99080116I APP+ICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY f I UU n l I
CITY OF CUPERTINO - BUDAING- ELECTRICAL.
BUILDING DIVISIONAPPLICATION/PERMIT PLUMBING - MECHANICAL
' `BUILDING PROJECT IDENTIFICATION '
V
BUILDING ADCSFSS: -
SANITARY NO.
APPJ/LIICATITOON SUBMITTAL DATE
WNER'. NAME: ,// w .\ PHO — Li
KH �f R
i
'S NAMIi: L C U:
NIC
❑
CONTItOLk
LCHITECT/ENGINEER: LIC NO:
A DRESS
Get!
CONTACT. PHONE i
❑ Consultant Fees Paid by Applicant (Initial)
-➢UILDING PERMIT INFO
BLDG „ H1E,CT P1.uMB MECy
®/
LICENSED CONTRACTOR'S DECLARATION
1 barony ,drnn mm I am hrrn,w modes vrovi,ions of Chapter 9 (commencing
won Section 7000).f Div,oina 3 ref me Busunnamed Professions Code, and my license ls'
in full farce and of c I I Q
License les Lic. # V
Data Cnnvacmr�
ARC HTECT'S DECLARATION C
I understand my plans shall be used as public corrects
- -
QTY ELECTRIC PERMIT ,FEE
1..
JOB DESCRIPTION
RESIDENTIAL: ✓
❑ SFDWL �pY<ITCHEN REMODEL.
❑ADDI 'TION ❑PLUMBING RE -PIPE
❑ MULTI -UNIT ❑ STRUCTURAL.
MODIFICATION
El INTERIOR El CHIMNEY REPAIR
yyII;,M''PROVEMENT SWIMMING POOLS
V<ATH REMODEVREPAIR El DEMOLITION
❑ OTHER
PERMIT IS
AVI'LIANCES-RESIDENTIAL
PANF.1,5
UP TO 200 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Continue a License Law for the
following reason. (Section 7031.5, Ilusiness and Prde�sions Code: Any ally or county
which requires a proof to construct, alter, iinprove, cion I'd, ,rope., any ,tructme
prior to its issuance, also reyuneameapplicam fmsuch pamtil to fileaeigned,lalemenl
that he is licensed pursuent In the provisions of No Contractor's License Law (Chapter 9
(commencing with Section 2a00)of Division 3 of the Boomers and Profession, Code)or
Nal he ix exempt dicefcan and the basis far the alleged exemption. Any violation of
Section 7031.5 by any applicant for u permit subjects the applicant Rr a civil penalty aP
not more than five hundred dollun ($500).
❑ Los owner of Ne propeny,or my employees with wages as their sole comperotiot.
will dothework, and Nearecarcisnm ireadedaraffered fmaale(S,e. 9f144, Ba,masn
,ill
and Professions Code: The Contractors License Law does not apply In an owner of
property who builds or improves Thereon, and who does such work himselror through
his own employees, provided that .such improvements am not intended or offered for
sale If, h the building improvement sold withiny f pleRm,the
aw builder '111' In burden I proving that h dict t build 1 for pu
pore f ).
E] 1, frit p pry I ly - l I g lit l' d l roes¢
o.t Idhp l l(S 90448: dP f Cube) The Connector, E
Law does net pplyl fp p ty b'Ifimprove,Ino r and
who wnmam, for such projects with a c ntraU ❑) licensed p s anno the Comramocs
License Law.
❑ I am exempt under Sec. _ ,B tit P C for @ie reason
201-IOWAMPS
OVER I000AMPS
SIGNS ELECTRICAL
'
SPECIAL CIRCUIT/MISC.
TEMP. METER OR POLFI NS 1'.
COMMERCIAL'
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
OTHER IMPROVEMENT
OTHER _
- POWER DEVICES
SWIMMING POOL ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELECI'R S
-^ ,e—_—
SQ. �. O AREA
Jr
�r AUG 17 1999.
J
PV
I
/SQ.EL
'I OfA L:
. :, .. ,.
QTY., PLUMBING PERMIT - �I - 'PEE
PERMI F ISSUANCE
_
.or Data
WORKER'S COMPENSATION DECLARATION
I hereby i ffimr under Penn],, of perjury ane of the following declarations
I have and will maintain o Certificate of Consent to self -insure foe Worker's Gempeo-
,mien, as provided for by Section 39110 of he Labor Code, for the performance of the
work rot which this permit is issued.
