00010037 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY ZOO Q O
'• CITY PCUPERTINO BUILDING-ELECTRICAL PERM] NO
BUILDING DIVISION - APPLICATION/PERMIT rl.unmmc-MECHANICAL ®�
BUILDING PROJECT'IDENTIFICATION ' IL
BUILDING ADDRESS: SANITARY N(1. APPLUAI'ION su Svf TIAL DAI'E
84 r -2000
OWNER'S NAME: + �53�I(7 .ONTRrn'S NAME:- LIC N[L
.l. l NIC CON TROLp
RCHITECT/ENGINEER: LICNO: ADDRESS: ❑
CONTACT. PHONE: BUILDING PERMIT INFO
- ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB Meal
LICENSED CONTRACTORS DECLARATION QTY. eLF•C?I'RIG PERMiT FEE
` 1 harcby mf rm that t I licensed a p r atapmr 9(courn g JOB DESCRIPTION
M94Z with Smtmn]000)rf D'visinn3 oOhnBusines,andP f.'mns Code and mylic Wase is PERM ISSUANCE RESIDENTIAL'
FF+ in fullforce vnd effect ❑SPDWL C1 KITCHEN REMODEL
�UU License Class Lie. - APPLIANCES-RESIDENTIAL ❑ADDITION P11r1M BING RE-PIPE
7�- Date—TS DECLARATION ARCIIITNAT - ❑MULTI-UNIT ❑STRUCTURAL
'9 DECL
Z O w Z I understand my plans,hall he mrd as public records PANELS MODIFICATION
OZ�� UPTO200AMPS El INTERIOR El CHIMNEY REPAIR
F sQ Fq'W Licensed Professional 201-1000AMPS - IMP VEMENT E]SWIMMINGPOOLS
' vy 2....11 OWNER-UUILDER DECLARATION OVER I000AMPS - AI'H REMODELREPAIR El DEMOLITION
WC'¢C¢1l d 1 hereby affirm that I ata exempt from ds,Contrucmr's License Law for the _ ❑OTHER
iW5 y U following reason.(Section 9031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL
Iu a ny which requires Issuance,permit re wnswd,aper,improve,h permit t fi repair nay swemm -
I"'��6� prionnitseedps also requires the applicant fine Compactors Liccasignadsmmment SPECIAL CIRCLE T/MISC.
that have licensed pursuant to(he of Division 3 the eBusiamh Licence Loons Code)or
WEQpC (cat he
(commencing Section7000)an)the basis for th alleged
ess corrnd uption
Any
Code)or 'TEMP.METER OR PoLE(NST COMMERCIAL
t1y c that he is exempt therefrom ars the basis for the alleged exemption.Any violation of _ ❑NEW BLDG/ADDITION ❑FOOD .ERV(
WZsty a.,Section 90315by hundred
dollar,
subjects the applicam tovcivil penally of POWER DEVICES ❑TENANT ❑FOODSERVICE
nor marc than Eve hundred dollars($Stift),
F Z N IMPROVEMENT
�Q Ole as owner of the property.or my employees with wages as their solewmpenaat ass SWIMMING POOL ELECTRIC ❑OTHER
will on the work,and the structure i...timendedomffored for sale(Six,9(144.Boniness,
3 and Professions Code:The Commandoes License Law does not apply to trimmer of OUTLETS-SWITCHES-FIXTURES
pmper,whe builds or improves thereon,and who does suchwork himself or through _
his own amployces,pnwiddl that...b imprexamena are not intended or offered for NEW RESIDENTIAL ELBCTR SQ Pr.
safe.It.however,the building or improvement is sold within one you ofcart'home.the .FI' OORARF.A S/SQ.ET.
