99100064APPLICANT TO FILL IN INFORMATION WITHIN RED LINES -USE BALL-POINT PEN ONLV IL LI U i f IZv IIA%
CITY OF CUPERTINO BUILDING - ELECTRICAL
ERMIT N
BUILDING DIVISION APPLICATION/PERMIT PLUMBING.. MECHANICAL.
BUILDING PROJECT IDENTIFICATION-
SQOQ lm
BUILDING ADDRESS:
/02o0 ., Sr O-
SANITARY NO. I
APPLICATION SUBMITTAL DATE
OW INAMF PH E:
�I 1 Iy cify Qtr.p GJ � t
CONTRACT. 'S NAM E: `/ LIC NO:
f, ^1'
I
N/C
7
CONTROL a
C 1'1'E ?NGINEER: LIC NO:
ADDRF_SS:
/ol.i0 S. D s
CONTACT: / PHONE:
PA M (NQJ t
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❑ Consultant Fees Paid by Applicant (Initial)
BUILDING PERMIT INFO
BI�.Dj(y ELECT PLUMB MECH
LJ ❑ ❑ ❑
LICENSED CONT CTOR'S DECLARATION
1 hereby aRnn that I am licensed ander provisions of Chapter 9 (cummencing
with Sermon 00001.f Division 3 of the Business and Professions Code, and my license is
m full forte and chat
� License Clas Lic. p —� ✓J I O � e'1
_
QTY] ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑ SFDWL ❑ KITCHEN REMODEL
PERMIT ISSUANCE
APPLIANCES -RESIDENTIAL.
Date Comic ,.
❑ADDITION [I PLUMBING RE -PIPE
t ARCHITELTS DECLARATION
I undersand my plans shall be used as public recmNs
❑MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑IMPROVR ❑SWIMMINGPPAIR
IMPROVEMb:NT SWIMMING POOLS
PANELS
UP TO 200AMPS
Licensed Professtnnal
j OWNER -BUILDER DECLARATION
201-IfgO AMPS -
OVER ILO AMPS
1 hereby aMo. that 1 am exempt from the Contractor's License Law far the
0 BATA REMODEURPKIRJ2 DEMOLITION
following reason. (Section ]031 5, Business and Puifessions Cole: Any Oyer county
which requires a Permit lecorm alter, improve, demolish, or repair any awdum
SIGNS ELECTRICAL
❑ COIHR
prior to its ixsoance. also requires the applicant for such Permit no file a signed statement
that he is l iuensed Namma to the,no,sions of the Convector's License Law (Chapter 9
SPECIAL CIRCUIT/MISC.
TEMP METER OR POLE INST.
COMMERCIAL -
❑ NEyi BLDG /ADDITION 1_1 DEMOLITION
'RYr^.�NANT ❑" DLIiION
(commencing with Section 7") of Division 3 of the Husinessand professions Code),
that be is exempt therefrom and the basis for the alleged exemption. Any violation of
name Section 7031S by any applicant for a permit subjects the applicant to a civil penalty of
not nthen Five hundred dollars (8.500).
POW17R DEVICES
SWIMMINGPOOLEL IC
OUTLETS - SWITCH PI%TUREs5 A
❑ I, as owner of the ProPeny, or my employees with wages as their sole compensation,
will do the work, and the water,, m not intended.,offcred for sale (Sea OfN4, Business
and Professions Code: The Contractor's License Law does not apply to an owner of
IMPROVEA1E
❑OTHER
Paulsen, who builds or improves thereon, and who does such walk himself m though
his own employees, provided that such improvements ore not intended or offered for
NEW RESIDENTIAL F.LF.CfR f �Q
sale.If. howe,em the building or imPmvement is sold within one year of cmnpletion,the
own o -builder will have the burden of proving that he did not build or improve for par.
Pusateri
SQ. FT. FLOOR AREA
VSQ. FT.
TOTAL:
❑ h as owner of the pmpeny, am exclusively contracting with licensed contractorsk,
conswd the pmject (Sec. ]M4ve
, Business and Professions Code:) The Connors Li.
, 1
O TA
Ile,
QTY, PLUMBING PERMIT FEE
se Low does not apply to an owner of,hamspy who builds or improves Hereon,and
License lame. for such projec¢wiNucmntmean(0licensed pursuant to the Contractor's
License Law.
E]PERMIT
I am exempt under gee. , R & P C fonhis reason
1
r
ISSUANCE
ALTF.k-DRAIN&VENT-WA (
I
Owner Dam
VALUATIO
OCT 2 � 1999
WITH KER'S COMPENSATION DECLARATION
I hereby affirm under p .try of perjury one of the F.Hossm, declarations:
BACK MOW PROTECT. DEVICE
4
DRAINS- FLOOR, AREA, D.
