9909050 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT
CITY OF CUPERTINO BUILDING-ELECTRICAL P t'
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL n
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRRR.. SANITARY NO. APPLICATIONSUBMITTAL ATE
O
OWNERSNAME: H CONTRACTOR'S NAME: LIC NO:
s� NIC CONTROL.
HITF,Cf/ENGINEER: LIC NO: ADDRESS:, I O F ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Appilmlit(Initial) BLDG ELECT PLUMB MECH
El IaJ ❑
LICENSED CONT'RACTOR'S DECLARATION QTY' ELECTRICPERMIT FEE
1 hereby aflifm had I am licensed under provisiaas of Chapter 9(commencing JOB DESCRIPTION
woz with Section7W0)of Division3 nDhe Business end Professions Coda and mylicense is RFSIU�NTIA1-:
a u1 F. to fuLia,rllll�forrcee a and PERMIT ISSUANCE E1SFDWI. ❑KITCHEN REMODEL
fZuu Dam�J= Con APPLIANCES-R&SIDENTIAL ❑ADDITION ❑PLUMBING LPIPE
Fay ARCHITECTS DECLARATION PANELS ❑MULTI-UNIT []STRUCTURAL
z O m K 1 understand my plans died be used as public records MODIFICATION
p Z.`o-a UPT02MAMPS [D INTERIOR [I CHIMNEY REPAIR
F2N4tw�.j Licensed Professional 291.IIX10AMPS IMPROVEMENT (D SWIMMING POOLS
CQ OWNER-BUILDER DECLARATION OVER 1000 AMPS [I BAT"REMO EIIREPAIR ❑D•MOLITI N
Wa I hereby ofnn thin I am exempt fourth,Cumbersome.License Law for the
U following reason.(Section]0315,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑ IE
ywhich requires.permit to construct,.Iter,impowa.demolish,or repair any e6uca me r
06, prior to its issuance,also requires the applicant for such permit o rile a signed statement SMCIALCIRCUIT/MISC
df that he is licensed pursuant m the provisions of the Convactoes License Law(Chapter 9 COMMERCIAL,
(commencing with Section 71001)of Di vision 3 of the Business and Professions Code)or TEMP.METER OR POLE INST.
4 q o thin he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION El DEMOLITION
a� Section70315 byinyrspplicwt firapermibsubjecis bheapplicantmacivil pe..I,y.f POWER DEVICES (-)TENANT ❑FOOD SERVICE
m� am more than five hundred dollars($500).
IMPROVEMENT
< ❑Lo'he owner
ish of the property, myemployees with wages aced far
their sole 0,14,Bunion, SWIMMING PWLELCCT
andvildnthewons Code
TheCommetchome is b,License
Law
amsabe ply to an,Business ❑
W-"�_ and Profession.Code:The Commcmes Lic<nse Taw does nm apply m an owner of OUTLETS—SWITCHES—FIXTURES
it.3 properly who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements art not intended or offered for NEW RESIDENTIAL.ELE SQ
Lj aide.If,however,the building.,impme,commt issold xithinoneysmafOunplethol.the LSy
DR AREA JQ�PI'.
pomer-builder will have the burden of proving that he did nob build or improve for par. -
of sale.). 1999
❑I,as oone,of the prnpeny,am exclusively contracting with li«nuJ cnnvamnrs n. A
construct the project(See 7044,Business and Professions Cade:)The Contractor's Li-
me L.dos.not apply man owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT EE whocoovac¢forsuchproject with aoontructods)licensed pursuant mthe Commdoes
License Law. PERMIT ISSUANCE
❑turn exempt under Sea. .B&P C fur his ma..a
ALDER-DRAIN&VENT'-WATER(FA) VALUATION
Owner Date /
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE ✓s
I hereby a� und
ren er penalty of perjury one of the following dalambinms:
❑ I have and will maintain a Certificate of Consent to self-insure for Worker's Compete- DRAINS-FLOOR,ROOP,All G,COND, STORIES TYPE CONSTRUCTION
cation,m provided for by Section 3700 of the Labor Code.for the performance of the
ark for which this permit is issued. FIXTURES-PER TRAP
I have and will maintain Worker's Compensation Insurance,as required by Section
3 of the Urbor Coda.firths performaus.fthe and,for which this pemmit is issued. GAS-II.SYSTEM. INC.4 OUTLETS OCC.GROUP APN
My Work and Policyyy�I�Q
Carriee �{1[)� Polley NaCl4l/" PBd1 nIA OAS-BA.SYSTPMOVER 4IEA) J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR HUILDING DMSION FEES
(Thissecdnn need not be completed lflhe permit is parent,hundraddollum($IW) GREASETRAP `
or less.) PLANCHECK FEE
I cenify that in the performance of the work for which this permit is issued,I shall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so m m became subject m the Workers'Compen- ENERGY FEE
OZ radon La` j"QW Die WATER HEATER WNEM'/ELECpR GRADING FEE
fA NOTICE TO APPLICANT:If,after making this wnithate h Exemption,you should WATER SYSTEM/fR[ATING SOILS FEE
abecome subject m the Worker's Compensation provisions of the onedr Cade.you..at
w Gmhwith cmnply with such provisions cellos permit shall FZ JcemeJ revoked. WATER SERVICE ,
0
Uz CONSTRUCTION LENDING AGENCY agency NEW RESIDENTIALPLMB. SQ.NT, PAID Date Receipt.
UQ ,for, whaffirm.bathosisaconstee.3097, agency Teethe perfoemance of
Fthe" Larwork for which this permit is insueJ(Sec.J09],Co.Civ.C.)
W Lendefs Name TOTAL:
V Lender's Address TOTAL-:
F cenify that I have read this application and state that the above of nation is BUILDING FEE
F y cii.i.l agree wamuply withall city and county ofdinancesand state owsrclmingm QTY, MECHANICAL PERMIT FEE
U building construction.and hereby umhnrim representatives of this city to enter upon the
SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree nOve,indemnify and keep harmless the City of Cupertino against ELECTRIC FEF.
liabilities,judgm cost nd expenses which may in anyway name against said City ALTER OR ADD TO MECH.
I n ranseyuenceo cat this PLUMBING FEE
APPLICANT DE IN SAND W1 C Y H ALL NON-POINT AIR HANDLING UNIT LTO 10,1X10 CRI) MECHANICAL FEE
SOUR . 'D NS.
AIR HANDLING UNIT(OVEN 10,100 CFM) CONSTRUCTION TAX
S' re of AppanVCnmmcmm 'Uate EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle harnrdous material HEATING UNIT CY 100."BTU)
as defined by the Caperton Municipal Cure,Chapter 9.12,and the Hat and Safety
Code,Secbinn 25532(x)" HEATING UNIT(OVER I00,000 BTU)
C3 Yes WN. PAID
VENTILATION FAN(SINGLE RFSID) Date Receipt.
Will Ne applicant or future building occupmn use equipment or devices which
crib hazardous air comeminanu as defined by ohs Bay Arca Air Quality Management BOILER-COMP(3NP OR I00,000 BTU) TOTAL:
toor B BOILER-COMP(OVER 100.1100 BTU)
❑Yes GIN.
I have re:v1 hmnrdoue materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
fomite Health&S •ty C e is 550 W. 55 .1 understand that it'the NEW RESIDENTIAL MECH. SQ.F-r
1han"i0"anBd sn .rre tem mit ny Aon ibilitY hirmadytbsae.pant
of the as ad top' of a Cenificam of 0ecupancy.
Ow or authorized agent r Dare TOTAL: ISSUED BY:
OFFICE