PF II Will Olathe burden fp gthat he did no,b'
el ) x
er [0 p pent 1 x IYe over g tl 1 m. AL.
construct h project(SW7044 Business andP fie%r CdIII
can: La d t apply to fp pony h builds amp th rcon std Q FEE OA
who contracts for such projects with a contrachosdIcetal purvarat to Court
ry t
License Law. I "V
❑Tem exempt under Sec. �.B&P rt 'x
A ) VALUATION �+�
WORKER'S W HISSATION DECLARA a K �t I. 1
Jore,
1 hereby nfOrm under penalty of perjury one oft lotto h I) p
❑Ihave and will maintain a Certificate n(Consenvo self-iosu INE' STORIES TYPE CONSTRUCTION
sation,as provided for by Section 3900 of the Lubar Coda,fo h
work for which this pemrit is issued. PIX ES- E kA
❑I haveand will maintain Worker's Compensation fromnee,as required by Sectio
3100 of the Labor Code,for performance:of the work for which thisph-runsismed. GAS-EA.SYSTEM-I INC.4 OUTLETS OCG GROUP // AP
My Workers Compensation Insurance carrier and Policy number are: ( b 3
Cameo Policy Ne.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASE9NDUSTRL WASTE INTERCEPTOR
P
(Thi,semimencednot hecomplctedifthepermit is terrine hundred doperx(SI00) - x' ax • 'Bl11GDIsNO 4iVI510N FEES ,
or less.) GREASE TRAP PLANCHECK FEE
(certify that in theperoodeormfthe work brunet,thl, cout is Issued,limit SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner se a,m Inatome subject 10 the Writers'Compen- ENERGY HE
z cation Law,of Califomia.Date WATER DEALER W/VENTIBLECTR
Applicant t GRADING FEE
NGGCF.TO APPLICANT:If, it,,making this CaniOdam of Exemption, .,,,build WATER SYSTF,M/fREATING
(~ become subject to the Worker',Compensation provisions of the Labor Cade,you must SOILS FEE
Wra forthwith comply with Welt Provisions or this permit shall IS,deemed revoked. WATER SERVICE
P A
UO
CONSTRUCTION LENDING AGENCY NF:W RESIDENTIAL PLMB. SQ.1'i', PAID Data ReGapta
hereby which
(hat there iceed(Sec,construction0 lending agency for the performance of
the work for which this pemdt Is issuetl(Sec 3(199,Civ.CJ
us
0 F' Larder's Name - TOTAL:
U. Lender',Address TOTAL:
s>s 131
1 sanity that 1 have read this application d state that the above informativeis BUILDING FEE p ;
iF.t y crrteet I agree to comply with all abysms'comaylardimarres ondwalm laws relatim,to QTY. '.MECHANICAL PERMIT FEE,
Ua7 building usmrmation and hereby auth0nte representatives ofths city to enter upon the '- -' SEISMIC FEE
imme-nmmioned properly for inspection purposes. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Chromium goorc ELECTRIC HE -
liabllities,judgmanls,costs lad expense,which may in any way acerae agalnstsaid City ALTER OR ADD'TO MECIL
ar,mcoquemce of the gaining of this peril. PLUMBING PEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CPM
^��.MF,GFIANICAI.FEE
SOURCE REGULATIONS. / � ._,,.
/� ��q AIR HANDLING UNIT(OVER 10,000 IvO 4s— CgNSTRIIfCTI NTAX
Signature nfA anJCoumanor Data EXHAUST 1400D(WMUC) 1 /
g Pp I HOIISIN�1 [ IGATRD[FEE
HAZARDOUS MAI nERIAISDS eorhanE - r I
Will the applicant or future building occupant stare orhndlehazardous materialHOATINC UNI'1'fl0100,000 BTI)
as defined by he Cupertino Municipal Cale,Chapter 9.12,and the Health and Safely
Code,Section 25532(a1P
HEATING UNIT(OVER 1UI,000 BTU
❑Yes ❑No VENTILATION PAN(SINGLE RE Ie,) % PAID
_ — utc Ra iptH
Wiil the applicam War future building occupant use equipment or devices which r-._.4
mit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP( HP OR 100.000 BTU) TO'TAII N
Dislrid9
L]Yes, ❑Nn BOILER-COMP(OVER 100,M)BIU)
1 have read the hazardous materials requirement under Chapmr 6.95(31 the Cali- Alk CONDITIONER ISSUANCE DATE
Fria Health&Safely Code,Sell...25505,25533 olid 25534.'1 understand 11ch if the NEW RESIDENTIAL MECH. SQ.TE
building does not currently have ancant,that it I,my re,of...ala,m notif the mceupaot
ofthe require lit whi haus a spoor miexuan oLyC 'R�Ocupyky. / P
Owner or amp ed agent - h 4.V Date TOTAL: ISSUED BY:
OFFICE