S 0689 APPLICANTTO.FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PERMIT NO.
BUILDING DIVISION - APPLICATION/PERMIT PLUMBING-MECHANICAL S 0389
BUILDING PROJECT IDENTIFICATION
BUILDING ADDR S: /1 SANITARY NO. APPLICATION SUBMITTAL DATE
l'D�D 5�irr� /l[x/kJ/ � Y ` G
OWNER' N E: -/ PHONE: CO C "N ME: L NO:
l
u N/C CONTROL
ARCHITEC-PENGINEER: OF LIC NO: ADDRESS
CONTACT: -aa. ' � N /� BUILDING PERMIT INFO
'v/_ ! ❑ Consultant Fces Paid by Applicant(Initial) BLDG F.LE PLUMB ME
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE ❑ ❑
I hereby affirthat I am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
W�W�Z with Sedimn]IXN))nf affirm that
of the Business undprofessiRns Cade.end mylicenae isREh RF Ifs DFryTI�_
RMIT ISSUANCE
in full force and /�` 5/K�� (/
M�UZV Lice uss - Lic.k USFDWL C KITCHEN REMODEL
Fs W put Commaar APPLIANCES-RESIDENTIAL El ADDITION L1 PLUMBING RE-PIPE
ARCHITECTS pECLAR ION PANELS.. 0 ❑MULTI-UNIT DSTRUCTURAL
zol,nI understand my plans shall be orad os puhlic re cards / MODIFICATION
024—0 UP TO 2LYI AMPS
�.N.E+1y Licensed Pmfessronal ❑INTERIOR UCHIMNEY
MINGREPAIR
OOL
201-1000AMPS IMPROVEMENT_ El SWIMMING POOLS
Oat I mn eUILDER m the Ci DECLARATION OVER 1000 AMPS C1 BATH REMODEUREPAIR D DE LITION
Ly 1 hereby afnmr that I em exempt from the Commdurs License Law for @e
{Ij 3 F following reason.(Section 7031.5,Business and Prafessinns Cade:Any city or county SIGNS ELECTRICAL ❑OTHER
y Oya
which requires a Permit m m
conmct,stmt,improve,demolish,or repair any swcrurc a g
m.i F.
priorroits issuance,also requires the applicant for such permit file a signed smtemein SPEC]AL CIRCUIT/MISC 5� L�(J�f/(�{'(L
syr G 'but he is licensed pursrant to theprwisionsof the Contractor's License Law(Chapter9
Iy p0 ie
(armmcncingwith Section9000)of Division 3oftho Business and Porlsions Cade)or TBMP.METER OR POL6INST. ,COMMERCIAL'
L p,o y that he is exempt therefrom and the basis far the alleged exemption.Any violation of - C NEW ERCIBLDGIADDITION [I DEMOLITION
'^N Section]031.5 by any applicant for a permit subjects the applicant to a civil penalty of POWER DEVICES
On more than five hundred dollar($500). ❑TENANT [I FOOD SERVICE
C 1,as owner of the pmpeny,or my employees with wages as their sole compensation. SWIMMING POOLE CTRIC IMPROVEMENT -
04 will dothewark,auddestru namis not intendederofferedforsale(Sec.]044.Business six []OTHER
6 a and Professions Code:The Contractors License Law does not apply In an owner of OUTLETS-SW S- TURES
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 RESIDE411A TRIsiSQ PT.
sale.If,however due building or improvement is sold within one year ofcomplerion,theS .F. s/ Q.FT.
owner-builder will have the Lumen of proving that he did not bund or improve for par-
Pass of sale J.
