99080026 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY 97,9O coz
CITY OF CUPERTINO BUILDING.ELECTRICAL PERMIT NO.
BUILDING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL
'BUILDING•PROI6CT IDENTIFICATION'
BUILDING ADDRESS: C LADCr SANITARY NO. A�ICATION SUBMITTAL DATE
. V81 PHONE:1VI,/6 CONTRACTOR'S NAME: LIC NO: 33 99
NIC CONTROL p
JHITECT/ENGINEER'. h �� LIC NO� O� gDDBESS: ❑ ��
CONTACT: V PHONE y BUILDING PERMIT INF
MKE cN tk �of 4`f 6 -g41% El Consultant Fed es Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
� ❑ 11I NSED CONTRACTOR S DECLARATION QTY." ELECTRIC PERMIT' FEE
I M1meny affirm that l licensed a provisions" mcnapme 9(comma ing :_ .-.� ,- - , {; JOB DESCRIPTION
pCD with Secion 7")ofD '-van Joftbe Busl d Prticanee Code,and mylcese PERMIT ISSUANCE RESIDENTIAL:
In fall force and effect
-U' License Class Lim.# ❑SFDWL D KITCHEN REMODEL
APPLIANCES—RESIDENTIAL.
ydd Dale Contractor [-]ADDITION ❑PLUMBING RE-PIPE
ARCHITEC TS DECLARATION ❑MULTI-UNIT []STRUCTURAL
z O y z. 1 understand my plans shall M1e used as public records PANELS
MODIFICATION
O Z UP TO 200 AMPS
G El INTERIOR El CHIMNEY REPAIR
F� Licensed Professional 201-1000AMPS IMPROVEMENT DSWIMMING POOLS
OWNER-BUILDER DECLARATION
L Q 1 hereby.(Sero that l am exempt from the Contractor's License Law for the OVER 100BAMPS D BATH REMODEL/REPAIR [I DEMOLITION
following reason(Section 7031.5,Business and Professionsdemolish,
h,or Any city or enemy SIGNS ELECTRICAL ❑OTHER
� which requires a permit to construct,alter,improve,demolish,or repair any sweture
5daty0 priormits issuance,also requires the applicam for such permiuoB rile statement SPECIAL CIRCUIT/MISC. 7�� t,41)
�. thatheis licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
W5G0 (tournament,with Section70001 Division 3ofna Business and Professions Coveter TEMP.METER OR POLE INST. COMMERCIAL:
d pt m y that he is exempt therefrom end the basis for the alleged exemption.Any violation of
C]NEW RLDGIADDITION E3 DEMOLITION
Ir1"m Section 70313 byany applicant for a permit.subjects the applicant to a civil penalty of POWER DEVICES
oat more than five hundred dollars D500)
❑TENANT El FOOD SERVICE
'F"SQ Dl,as owner of the pmpeny,or my employees with wages as theirsolecomperenaimn, SWIMMING POOL ELECTRIC IMPROVEMENT
Ir will do the work,and the suvemre is not intended omHered for sale(Sea. Business DOTHER
Irl se and Professions Cede:The Contractors License Law does not apply to an owner of OUTLETS—SWI CHES—FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENtWeELECTR SQ ET.
sale.If,however,the building or imptoverrom is sold within one yearofcompletion.the SQ.FT.FLOOR AREA $/SQ.Fr.
owner-builder will have the burden of proving that he did not build or improve for Put-
point of
ur-
po¢of sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL
consumer the project(Sea 7044,Business and Professions Cade:)The Contravenes In- -
ase Law does not apply m an owner of property who builds or improves thereon,and QTY,t PLUMBING PE FEE
who contracts for such projects with a contrucmgs)licensed pursuant to the Contmemr's
License Law. PERMIT ISSU
DI am exempt under Sea ,B&P C far this reason
` ALTER—DRAIN&V. WATER(EA) VALUATION
AIMPOe
Owner Date
O ERS OM NSAT N DECLARATION BACK FLOW PROTECT D 2 1 1
ffirm
I hereby aander penalty of perjury one of the following declarmims: a b
'I have end will initiation Certificate of Consent to self-insure for Worker's Camped- DRAINS—FLOOR,ROOF,AREA, STORIES TYPE CONSTRUCTION
bn,as provided for by Section 37M of the Labor Cede,for the performance of the
smiCtor which this pearna n,issued. FIXTURES—P
D I have and will maintain Werker's Compensation Insurance,as required by Section ,\ �!
