99110005 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
I TY OF CUPERTINO BUILDING-ELECTRICAL
CPERMIT NO.
II HUILDING DIVISION t, APPLICATION/PERMIT PLUMBING-MECHANICAL p000�
BUILDING PROJECT IDENTIFICATION O
BUILDINGADDRESS: - SANITARY NO. APPLICATION SUBMITTAL DATE
223 1 GAF-rlodST19. GT /� /� 9r `t'
NF.R'S NAME: PHONE: CONTRACT'OR'S NAM@ - LIC NO:
1H,K, OI�jIs tA-k 606es "l. G GDT) 101.1 rvlc coNTROI.a
nRCHITECT/ENGINEER: LIC NO: ADDR SSS: ❑
Jo�FF� Po A GO to �� G, tsnlb
CONTACT: �( pj�f" -PHONEiS�— t IS BUILDING PERMIT INFO
(T'/ qony. r. �� * ' ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
1+ RN dA 4Kli:�2
■ ' ■ ■
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT r FEE
1 herchy affirm that I am licensed ander provision.of chapter 9(commencing JOB DESCRIPTION
204Z with Section 11007 of Divi.sion3ofthe B.,,messvnd Professions Code,md my license is RESIDENTIAL,
{ 00 nluEforce and effect. PERMITISSUANCE
I"IL^ i 6 ❑SFDWL KITCHEN REMODEL
�Vrj Liccnu Cl Lica APPLIANCES ❑ADDITION ❑PLUMBING RE-PIPE
Ciba ume GanlDECL
ARCHITECTS DECLARATION s ❑MULTI-UNIT ❑STRUCTURAL.
F.7 vs PANELS MODIFICA'T'ION
Z pvJ 1 unticrsmnd my plum e used as bad as public cords
uP T0210 AMPS 0INTERIOR El CHIMNEY REPAIR
; Licensed Prafeaainnal 201-1000AMPS IMPROVEMENT 0SWIMMING POOLS
X OWNER-BUILDER DECLARATION pyBR I000 AMPS ,BATH REMODEURIiPAIR El DEMOLITION
y I hereby uftinn thin I am exempt from the Contractor's License Law for the
Sd a V following reason.(Section 7031.5,Business and Professions Come:Any cityor county SIGNS ELECTRICAL OTHER
t W LL li which requires a pemut to construct,slier.improve,demolish,or repair any someone,1z 0Q prior to its iswomeq also requires the applicant for such permiuo file a signed statement SPECIAL CIRCUIT/MISC.
X;!16 that he it licenudp...nota uothe pm,kions of the Connector's license Law(Chapter 9
W a—QO (commencing with Section 70(10)of Division 3 of the Business and Profeesionx Care)or TEMP.METER OR POLE INST. COMMERCIAL
L 6 p K that he is exempt therefrom and the basis for tM alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
B' Section 7031.5 by any applicant for s permit subjects the applicant to a civil penalty of POWER DEVICES
nm more than Eve hundred dollars($510). [:]TENANT ❑FOOD SERVICE
F+ is IMPROVEMENT
Q (] hos owner nl Ne progeny,or my employees with wages evheir sole catagens S
will do the work.and the structure is not intended aroRe dfor sole(Sec.]D44,Bus []OTHER
6 3 m and Professions Code:The Contractors License law does not apply
m an smvn - - O F 1'
property who builds or improves thereon,and who does such weak himself or nh
his own employees,provide)that such impnrvemcros ere nor intended m o0'ere or - RE T ECR SQ IT
sale.If.however,the building or improvement is sold within one year ofcompletion,the SQ.FT.FLOOR AREA LSQ.FT.