E]1.as owner of the property,am exclusively contracting with licensed contractors m TOTAL: SEP 1 6 199 .�
construct the project(Sec.9044,Business and Professions Cade)The Chianti Li-
c rase Law does not apply to an owner of property who builds or improves thereon,and QTY PLUM T FEE
who contracts for such protects with a corrections)licensed pursuant the Contractors BY:
Lice se Law. -
C I nm exempt under Sec. .B&P C for this reason PERMIT ISSUANCE
OwnerALTER-DRAIN&VENT-WATER(IA)
Date �V////��llal�,AgUAT10N
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE //TT,'
' Ihmehy affirm under Penalty nfpmjury one of the following decimations: �r
❑ I have and will maintain a Certificate of Consent to aelf-insure for Warker'.s Comped. DRAINS-FLOOR,ROOF.AREA,COND. STORMS TYPE CONSTRUCTION
rattan,as provided for by Section 39W of the Labor Code,for the perfmmance of the -
w.jk for which this permeu
it isised. FIXTURES-PERTAPI have and will maintain Worker's Compensation Insumnoe,as required by Section
3700ofthe Lr or Code,far lifeare of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP APN
My Wo d o sari tr r artier and Polic�yturvhel,/gc l
Gainer A\\\\\ Policy NOM WOJ[1/O GAS-GA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR '
(This section need not be completed ifthe permit Is for one hundred dollars($100) BUILDING DIVISION FEES
or less) GREASE.TRAP PLANCHECK FEE
(certify thatinthe perfinouanymannerof the work for whichthu,namanis the Workers
rLsued,Co shallpact- SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any manner so as m became subject the Wnrker,2 Comped- ENERGY
0 cation s of California,pate WATER HEATER WIVENT/ELECTR
GRADING PEE
a
NOTICE TO APPLICANT:If,ager conking this mesonof Exemption M/T
you should WATER SYSTEREATINC? ct a become subjethe Workers Compensation provisions
of of the Labor Code,you must SOILS FEE
LLl ti forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
0. 0
iU. z CONSTRUCTION LENDING AGENCY NEWRESIDENTIALPLMB. SQ.PT. PAID
Thereby affirm that there issu (See,,construction len ding agency Torahs performance of Date Recciptp
� � .Ihe work for which roissued permit is ed(Sec,3099,Civ.C)
Lenders Name'
LUkI Lender's Address - TOTAL: tpO T<YfAI.: I
(� I certify that 1 have read this application and state that the above information is BUILDING FEE {fir
wry7 correct,l agree to comply withal]city and county ordinances and state laws relating to QTY, MECHANICAL PERMIT FEE
G .
U building concoction,and hereby authorize representatives of this city a enter upon the SEISM IC FEE
above-mentioned property for inspection purposes. h
(We)agree minus,indemnify p City per g PERM IT ISSUANCE
g ewhich
hay in any
way
cea tinea against 4✓ ELECTRIC FEE
in
of the grants ting
expenses mit, may many way uane against said City ALTER OR ADD TO MECH.
in consequence of the graining of this permit PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT TO IQ(1(gl CFM)
SOURCE REGULATIONS. MECHANICAL
AIR HANDLING ON]r(OVER 10,000 CFM) CONSTRUCTION X
Signaluronf Apphcant/ConOactor Data EXHAUST HOOD OVMUCT)
HAZARDOUS MATERIALS DISCLOSURE
Will the upplilich or future building rccupain same or handle hazardous material HEATING UNIT(TO I atBTU) HOUSING MITIGATI NFEE
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)'! HEATING UNIT(OVER 100,01)(1 BTU)
❑Yes pp /No
ffFFFF
VENTILATION FAN(SINGLE RESID) PAID --
Will thea applicant or future building occupant use equipment or devices which Data Receipt N
emit hwadous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP CHP OR 1011,061 BTU)
District? - TOTAL:
El yes el .,o - BOILER-COMP(OVER Iang BTU
I have beeme hismandous materials requirements ruder Chapter 695 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health& afely Cole.Sections 25505,25533 end 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT. _
buildingdoes tcure have amnamt.thatltismyresponsibi lye tifythoresupant 7 lG 7
of the is i most h met prior to issaance n reancy. lJ '
wit
Uw er aul 'zed a I Data TOTAL: ISSUED BY: ',
OFFICE 3JbLo `