3700afthe Labor Cale,for the performance of the work for which this permit is issued. GAS—EASY$ M-1 INCA,01ITLETS OCC.GROUP
My Workers Compensation Insurance carrier and Policy number arc: i,
Carrier Policy No.: GAS—EA.SYS EM'-OVER 4(EA) h'
CERTIFICATE OF EXEMPTION FROM WORKERS' n
COMPENSATION INSURANCE GREASF/INDU TRLW T�INTFlfficTOR 9 I; BUILDING T)IVI$'T¢N FEE$
This section meeddot hecmndated ifthe permit is Ionone hundred dollars($100) III
tar lase] GREASE gRAP PLANCHECK ME
foenify matin the perfoormatuflhe work for which this pemiltis issued,)shall SEWER—SAN R —STORM EA.200 FT.
not employ any parson in any manner so as to become mi to the Workers'Coogan- ENERGY FRE
sedan Laws of California Date
z O Applicant ` WATER HEAT. GRADING FEE
y NOTICE TO APPLICANT If,after making Of,Cal ifiwte of Exemption,you should WATER SYSTEM/TREATING
a ; become subject to 0o Workers Compensanon provisions of the Lather Code,you must SOILS FEE
W moment comply with such provisions or thio permit shall be deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID
UQ l far
rwhich rtn that there isaco (Set.anlendagency for the performance of Data Receipt
w P the work for which this permit is issued(Sec.3097,Co.iv.CJ
C) U Leaders Name TOTAL:
W Lender's Address TOTAL:
ly 1 certify that I have read this application and state that the above information is BUILDING FEE
o-F"r to correct.I agree to comply with all city and county ordinances and state laws relating to QTY MECHANICAL PERMIT FEE' '
U ,7., M1uilding wnstmuimn,end hemby authorize representatives of this city to emerupcm the SEISMIC FEE
shove-memioned properly for ma,vailon purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against ELECTRIC FE
liabilitics,judgmenq costs and expenses which may in my way accme against said City
in consequence of the granting ofthis permit. ALTER OR ADD TO MECH. PLUMBING
APPLICANT UNL4FRSTANDS AND WILL COMPLY 00 ITH ALL NON-POINT AIR HANDLING UNIT(TO 10,0CFM)
SOURCE REG I IDN MECHANICAL
AIR HANDLING UNIT(OVER I0,"CFM) CONSTRUCTION N
X
Signature of plica Contractor ate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazeNaus material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Gide,Section 8532pol HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No VENTILATION FAN(SINGLE RESID) PAID --
Will m the applicant building occupant oreequipment ordevices eDam Receipt#
Q1Xg)BTU)
I hazardous air enmamimnun defined by the Bey Arra Air Quality Management
nt BOILER—COMP UHP OR IBTOTAL
n0mp
❑Yes E]No BOILER—COME(OVER 100,M)BTU) 3
I have read the hazardous materialsmens under Cha tu695 mile,Cali- AIR CONDITIONER
require p SSUA E DA �
forma Health&Safety Cede,Sections 8505,25533 and 25534.I understand that if the NEW RESIDENTIAL MECH, SQ.FT.
building do of cumn0y have etenant,that it ismy..her fa Cality to fidua mace any,
fah reyj e e hich must hem or to iasuvnen ofe Cenificale of Occulwnry.
Owne ami ized agont Dine TOTAL. ISSUED BY ( '"
OFFICE