I have and will maintain it Cenificme.f Consent toself-insure for Worker's Camper-
satin,ROOF,
as provided for by Section 3000 of the father Coble, for the Performance of the
STORIES
EC ONSTRUC'I'ION
FIXTURES -PER TRAP
work for which this permit is issued.
❑ 1 have and will mserum Workers Compensation Insurance, as required by Section
3700n1Ne Labor Code, andiepalfnrmanceofmhewo,k l ewhichtbispemloissued.
My Workers Ceepenmtinn Insurance tamer and Policy number me:
GAS - EA. SYSTEM -1 INC. 4DO[ 'LP
90
APN
GAS- EA. SYSTEM -OVER 4 (EA)
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
3 6 f o 0 3S
GREASE/INDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE
(This sating need not be completN if the permit is home hundtNdollars ($100)
or less.)
1 verify that in the performance a iasshe work for which Nis Permit is issued, l shall
ver
not employ any person in any manner to become subject to Worked Compen-
radon Laws of California. Date
Applicant I
BUILDING DIVISION FEES
GREASE'I'RAP
PLANCHLCK FEL
SEWIiR- SAN) 'T'ARY-STORM EA. 200 t1'.
ENERGY PER
WATIiH HEATER W/VFiNT/ELCCTR
GRADING FEF.
NOINCbecome? TO AP. the WoT: IL after making this Certificate of Lather iod. , you must
become subject to the Workers Compensation Provisions of Ne Lather Cale, you must
forthwith comply with such provisions a, this permit shall he deemed revoked.
WgTtiR SYSTEM?BEATING
SOILS ITiC
WATER SERVICE
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the Performance of
PAID
Dam Receipt#
NEW RESIDENTIAL PUNCH. SQ. FT.
the work for which this penal is issued (Sec, 3097, Civ, C.)
TOTAL:
Lender's Name
Lender's Address
TOTAL:
1 cenify that I have real this application and sem that the above inlirmatinn is
BUILDING FEE
QTY. MECHANICAL- PERMIT FEE
rat. l agree to comply with all city and county ordinances and sate laws relating in
building consta ction, and hereby authorize mpresenatises of this city to enter upon the
SEISMIC PCE
ahovc-mentioned pmpedy far imp', or purposes.
(We) agree o save, indemnify end kap hmmless the City of Continua. against
PERMIT ISSUANCE
ELECTRIC FEE
liabilities,judgments, costs andexpenews which may in any way accrue against said City
in c.nsegevarr el the granting of Nis permit.
ALTER OR ADD TO MECH.
PLUM RING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE R�EGU/L,Tl��E
AIR HANDLING UNIT (TO IQgg1 CFM)
MECHANICAL FEE
AIR HANDLING UNIT (OVER 10,11(0 CFM)
CONS'1'HIICTIONTAX
HOUSING MITIGATION FEE
Signature of ArlittijungConlesselor Dm
MATERIALS DISCLOSURE
EXHAUSTHOOD(W/DUCD
HEATING UNIT TO IMAX) BTU)
Will Neapplicatn.Tfietre building occupant more orhanJlc huardomeraterial
as defined by the Cupcnino Municipal Code. Chapter 9.12, it the Health and Sal'ny
rmon
Code, Se25532(x)?
0 Yes
HEATING UNIT(OVER IW." BTU)
VEN)'ILATION PAN (SING LF. RE SI D)
Will the applicant m, furor building aapant use equipment or devices which
it haeardous air contaminants as defined by the Bay Area Air Quality Management
-
Date Rescipt #
BOILER -COMP (3HFOR 100,000 BU)
T
Nitric?TOTAL:
C3 yes LFs.
BOILER- COMP (OVER 100,0111 BTU)
AIR CONDITIONER
I have Mal the hazardous materialsequlmend under Chpter fiY5 of the Cali -
fomia Health & Sultry Cade, Sections 25505, 25533 it 25534. 1 onderstemvJ Nat if the
builJingdcesnmcurrntl have alcmnt.Natitismyresp)nsibiliryondify Net pant
o"fic reym't m swhich am bemdpdortolssumeeofu Cenifc f �,ny.
I OIC z
ISSUANCE DATE
/
ISSUED BY:
NEW RESIDENTIAL MECH, SQ. Fr
Owner or auNonsd agent Uate
TOTAL:
OFFICE