❑ I have and will maintain Worker's Compuuntion Insurance, as required by Section
3700 of No Labor Code. For the performance a fore work for which Nieppnnt,manned
My Werke ce d Palicyrller
Corner oroIII I [D Polley No; 1 a��L�
v CERTIFICATE OF EXEMPTION FROM WORKERS' to,7 �
COMPENSATION INSURANCE
(TMs section nerd not be contplcled if the pen0il is lmm�e handsel dollart ($1011)
or less.)
I cemfythat in the performance ofthe work for which this permit is issued, l shall
not employ any person in any reliance so as m became subject m the Warkeai Camper-
sation Law, of California Date
Apple, nl
ALTER -DRAIN&VENT-WAI'I'll IRA)
VALUATION
(/
BACK FLOW PROTECT. DEVICE
DRAINS- FLOOR. BOOP, AREA, COND
STTTRIEA
TYPE CONSTRUCTION
FIXTURES -PER TRAP -
IIIGAS -EA.SYS TEM -I INC. 4 OUTLETS
OCC. GROUP
'] OAPN��
.J CZ
GAS -EA SVSTRM-0VP.R4(P.A)
GREASFJINWSTRI. WASTE, INTERCEPTOR
y(I PI�'G,DIVISIOM FEESu °
GREASETRAP
n
PLANCHECK GEE
SEWER -SANITARY -STORM F.A.200 FT.
ENERGY FEE
WAFER URA'fER WNENT/ELECFR
GRADING FEE
NO'[ RF TO APPLICANT: If, after making this Certilunte of Exemption, you should
become.mnlaa it, the Worker's Compensates, polemics, of m, Labor Cade, you must
Forthwith comply ..,It such provisions or this proach,hall be deemetle,sAad.
CONSTRUCTION LENDING AGENCY
I heabyofoca Nat(bere is o cornmction lending agency rnr Ne pmfarounee of
(he work Cut vvueh this pemel is issued (Sec 3097. Cr, C.)
larder's Name
WATER SYSTENYTREATING
SOILS FEE
WATER SERVICE
PAID
Data Receipt#
NEW RESIDENTIAL PLMB. SQ. Fr.
'TOTAL.
Lender's Address
TOTAL
BUILDINGFEE
I car ify that 1 have read Nis application and state that the above nomination is
correct.I agre, to comply with all city and county ordinance, and state laws relating to
building coast mminr, lad hereby authors, mprcamnmive, of this airy to cone upon the
above-manlionul property rnr in,pmtion p.,,,as
(Wo) agree to save, indemnify and keep heretics, the City of Cupertino against
Iiabihuas,judgmnnx,costs and expenses which may in any way accrue agaiw said Cil,
in consequence of ma Canting m this permit.
APPLICANT UNDERSTANDS AND WILT. MP Y WITH ALI. NON -POINT
SOURCE. REGULATIONS.
'/
QTY. -, MECHANICAL PERMIT t. ' t PEE • t
SEISMIC FEE
PERMIT ISSUANCE
-
ELECTRIC FEE
ALTER OR Alf) GMECH.
PLUMBING FEE
AIR HANDLING UNIT (TO 11,111X1 CFM)
MECHANICAL P1313 .
AIR HANDLING ON]f(OVER 10,000 CPM)
CONSTRUCTIONTAX
tgnmuresf Applicaa omract D c
HAZARDOUS MATERIALS DISC OSURE
' Will the applicant nrlbmm buildingmempant.vmreor handle hazardous malarial
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Secnna 25532(x)?
El Yes No
-
mor lity alf., ownManagement
Will the oI,comnorfmnredefirinC by the ran use Bay
alt hezaNnu, air comaminams as defiant by the Bay Area Air Quality Manugemenr
Air
Disidctp
❑ Vee []No
aNms saccounts nalmoomctnf, under Cnap er 695 othe Cali-
1 have mW the hm
forms Health & Safety Cale, Sections 255(E 15533 and 25534. I understand that if he
nuildi doe,natetp��nn Ire aalonen4 mar my am"afy lam ifyme ern, It
equir,ments an s a n a c a 0 d
EXHAUST HOOD(W/WCs)
HOUSING MITIGATION PEE
HEATING UNIT (TO 100,000 BTU)
-
HEATING UNIT' (OVER 100,000 BTU)
PAID -
Date Roc,ip
VENTILATION PAN (SINGLE RBSID)
BOILER- COMP(3HP OR 1(0,000 BTU)
T
BOILER - COMP (OVER 100,000 IF
AIR CONDITIONER
ISSUANCE DATE
ay ��• r—CT//�,J
V//
ISSUED BY:
NEW RESIDENTIAL MECH. SQ. Up
wner', ewle rizW agent , D e 1,
TOTAL:
OFFICE