99090167 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY o (�
CITY OF CUPERTINO BUILDING-ELECTRICAL ,P ,'Te
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTALDATI
UP ,, C{ESTITIV DIP, CUPERT]-N0 % GA - 1 5 b 1 Lf
OWNER'SNAME: Og PH�� _O� CONTRACTOR'S NAME: LIC NO:
N/C CONTROL#
lei ARCHITECT/ENGINEER: iLIC NO: ADDRESS: !a' 2 ri
CONTACT: /// PHONE: BUILDING PERMIT INFO
DoPoTNy5l+Rr7-ocKK (4LOri L'j-_02g, Consultant Feet Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
k.. Q�
LICENSED CONTRACT'OR'S DECLARATION QTY ELECTRIC PERMIT PEE
1 hereby affirm that 1 nm ban Bu under and
Professions
of chapter 9(commencing JOB DESCRIPTION
WWZ with Section]000)of Division3of the Business and Rofessions Code,and mylicenseis
W O O PERMIT ISSUANCE RESIDENTIAL,
F W F in full force and effect. ❑SCOWL ❑KITCHEN REMODEL
F+<VU License Class Conti
W Dae Contractor APPLIANCES-RESIDENTIAL ADDITION [I PLUMBING RE-PIPE
ARCHITECT'S DECLARATION
F O PANELS ❑MULTI-UNIT []STRUCTURAL
Z O y Z I understand my plans shall be used as public records MODIFICATION
O_z4a UPT02MAMPS ❑INTERIOR El CHIMNEY REPAIR
C'=^WLicensed Professional 201-1000 AMPS IMPROVEMENT
OWNER-BUILDER DECLARATION ❑SWIMMING POOLS
C
6I hereby amrtn that I am exempt from the Contractors License Law far the OVER I(1W AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
1 W 30.U fallowing reason.(Section 70315.Business and Professions Code:Any city of county SIGNS ELECTRICAL ❑OTHER
u.y which requires a permit to construct,alter,improve,demolish,or repair any structure,b"..�f�fnnI prior to its issuance,also requires the applicant for such permit to file asigmd statement SPECIAL CIRCUIT)MISC.
yg�N�qympursuant at he is licensed pursuano the provisions of the Contractor's License Law(Chapter9
ul 1500 (commencing with Section 7000)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
C, c z that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
4• Section]031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES.>' nounore mon rive hundred dollars($500). ❑TENANT [I FWD SERVICE
F=C `7I,as owner of me property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
will do the work,and the swcture is not intended or offered for sale(See 7044.Business ❑ THBR
W and Pmfessions Cade:The Contractor's License Law does not apply to as owner of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended of offered for NEW RESIDENTIAL ELECTS SQ FT
sale.If,howeve,the building or improvement is sold within one yearofecmplifm,the SQ.FT.FLOOR AREA $/SQ.EP.
paxturbuilde,will have the burden of proving that he did not build or improve for pur-
asowen'e �5 2 $`
owner the property,am exclusively contracting with licensed commmes n- TOTAL:
wconstLa me is notaect ply to a owner of proandperty
rty who
ds or i The Committees Ll- -
arse Inco does not apply to an owner of property who builds or improves thereon,and QTY PLUMBING PERMIT -FEE
who
ense.Lcontracts for such njectswithucontn¢tor(s)Ilansed pursuant to Computer's
License Lu (a PERMIT ISSUANCE
❑lame et under ,B&PCfor thisreason
Owner a Date ALTER-DRAIN&VENT-WATER(EA) VALUATION
W �R'S COMPENSATION DF,CLARATION BACK FLOW PROTECT.DEVICE
I heregy ren under penalty of perjury one of the following declarations: ( CJ
❑IEnve will maintain aCertificate mf Consent toself-insure Por Workers Crmpen- DRAINS-FLOOR,ROOF,AREA,CONE). $TORTE TYPE CONSTRUCTION
wtion,as provided for by Section 3700 of the Labor Cade,for the performance of the
ark far which Oils permit is issued FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700ofine Labor Code,for the performance offle work fur which this permit isisuucd. GAS-EA.SYSTEM-I INC.4 OUTLETS
My Worker's Compensation Insurance sumer and Policy number are: OCC.GROUP 37 APq
Carver: Policy No.: GAS-EA.SYSTEM-OVER 4EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' 3
COMPENSATION INSURANCE GREASFIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed ifthe permit Is focone hundred stations($100) eeN RUIL I'G D1V)6101iFEBS p't or less.)less.) GREASE TRAF
PLANCHECK FEE
Icenify mat in the performance of the work for which this tannins issued,lshall SEWER-SANITARY-STORM EA.200 FT.
not employ any person in any manner so as m become subject to the WorkerR Compen- NER Y FEE
Z Applicant
Laws of California.Date /�s\
� WATER HEATER WNGNTIEL T /
Z Q NOTICE
rot G�LADI G FEE
NOTICE TO APPLICANT.If,ager makin this Certifcate of Exem t n ushould IfY u 1 _
y g pio.yo WATER SYSTENU REATING
CZ
'�"t became subject to the Worker's Compensation provisions of the Labor Code,you nmst 3 IL E
W fonhwim comply with such provisions or this cennit shall be deemed revoked WATER SERVICE 219
QDEP
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.Cr. PA D
V 0 I hereby hicfrm that there issued((Sec,
lending agency for me purfnrnance of Dae Receipt#
{L H Le soak for wM1lch this permit is issued(Sw.309].Civ.C.)
Lenders NameTOTAL
WLender's Address y IOTA-
y nee that I have read this y and c un and state mat the above cos relating is BUILDING FEE
h comet.I agree m comply with all city and county ordinaries and state laws relating ei QTY' MECHANICAL PERMIT FEE
1..1 z building construction,and hereby authoriu representatives of this ciUmenter upon the SEISMIC FEE
above-mamianed property for iuspectlon purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep hermless the City of Caperdno against ELECTRIC FEE
liabilities,judgme s costs and expenses which may in any way accme against said City ALTER OR ADDTO MUCH.
egmntngofthispermit. PLUMBING FEE
!nr�cquarcvo
NT U 1 ERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM)
REGU1 TIO MECHANICAL FEE
fj
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCTION TAX
g at A Contractor me EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT(TO 100.000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)'I HEATING UNIT(OVER 100,000 BTU)
❑Yes ❑No - PAID b
VENTILATION FAN(SINGLE RESID) - o
Will the applicant or future building accupant use equipment or devices which Dae Receipt# O,�
emit hazardous air contaminants as defined by the Bay Area Air Quality Management BOILER-COMP(3HP OR 100,000 BTU)
Diarist, - TOTAL:
❑Yes No BOILER-COMP(OVER 100,000 BTU)
1 have read th exammus andenals requirements under Chapter 6.95 of the Cali- AIR CONDITIONER
ISSUANCE DATE
inedm&Safe ode,Sections 25505.25533 and 25534.I uvderswnd met if me NEW RESIDENTIAL MECH SQ.FT. ) �-9�]
Wiling c oyh aassesso mauu,a..y s�.vs a5inenymaomy nm«currom fl/ Yl
cut
r ch pd;rto owesnce of o Cenlaeme o! cc try. _
12
win 'iSic
Da TOTAL ISSUEU BY:
OFFICE