99090001 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY
CITY OF CVPERTINO BUILDING-ELECTRICAL iP R r'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL tY/
• - 's !';(i t} BUILDING PROJECT IDENTIFICATION.',f '
BUILDING ADDRESS: SANITARY NO. APPLICATION 5 L DAT
35
OWNF.R'Sy@ME: � � PHONE: ±, C RA tO 'S ME: LIC NO
�/ i�illf �j3` N/C CONTROL#
RCHITECT/ENGINEER: L N ADDRESS / cdx,,4 ❑
.253
CONTACT: PHONE: BUII:DING PERMITINFO', I'•
/) ` 4 q 8 9,/: ❑ Consultant Fees Paid by Applicant(Initial) 'BLDG ELECT PLO MUCH
MUCH
LICENSED CONTRACT ORS DECLARATION �!_ s.
I hereby atTmm hot I licensed d p rens ter 9 QTY " /' ,ELE•CTRIC PBRJ,, ,"FEE''' JOB DESCRIPTION
P (comm c g - t'., ., . h 1 r:
7. sab Sectio 7000)ofly 'on 3 ofthe Business and Professions Code and my naensets RESIDENTIAL,
F � toll Toro,�nA e PERMIT ISSUANCE
�UV Licen Lia,# ? S(,/: DSFDWL D KITCHEN REMODEL
yWM Date Contractor APPLIANCES-RESI)ENTIAL L1 ADDITION [I PLUMBING RE-PIPE
ARCIII'fC��{{'S DECLARATION []MULTI-UNIT []STRUCTURAL
� ZOyZ /t9n�crsaryl my pla s dao olio rced1ds PANELS MODIFICATION
OZ - N (4� ZAZt UP TO 200 AMPS
key Licensed Professional D INTERIOR D CHIMNEY REPAIR
201-1000AMPS - IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION D
O st U I hereby atlirm That i am exempt from the Contractor's License Law for the OVER I OW AMPS []BATH REMODEUREPAIR D DEMOLITION
yD 3 W F following reason.(S«tion 70315,Businessman]Profcsdons Code:Any ally at county SIGNS ELECTRICAL DOTTER
wInch requires a Peru,,w construel,all.,umprovo,demolisq or actual uny structure _
pmrwit,meance,olaiominres the applicant for such permit to file a signed statement SPECIAL CIRCUITIMISC.
2Wp. that he is licensed presuantto the provisions ofthe Contractors License Law(Chapter9
CmMI
(commencing with Section7000)or Division 3 ofthe Business and Professions Code)or I'EMP METER OR POLE INST MM I
6 a. c that he is exempt therefrom and the basis for the alleged exemption.Any violation of []NEW BLDG/ADDITION ❑DEMOLITION
' , Seedun7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES
not more than five hundred dollars($500). D TENANT [I FOOD SERVICE
Fzd I] L as owner of the property,or my employees when wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the structure is not intended,"offered lormle(See 7044,Business DOTHER
d 3^w and Expressions Cade:The Contractors License Law docs not apply In an owner ofOUTLETS-9W1'fCtIFS-FI S
^ puppetry who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL ELECT' FT.
Ind.If,however forbidding orimprowerem is sold within one non.finan ion,the SQ.FT.FLOOR AREA $/SQ.FT.
owner-builder will have the human of proving that he did not build or impmve for pmr
pu sof sole).
