99100159 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY l
CITY OF CUPERTINO BUILDING ELECTRICAL PE MTNO.
BUXUING DIVISION APPLICATIONMERMIT PLUMBING-MECHANICAL.
I BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATE
ZZ�I`l � C�1GKs;T Ni�L- � to
NER'S NAME: PHONE: CONTRA 'S N LIC NO:
.1 N/C CONTROLM
ARCHITECT/ENGINEER: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ �J
LICENSE)CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
qOO with Section 7")of Division 3 of the Business and Professions Cade,and my license is RESIDENTIAL
UDC in PERMIT ISSUANCE
�W� full force and eBecr, SFDWL ❑KITCHEN REMODEL
Q yUzU License Class Licit APPLIANCES—RESIDENTIAL MUFF ION [I PLUMBING RE-PIPE
NQW (late Contractor
.10. ARCHITECTS DECLARATION PANELS ❑MULTI.UNIT ❑STRUCI'l1RAL
Z p H Z 1 understand my plans shall he ued as public records MODIFICATION
4" UPT02MAMPS [I INTERIOR ❑CHIMNEY REPAIR
F�._q Licensed Prule,dinil 201-1g10AMPS IMPROVEMENT SWIMMING POOLS
Y C 6 I heteby off int that 1 em a elmpe nscr tb Contractors License Law for the OVER I000AMP5 ❑BATH REMODEL/REPAIR D DEMOLITION
igyx506 U following reason.(Section 1031 5,Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 K y which requires a Permit to construct,alter,improve,demolish.or repair any structure
primmitsissuance,almonifiresthctieficant fwxwh permit m 6leasigned statement , SPECIAL CIRCUITNISC.
tt
�y tbut heislicensed Pursuanothe previsions ofthe Contractors License Law a7hapter9
W pJ'p0 (commencing with Section 7K10)of Division 3 of the Business and Professions Code)or TEMP.METER OR POLE INST. COMMERCIAL:
tY IS cy that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADDITION ❑DEMOLITION
XIN Section 1031.5 byany applicant fora prrmit subject theapplaterama civil penalty of POWER DEVICES TENANT ❑FOODSERVICE
F- p„ t more than five hundred dollars(E500). THE'RV
EMENT
6
DK 1.as owner of the pntpeny,mmy, employees with wages as their compensation, SWIMMING POOL ELECTRIC
' q will do the work,and the structure is not intended oroffemd for sale(Sec.1044,Business
6 3$ and Professions Cite:The Contractors License Law does not apply m an owner of OUTLETS
—SWITCHES—FXTURF_S
property who builds or improves thereon,and who does such work himmlf or through
his own employees,provided that such improvements am not intended or offered for NEW RESIDENTIAL ELF.CTR SQ FT.
sale.IG however.the building or improvement is sold Within one yew of completion the Q.FT.FLOOR AREA SISQ.FT.
enm-builder will have the burden of proving that he did not build or improve for pur-
pose ass(axwe
❑ Las owner of the pmpeny,pm exclusively contracting with licensed contractors m TOTAL:
construct they project(Sec.7044.Rosiness and Professinnx Code:)The Conwaor's Li-
cense Law does not apply m an owner of property,who builds or improves therein,and QTY. PLUMBING PERMIT -who commas forsuch projects with a commnor(s)licensed pursuanuo the CommcmrsLicense Low. 1999
❑IameacmptundsrSec. ,B&PCfmthisreason PERMIT ISSUANCEALTER—DRAIN&VENT—WATER IEA) VALUAT
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the following declarations:
❑I havemd will mainmin a CMificme of Conowas self-insure for Workers Co.,.- DRAINS—FLOOR,ROOF.AREA,COND. STO PE CONSTRUCTION
satinn,as provided for by Section 3100 of the Labor Code,for he performance of the
work far which this pemtit is issued, FIXTURES—PER TRAP
1 have and will maintain Worker's Compensation Insurance,as required by Section
3100ofthe Libor Cade.forrheperfortnanceofthe work forwhichthispemtit is issued. GAS—EA.SYSTEM-I INC.4 OUTLETS OCCGROUP P�
My Worker's Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: GAS—EA.SYSTEM-OVER 4(EA) Lt
A
CERTIFICATE OF EXEMPTION FROM WORKERS' �l
COMPENSATION INSURANCE ORfASEIINDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEES
(This section need not becompleted if the permit is lesions,hundrtddollars(EI00) GREASETRAP
nr
less) PLANCHECK FEE
I certify Nat in the perrortnunee of the workfor which Nis permit is issucJ,I shall SEWER—SANITARY—STORM EA.200 FT.
•not employ any person in any manner so as m become subjccr to the Workers'Compen- ENERGY FEE
O Z s cion Laws of California.Date 1 WATER HEATER WNENT/F.LEM
Z Applicant GRADING FEE
rs to NOTICE TO APPLICANT.If,ager making his Certificate of Exemption,you should WATER SYSTEM1DU ATING
F become subject the Workeo
rs Compensation provisions of the Latin,Cade,you must SOILS FEE
n
Lakl forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
= z
CONSTRUCTION LENDINGAGENCY NEW RESIDENTIAL PLMN. SQ.FT. PAID Date Receipt It
1.1 I I.,which
lh his
thin Nim is a cmoSer.30 lending agency for the performance of
H
Lenders
for which this permit is issued(Ser.3097,Civ.CJ
Lender's Name TOTAL:
V Lenders Address TOTAL:
1 1 certify That I have read this application and vale that the above information is BULLRING FEE
✓ VI correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U Z building consenetion,md herebyauthoriase
cmpreanin es ofthis citym entcTupon the SEISMIC FEE
above-mentioned property for inspection porpoises. PERMIT ISSUANCE ELECTRIC FEE
(We)agree to saw.indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any wayawmc against said City ALTER OR ADD TO MECH.
consequence of the granting of this permit, PLUMBING FEE
rAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO HLOW CFM) MECHANICAL FEE f
SOURCE 9/5ATIONS.
AIR HANDLING UNIT(OVER IO,(MIO CFM) CONSTRUCTION TAX r
Sigmt sof Applic�iam/CCoont---racmr Date) EXHAUST HOOD(WIDUCf) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will[heapplicam in future building occupant store ar handle hmmdous mmenal I HEATING UNIT(TO 100,000 BTU)
as definel by the Camino Municipal Cale,Chapter 9.12,and the Health and Safety
Cade,Section 25532(x)? HEATING UNIT(OVER]hit,"BTU)
[I Yes X1 No VENTILATION FAN(SINGLE RFSID) PND -
Da¢ ReceiprN
610 Will the applicant or future building occupant use equipment or devices which
emit havmlous air contaminants is defined by the Bay Ann Air Quality Management BOILER—COMP(3HP OR 10(1,000 BTU) TOTAL:
Diana^
❑Yes KNn OILER—COMP(OVERUX1i 0BTU)
I have mad the haurdous materials requiremena under Chapter,6.95 of the Cali- ' AIR CONDITIONER ISSUANCE DATE
fomes Health&Safety Code,Sections 25505,25533 and 25534.1 undersand that if the NEW RESIDENTIAL MECH. SQ.EF. r I '/
building does not currently have a tenant,that it is my responsibility to notify the oecuten - )
of the require a hath musthm pnnnninuanre of a Cerilicue of Occupancy. y
�Z �pn,_ to-1C—S9
Owner m dam,adogent Date TOTAL: ISSUED BY:
OFFICE