIAL MECH. SQ.FT.
huilJing of currently have at<nan.that it is my responzibiliry to notify We mcupam
ofth quire ns which uslMmet normi eofaCmifwreo Oc<upa c
O ora a TOTAL: ISSUED BY.
OFFICE