99090065 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL 'J� PE IT NO.
BUILDING DIVISION APPLICATION/PERMIT PLUn1BING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
NO
B ILDINGADDRESS: '�1 SANITARY NO. APP CATION SUBMITTAL DATE
OWNEI�'�NAME: �N9 : ^� CO ItA��R'SNrb. ��a SIC CO ROI.#
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HITECT/ENGINEER: LIC Na ,. 5�'1
A R S. ❑
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CONTACT: PHONE: BUILDING PERMIT INFO
❑ CUn$ultant Fees Paid by Applicant(Initial) BLDG ELLE-CTT PLUMB MEC
(y/
❑ L✓J ❑ IJ
LICENSED CONTRACTOR'S DECLARATION ELECTRIC PERMIT FEE JOB DESCRIPTION
I hereby affirm that I am licensed under provisions of Chapter 9(commencing QTY.
Qg4Z with Section 7000)cf Division 3 urine Businessand Professions Code,arm license is RESIDENTIAL'
PERMIT ISSUANCE
eon in Poll force andetRct�O jj�I y ❑SFDWL [_1 KITCHEN REMODEL
I_U License Class Lic.# APPLIANCES-RESIDENTIAL -I ADDITION ❑PLUMBING RE-PIPE
H W Date -q-n ; Cmntraam
rn a ❑MULTI-UNIT El STRUCTURAL
F O no ARCHITECT'S DECLARATION PANELS MODIFICATION
Z p to Z I understand my plans shall be used ie public records
OZ�� UPT0200AMPS El INTERIOR [D CHIMNEY REPAIR
frcilE'W Licensed Prof"Imarl 201-100AMPS IMPROVEMENT 0SWIMMING POOLS
p RM OWNER-BUILDER DECLARATION OVER 1000 AMPS El BATH REMODELRtEPAIR El DEMOLITION
1P�' I hereby affirm that I am exempt from the Contractor's License Law for the
{7Ly L U following reason.(Section 7031.5,Business and Professions Cade:Any city or may SIGNS ELECTRICAL ❑OTHER
u+a W y which requires a permit to comtmet,alter,improve,demolish,or repair any structure
♦:W+o-1 prior to its issuance,at,.requires the applicant for sach permit m file a signed statement SPECIAL CIRCUFONUSC.
O
that he is licensed pursuanto the provisions ofthe Contractor's License Law(Chapter 9
CO (commencing with Section 7")of Division 3 ofthe Business and Professions Cade)Dr TEMP.METERORPOLEINST.
that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION [I DEMOLITION
uX7 on Section 1031.5 by any applicant for a permitsuticell theapnimm 1.a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
Onot more than five hundred dollars(8500). ROVEMENT
❑ 1,as owner of the property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F will dathewons moth,The
Liivem orowdu f,act
7044,Business THBR
and Professions Cale:The Commeoi s License Law does not apply In an net of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his awn employees,provided that such improvements are not intended or offend for NEW RESIDENTIAL ELECTR SQ FT
sale.If,however,the building or improvement is sold within one year ofcompletion,the
SQ.FT.FLOOR AREA USQ.FT
caner-builder will have the burden of proving that he did not build or improve for pur-
pose of sale.).
❑ h as owner of the property,am exclusively contracting with licensed Winn Glom 1. TOTAL:
Distract the project(Sec.7044,Business and Professions Cade:)The Contractors Li-
cens,Use dcesnot apply to an owner of property who builds or ime provthereon.and QTY, PLUMBINGPERMIT FEE
who contracts for such projads with a eommemr(s)licensed pursuant o the Contractor
License Law. IPERMIT ISSUANCE
❑ I an exempt under See .B&P C for this imson
ALTER-DRAIN&VENT-WATER(EA) LU 1'I
owmer Dam
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
I hereby affirm under penalty of perjury one of the following deelamtions:
I have and will maintain a Certificate of Consent m self-insure for Worker's Croatian- DRAINS-FLOOR,ROOF,AREA,COND, STORIES TYPE CONSTRUCTION
anon,as provided for by Sermon 3700 of the Labor Code,for the performance of the
work for which this permit is issued. FIXTURES-PER TRAP
have and will maintain Worker's Compensation Insurance,as required by Section
3700 otthe Labor Code.forthe performance of the work fd Put popfgvehichthls permitisissued. GAS-EA.SYS TEM- INC.4 OUTLETS OCC.GROUP 3 O AAPPN^
My Workeh`mgeasort oIsur Policy No.y'Sf t VID GAS-EA.SYSTEM OVER 4(EA) �(� LIQ
Certiu: ll 11 .�';ertier an
CERTIFICATEOF XEMPTION FROM WORKERS' GREASFIINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This secarm need not becompleted tithe Throat is faro.,hundred dallars(SIOJ) GREASETRAP
PLANCHECK FEE
mles.)
I termly that in the performance office work for which thispermit is issued,I shall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner so as to become subject to the Wmkers'Compm- ENERGY PEE
,Z sation Law.,hf California.Dam WATER HEATER W/VENUELECTR
Q Applicant GRADING FEE
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM?REATING
(-' ^ become subject to the Worker's Compensation provisions of the Labor Code,you must SOILS FEE
forthwith comply with such provisions or this permit shall W deemed revoked. WATER SERVICE
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLB. SQ.FT. PAID
M
U p (hereby affirm thauhere isaconswction lending agency forthe performance of Dete R eipt#
QLeaders or which this permit is issued(Sec.3097,Cie CJ TOTAL:U Lender's Name
Lender's Address TOTAL:
1 certify that 1 have read this application and stare that the above information is BUILDING FEE
i..� i,l correct 1 agree to comply with all city and county ordinances and state laws relating to QTy, MECHANICAL PERMIT FEE
U z, building construction.and hereby tanneriu representatives ofthis city to enter upon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(Wh)agree ne rove,Indemnify sad keep harmless the City of Cupertino against ELECTRIC FEE
habilities.judgments,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECH. PLUMBING FEE
in eoeegmence of the granting of this permit.
APPLICANT UNDERSTANDS AND W . OMPLY WITH ALL N///����ONN����-POINT AIR HANDLING UNIT GO 10,000 CPM) MECHANICAL FEE
SOURCER ,TIOI`L
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
gnamre of Applicam(Contrzmnr Date EXHAUST HOOD UNMUCq) HOUSING MITIGATION PEE
HAZARDOUS MATERIALS DISCLOSURE
Will the uppllcant or future building occupant succor handle hazardous material HEATING UNIT TO IlNl,0006TU)
as defined by the Cupertino Municipal Code,Chapter 9.12,mad the Heald,and Safety
Code,Section 25532(a)'! HEATING UNIT(OVER 100,01 BTU)
❑Yes [:I No VENTILATION FAN(SINGLE RESID) PAID
Date Rmeipl#
Will the applicant or future Wilding occupant use equipment or devices which BOILER-COMP(3HP OR IW,OW BTU)
it hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL;
strict? BOILER-COMP(OVER I100,000BTU)
L]Yea 0 N
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
forma Health&Safety Cade.Sections 25 5533 and 25534.I understand that if the NEW RESIDENTIAL MECH. SQ.FT.
Wild c n0 m t tit is my,te,,mobility m notarythe occupant
of e Leante of a Cerlf�
Owner or i uthonaed agent Date TOTAL: ISSUED BY
OFFICE _ -