99080200 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY A O 14OZ0110
CITY OF CUPERTINO BUILDING-ELECTRICAL R TNO.
BUILDING DIVISION APPLICATION/PERMIT PLUMBINGMECHANICAI.
• BUH.DING'PFERIF;TIDE W
F'ICATION'.. .' 't,.;'
BDILUINGADDRESS: SANITAHY NO. APPLICATION SUBMI'ITAI.HATE
o02 Q lca� re �- 9
OWNF NAME PHONE
ACT MF. LIC NO:
�� -X A/�.I1�1`rl� N/C CONTNfII.p
R HITECI'/ENGINEER; LIC NO: ADDRESS'. (J/�/Ya/��I�� ❑
nMfnC,T: PHONE: ;:'•y,, .i..BUILDING PERMIT INE,
�A , ^ �� ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB ME❑CH
ucervseo coin RACTOIts Drcla Ia QTy ELECTRIC PERMIT ') FEE i:'
I hereby affirm that I or licensed and"p o CIr er amine g 1 n-. .{ ' ^':.r-: JOB DESCRIPTION
FOO 0'Z with Se Ron 7000)x11) n3of the Has d s] sCo and my been. is RESIDENTIAL:
O full farce and eRec J PERMIT ISSUANCE
LLl� l" / ❑SFDWL ❑KITCHEN REMODEL
I4�V~ closs Carl APPLIANCES-RESIDENTIAL
<i Dam Commcmrill []ADDITION [I PLUMBING RE PIPE
F7q ARCHITECTS DECLARATIO PANELS MULTI-UNIT ❑STRUCTURAL
Z O I understand my plans shall he used as public records MODIFICATION
oz-Z UPTO 200AMPS ❑INTERIOR L1 CI IIMN17Y REPAIR
I-y�W Licensed Professlsnel 201-1000AMPS IMPROVEMENT SWIMMING POOLS
CC66 g
OWNER-BUILDERexempt
DECLARATION OVER I"AMPS ❑BATH REMODEUREPAIR DEMOLITION
C�6 1 hereby affirm thin 1 am exempt from me Contractor's License Law for the
{LS O d O following mason.(Section]on.5.Business and Pfofan moll h.or Any ell,or ninny SIGNS ELCC'IItICAL El OTHER�.�/�
W 3 0 F' poor
rM1 it,iss s a permit m ami, ct,alter,improve,h"unsM1,or repair any stmomre
f-LLO pat heisscense issuance. to the movisioso fm suchperminLfile.icenseaw(Chamem SPECIAL CIRCUIT/MISC.
E } thin he in licensed pursuant m the provisions of the Cumrvcmrs License Law(Chapter 9
W �Na (commencingwith Section 7000)of Division 3 ofthe Business and Professions Code) COMMERCIAL'
wi TEMP.METER OR POLE INSI'.
a e W thin he is exempt therefrom and the[.axis for the alleged exemption.Any violation of 0 NEW BLDG/ADDITION ❑DEMOLITION
1i•
Section by anyapplicant for.permit suh ey meapplicamm a civil cash,of POWER DEVICES
�y ❑TENANT ❑FOODSERVICE
not mom man five hundred donors y employees
ll IMPROVEMENT
FgSQp ❑Lo the wet ,the property,r myyemplendes wilhwaga asaleir tole compensation, SWIMMING POOL F.LF.CfRI
s7 Ise
will do the work,and the structure is not intended compered for sale(See]0i4,Business []OTHER
I2 � and Professions Cole:The Contractors License law does not apply to an owner of OUTLETS-SWITCHES-FIXTURE.
o' property who builds or improves thereon,and who docs such work himself or hnmgh
his own employees,provided tha such improvements am not imenJed or offered for NEW RE5IUGNTIAL ELECTN Q F.
sale.If,however,the building or improvement is sold within oneyearnfmmpleion.the SQ.FT.FLOOR AR ESQ.FT.
e b Ids will have the burden f facing that h did r bu Id or improve for p r,
'we f ).
D ...
l f 0 pr pent of 'velY I 't g with Tamed wnmucn l TOTAL:
conswm the project(Sec 7044 Business and Professions Code)The Coouacmr:U- --I - .,
se d 0 ,1,1 fprpeny h t Ids or Improves thereon d QTY PLUMBING PERMIT. f II' t PEE 3 0 1999
who contracts forsuch Projects with a connotations)ions)licensed pursuant the Contractor's I pUG
License taw.