ser-builder will have the burden of proving that he did not build or improve for pur-
prseofsaleJ. -
h as owner of the property,am exclusively contracting with licensed contractors m
s
construct she project(Sec.]044,Business and Professions Cade:)The Gita.....Li-
cemeLswdoesnotapplytoanownerofpnspertywhobuildsorimprovesthcren U 1
who conuscts for such projects with a amatictar(s)licensed pursuant m the Cam JIM
License Law, g '
❑I am exempt under Sec. ,B&PC for this
ALTER-DRAIN&VENT-WATER RVO VALUATION
net ume y
WORKGR'S COMPENSATTON DCCLARATIUN BACK FLOW PROTECT DEVICE J( D O
r I hereby ulfom under penalty of perjury ancof the following declarations: Fl
0 l have and will maintain aCenifirmc of Consent to self-insure for Workers Compen- DRAINS-FLOOR,ROOFl AREA,GOND. STORIES 'FYPECONSTRUCTION
cation,as provided for by Section 370 of the Labor Code,for the performance of the 1
work for which this permit is issued. FIXTURES-PER TRAP /A'1
❑ I have and will maintain Worker's Compensation Insurance,as required by Section kz
3700 of the laWr Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-1 NC. TLETS OCC GROUP I X APN
My WorkersCompensation Insurance carrier annumber are:
Chair, PolicyN., GAS'-EA. OF�PAv 3�i�a3�Z3
SYSTLM-OVERY(F.
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE/INOUSTRL WASTE INTERC
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This seclinn Leal m(becomplcud ifthe permit is faros hundrtddollars(SIOn GREASETRAP -
nrless) PLANCHECK PEE
I eerily that in the perfanneneenfthepwork
yfor
rwhich this permit in issued,l shall SEWER-SANITARY-STORM EA.200 FT,
nm employ any personi any Y/79ubjecnothe Workeri Compete GRADINNERGY M
z saline taws of Ca' .Dov WATER HEATER W/VENT/ELECIR
Q Applicant �� - � GRADING FEE
ti NOTICE TO AI'PI.CA T.If,v ng this Cenificnte of lxe
imptinn,you shoslJ WATER SYSTEMTREATING SOILS FEE
a ' become subject to the Worker's Compensation provisions of the Labor Code,you must
{tI forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
�z CONSTRUCTION LENDINGAGENCY
duty NEW RESIDENTIAL PLMH. SQ,FT, PAID Data Receipt is
V l for by which tm thatthemi isocsmsuec.3097ndis,agency l'nnhe performanceof
IL s•+ the work for which this Permit Is Issued(Sea J09].Civ.CJ
E'r Lenders Name TOTAL:
V Lcndcrs Address TOTAL: -
a BUILDING FEE
1 certify the I have rend this application and dime that the shove information is
N correct lags to comply pile ymall bo in countyordinancesafandstate citytolaws
natelatingm QTY. MECHANICAL PERMIT FEE SEISMIC PEE
L)z building construction,and hereby authorize repreunmtives of this city to enter upon the
mine-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)ugdra to ansa,indemnify and keep harmless the City of Cupertino against ELECTRIC FEE
Iiahilities,judgments,costs and expenses which may in any way accrue againatmid City ALTER OR ADD TO MUCH.
in consequence of the granting of this permtiPLUMBING FEF.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO IO.0RCPM)
MECHANICAL FEESOURCE REGULATIONS.
AIR HANDLING UNIT(OVER 10,010 CFM) CONSTRUCTION TAX
SignamreofA,drin/Contmchn Data EXHAUST HOOD(WIDUCIO HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
as defined by the Cupertino Municipal Come,Chapter 9.12,and the Health and Safety
Cock,Section 25532(a)? HEATING UNIT(OVER 10B."BTU)
1
E]Yes JINo AID
VCNTILATION FAN(SINGLE RESID) Date Receipt#
Will the applicant or future building acceptors use equipment or devices which BOILER-COMP QHP OR 100.000 BTU)
emit hmardaus air com un ons as defined by the Bey Area Air Quality Management TOTAL. s
Urgna?
El Yet Slit, BOILER-COMP(OVER 110,000 BTU)
,
I have read the hvallou*, 5,
sire ..under Chapter 6.95 oftM Cali- AIR CONDITIONER ISSUANCE DATE
Toni lin&Saf Code 25533 and 25534.1 understand(bun if the NEW RESIDENTIAL MECH. SQ.FT.hail ing xnnotc d3. iemyrcepansibilitymnnufy( ncc m issuance ofa Certificate�jjc yptn '
4 (J
Owner q filon41,1 agent Vale sat TOTAL: ISSUED BY:
OFFICE