❑1,as owner of the property,em exclusively contracting with licensed eontreanns to WE
consumer the project(Sao,7044 Business and Poofiessions Carie)The Contractor Li-
cense
Law❑es not apply to f property who builds or improves there, d QW.,{i f[ ` 1 PLUMBINGPERMITi FEB. ss
who contracts lar such projects with a contracmgs)licensed pubmannr the Contractors
Limns,Law. PERMIT ISSUANCE
EJm
Inoxemptunm
de-S . ,B&PCfarthlsreawr
waw Data ALTER-DRAIN Air VENT-WATER(EA) 's�VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ,1
I hereby athrm under penalty of Perjury one of the following deal omties,: .3yT
I have and will maintain a Certificate ofComent mself-insure for Worker's Compen- DRAINS-FLOOR,ROOF,AREA,COND. STORIES 'TYPE CONSTRUCTION
moan,as provided for by Section 3700 of Ne Labor Code,far he p,ifurmance of the
wor ch this permit is issued. FIXTURES-PER TRAP
nave and will maintain Workers Compensation Insurance,as required by Section
3700of Ne Labor Code for the performance ofthe work for whichdox armnisissued, GAS-EA.SYSTEM-1 INC.4 OUTLETS OCCGROUP APN
My Works 'pAtpen�{ian larytdnce w tar ens Policy
Cartiee`� RT�/ YT Iicy Nn.: GAS-F.A.SYSTEM-OVER 4(EA) •7� r is/v�
CERTIFICATE PE EXEMPTION FROM WORK S'
COMPENSATION INSURANCE GRCASF/INDUSTRL WASTE INTERCEPTOR
(ITtiaaeetmn neat mat l>e,amPletedlnnepern,dia rorane nnnared dollars($100) k,J gI t#t HICHIDINd IJ131siDNPEJE;s 0@'3It
tar less.) GREASETRAP n PLANC E KFE
Iocnify shut in the any
the work foe while this the Workers Cooties- SEWER-SANITARY-STORM EA.200 FT. LI—�
not employ any person in any nmmnw so as to become sub]em ro the Workers'Counties- -L+NBRG - 68
staimi Laws of California Data qbff6O 'Z WATER HEATER WNENT/ELECTR c�tA
Y E
Applicant
V1 NOTICE'I'O APPLICANT If,after making his CenlOwte of Exemption,you should WATER SYSTEMOEEAHNG Y
ah become subject m the Workers Gompemclan pros cions of the Labor Code,you must SOIL E
Ila �y forthwith couiply with such povisions or this permit shall Id deemed nevoked WATER SERVICE
Q
Zoo) z CONSTRUCTION LENDING AGENCY NEW RESIDENT'IALPLMB. SQ. . � PAID
U C) I hereby a firm that here is a cnnswcllon lending agency for the performance of
W Hthe work for which this Permit is issued(See 3097,Civ.C.)
Leaseu's Nam, TOTAL
o W Lenders Address TOTAL: ,5a
FFFf�y+tt d I cerry that l have ted this ppl cat on and state that the b [ t t. .,. ti .. BUILDING FEE it
s.t
L6 ampat g t ply lh II 1y dreuntY ordmanws d.rt I If gt QTY/ f '•!MECHAN:ICAL,PERMIT ] .It� }' PEP, I t
G Z building .rtuction,add hereby outhouse representatives of this city toemerupon the J t - •II sSEISMICFBB
abovo-mumu ned pm silly far inspection pu wes. PERMIT ISSUANCE ELECTRIC PBB
(We)agree to save,indemnify and keep harmless the City of Cupertlo,against
Iirbilities,jutgmmerts,resistant expenses which may in any way accrue against said City ALTER OR ADD TO MECH. PLUMBING FRE
in convenience of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOIJRC REGULATIONS. is
1� �Y� AIR HANDLING UNIT(OVER IO.IIWCFM) CONSTRUCTION TAX
Signature ofApplt/ tractor Date EXHAUST HOOD(W/DUCT)
HAZARDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will the applicant or future handing incident store or handle hazardous material BE,AT'ING UNI'P(1'0100,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Segfun 25532(x)') HEATING UNIT(OVER 100.000 BTU)
D Yes
o VBN'fILATION PAN(SINGLE RESID) PAID Data Re,elpl#
Willthe
air
futureb'Idg occuhydpamyse Aequipment devices mn rt BOILER-COST OR 100,000 BTU)
.it hoe 1 � nlu p',Jf day the Bay Arco Aur Q Ily Management TOTAL:
- Disl I BOILER-COMP(OVER 100,000BTU)
We No
1 have read he hnevdot:marand,r.yu rements under,ChaPt� AIR CONDI'IKNEE.95 of the Cali- ISSUANCE DATE
forma Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.PT.
buildingdr w,ted,ramently have ntevmt,than[is my responsibility to ratify the« pant
afire rytair�/nenls wM1ich muss rte t prior taj eyf a Cenjtic a p�y
C l/ILt.f•/A �2� Y �C.�
Owner or anthonzed a6 � � 7fI Data TOTAL: ISSUED BY:
OFFICE