PERMIT ISSUANCE
F-1lnnl enempl under Sue. ,B&P C for this raison
ALTER-DRAIN&VENT-WATER RA) Vg1,UAT1ON
Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE gy_
I herchy affirm under penahy of perjury one of the following declamtims:
Ihavu and will mandato a Ceni fmwe ofCoa msetf-more fn.Worker's Cmrpen- DRAINS-FLOOR,ROOK AREA,COND S' ED
TONIE TYPE NSTRUCTION
u.presided for by Section 3700 of rhe[.her Code,fertile performance of the
mk far which this p,m n is issued. FIXTURES-PER TRAP
❑ 1 base and will maintain W'orkds Compensation Insurance,as millions]by Section
37M of the Labor Code,for the performance of me work for which this permit is issued, GAS-EA.SYSTEM-I INC.4 OUTLETS ICC.GROUP al'Nl-s
My Worker's Compensation Insurance wrier and Policy number am: Cl r
Carrier. Policy No.: GAS-EA.SYSTEM-OVER 4(I?A)
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASFIINDIISTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE sBUILDING DIVISION FEES. ( r ;
(This section need not bo completed if the permit is forces hundred dollars(SIM)
or less) GREASETRAP PLANCHECK FEE
I ceray that in meperformancoof theworkltnwhich thispenna is issued,l shall SEWER-SANI'1'ANY-S'TOHM GA.2OF PI'.
not clnLa0 any person' manner so o bcFr e. cr m the We s'Compen- ENERGY FEE
O Z section laws f n'n �e WATER HEATER WNENT/ELEC R
z Appliwm GRADING FEE
p.t y NOTICIi T A NT after making this Certificate of Exemption,you should WATER SYS]EMffREATING SOILS F'EE
beeomo subject to Ibn ;ors Compensation provisions of the[.shot Code,you nno,
(31 forthwith comply wit such provisions orchis permit shall be deemed revoked, WATER SERVICE
0
z CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMB. SQ FT. PAID
L) O I hereby affirm that there is a construction lending agency fin the performance of Dao a ip p
the wofk fur which this permit is Iselin](See 3097,Civ.C.) -
Lender's Name OTAL.
wLenders Address TOTAL:
Fy I certify that 1 have read this application and state that the above inforanation Is - - 0 BUILDING FEE
r
to correct 1 agree to comply with all city and county ordinances and state laws relating to QTX. MECHANICAL PERMIT TEP'
V Z.. building nnlstrmumn and hereby, ]aurin pmsenutves oftbis city m ermines,the SEISMIC FEB.
abovomcmbned property for inspcctimn purposes. PERMIT ISSUANCE
(We)agra save,ve,indemnify and keep halmlwx the Cityof Cupcnino against 13LECTRIC FEE
Iiabilities.judgmems,costs and expenses which may in any way trams against said City ALTER OR ADD TO MECH.in nseyuer a,of the granting of this permit PLUMBING FEE.
APP LICA UNDERSTA DS AND WILL COMPLY WIT LL NON-POINT Alit HANDLING UNIT(1'O nI,IM)B CPM)
SO GULATI0 MECHANICAL ItiE
AIR HANDLING UNIT(OVER 10,000 CFM)
CONSTRUCTION TAX
nature A611irecal manna Date EXHAUST HOOD OGDUCf) I{OUSING MITIGATION FEE
HAZARDOUS MAGiRIALS DISCLOSURE
Hime a,dinmt or future building occupant shmorhondlelmadmixanterial HEATING ON IT(TO 100,000 BTU)
az le toed by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532hu? HEATING UNIT(OVER 101,000 BTU)
❑Yes [D No PAID
VCNTILATION PAN(SINGLE'RESID7 Dam Reseda
Will the applicantcontaminants as
building by thpant eBy Area
Air Quality
evice,whichManagement
BOILER-COMP(3HP OR 100,000 BTU)
it bmardous sir amlaminanrs as defined by the Buy Area Air Quality Managcmcnt TOTAL:
❑Yes ❑Nn BOILER-COMP(OVER 100,0E BTU) .
I lmva mad the hartiol s mmerirl.l I uucloca s mile!Chapter 6.95 of the Cali- AIN CONDITIONER
9 p ISSUAforN E DATE.
bullHcelt Safety Cale,Sections 25505,25533 end 25534.1 understand mar if the NEW NESIDIiNT1AL MECH. SQ.FT. q � — � Q
buil ' of currently � alert ohm lis my mspm nlirymnmif]]]]''''the occupant V/1 O
of Is whi' list be m• Certifenleldlll c
rurau tried agcm o Date TOTAL: ISSUED BY:
OFFICE