99080064APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELECTRICAL
ERA11
BUILDING DIVISION APPIACATION/PERMIT PLUMBING -MECHANICAL.
BUILDING PROJECT IDENTIFICATION
BUILDINGADDRESS:
SANITARY NO.
APPLICATION SUBMITTAL DATE
OBLrIti NAMIi;PHONii:
'
CONTRACTOR'SNAM, LIC NOkri, etc-,:
T
N/C
CONTROL
CFO rECT/ENGINEER: LIC NO:
ADDRESS:
N `
PHONE:
oNTACT:BUILDING
PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
HLDG ELECT PLUMB MECH
❑ 1
X00
`,0C'
x_F
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LICENSED CONTRACTOR'S DECLARATION
1 hereby alum that 1 am E«n.ed ander provision, Of chapter 9 marrmenring
with SCCtian 9IXID) of Divi en 3 ofthe�est�tes and Fort..ions Cale. and my llcen¢]a
wt
Ili force `m Ic i_- • S-
Lieanse Licx
Dae enols '
QTY ELECTRIC PERb11T FEE
JOB DESCRIPTION
RESIDENTIAL
❑SFDWI. C1 KITCHEN REMODF.I.
❑ADDITION ❑ PLUMBING RFPIPE
❑MULTI -UNIT [3 STRUCTURAL
MODIFICATION
PERMI'I'usunecls
APPLIANCES - RESIDENTIAL
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ARCHITECTS DECLARATION
CL
I aadarxvrA my plan',ball be u,e as publle o tamis
VANIiI.S
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UPT0200AMP5
C1 INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
[I RAI RP OIIEURF,PAIR _1 DEMOLITION
[IOTHER VakG el
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Licensed Pmfcuional
OWNER -BUILDER UECLARA'1'ION
1 hereby affirm Thal I ant exempt Gom the Contractor's Liccaxe Law Ire' the
following maws. (Section 7131.5, Business and Pronasions Calc Any city or county
xblch ma,mI a permit ,amarum, alter, improve, dcrualish or.,a, aa, druatre
prinnotu isetar,odso myrI Cheapplicam for%uch pcimiun file aaigned statement
that he is premed pursuant m chaptaalslnrnaf the Comrarors Licenm I.e.(Chapter9
(cmmmoo,ing w ah Scaion 700(o of Diviaion3 ofthe Bossiness and Prcmasions Coos) or
that he is exempt therefrom and the basis I'or the alleged eaemptinn. Any,violation of
Section ]031.5 by any applicant for a permit subject% the applicant to a civil penalty of
oat are thdollars, Ili.. five hundred dolla(S5(H).
ua owner nl lbcpmpeny,unny entployetis wliwngn us ihcireolemn+pnnmtion,
will dothework, and the staotem iamdarauadodiocdomd( wIa(SaxJOd4, Bushes
2014NX)AMPS
OVER l(XX)AMPS
SIGNS ELECTRICAL
SPECIALCIRCUIT/M ISC.
r
� l�
TEMP. METER OR POLE INST.
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑FOODSERVICE.
IMPROVEMENT
IMPROVEMENT
POWER DEVICES
SWIMMING POOI,IiT,ECTRIC
u: w
a Z-
and 1'nffcssiom Cale. The Contractors License Law docs not apply to an weer of
prnpeny who builds or improves thereon, and who does such work himself or through
OUTLETS - SWITCHES - FIXTURES
his own employees, provide That such in+pmvemcOx are not intended or altered far
nnle lLhowever. the buildingar intervention is sold within one yearefrnmplction. the
owner -builder will have the burden of proving that he did not build or improve for per-
NEW RESIDENTIAL ELEC'i'N SQ FT,
SQ. Ii-Bltt't�
LSQ. FT.
,lose of sale.).
rte-m
1, as er of the pra,my, am caclusivcly et noose , with licensed conmmton to
D
TOTAL:
+Inwet the Pmjecl (Sao 7(M4, Hmiro s and Poaessions Code.) Lie Contractor%Li-
Law does not apply to an owner of property who builds or improves tlmmon and
AUG 1 0 1999
Q TY. PLUMBING PERMIT FEE
wfise
o contracts for such pmjcds with s amtracmrrv) homo l punuam to the Conirsour'%
PERM] I' ISSUANCE
Lacmc Law.
❑ 1 an+ cmempt uedcr Sa. , It& P C for Thismeson
_
ALTER — DRAIN h VF..YI'—WATER (EA)
Owner Date
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROIEC, DEVICE
1herchy alfirm under penalty of Perjary one M the fallowing declarations:
DRAINS— FLOOR. ROOF, AREACONU'
I Inveand wlll maintain a Certificate of Corvcataosell'-inure for Worker's Coronet-
tion, as provided for by Section PW of the Labor Cade, for the performance of the
STORIPS
TYPE CONSTRUCTION
wad for which this permit is issue.
FIXTURES — PER'I'RAP
have and will maintain Workers Cm,vmn rtion Insurance, as moluimd by Section
GAS —EA.SYSTEM-I INCA DOrLETS
391X1 Mflo, Labor C It. telO ,soder sof the work l or hie b this pcnnit lx uxucd,
My Woryryo� {{d�ry aro Insurance carrierand Policyasp C�
OCCGROUP,
APN
1
GAS— BA. SYSTEM OVER 4(EA)
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Cam'erInawlTlfN z fool... Nu.�O�H� a111R
1
A
C17RTIFICNIIi OP EXEMPTION FROM WORKERS'
COM PENSATI ON INSURANCE
[Thisswtion aced nrn b+cnmplcte if the pcnnit l'Ioronehundial Jollan 15100)
or Incl
GREAS Ed NDUSTR L WAS'T'E IN'EERCEP'I OR
BUILDING DIVISION PETS
GREASETRAP
pUSNCHF.CK FEE
SEWER — SANITARY — STORM EA. 2W ME
2 z
I certify that in the performance of the work for which this permit is issued, l shall
not employ any person in nay manner sat as I, becnmo,uhjcct la the Worked Cnmpca-
'Blinn haws of California llrc
Applicant
ENERGY FEE
WATER HEATER W/VENT/ELECTR
GRADING FEE
NOTICE TO APPLICANT: IL after making this Ccnificme of Exemption, you should
Icumm %ubJcel it, the Workers Compensation pmvi,ions of the Labor Cee, you must
Rmbwall comply with such prnnu ons o. Phi, peora,,lhall be dev voce—lord,
CONSTRUCTION LENDING AGENCY
hereby wool, rte that theta iso tel(Sor. 30 lending agency for pedonwnce of
Ilia woeNa which this De'rmit is lowed (Sec. 3119]. Civ. CJ
WATER SYSTEMUTREATING
y
a ;
a�
7 Z
U Q
SOILS 103E
WATER SERVICE
PAID
Date Reeciptx
NEW RESIDENTIAL PCMB. SQ. FT.
TOTAL:
O U
F1
h
U 2
Lender'' Name
l<nder's Addmxv
I certify that 1 have reed thi%applicaion and arc that the aMivc infoimaian is
correct. 1 agree to comply with all city and connry otdin:mces and state laws mlatiag to
htildingmnsarucdon. and hereby truth mprettnwtives ofihi aqu, caterupon the
shovc-mentioned prnpcny for iispection purposes,
(Wc) agree to save, indemnify and keep harthe City of Cup ,
mless Cupertino again
TOTAL:
QTY. MECFIANICAI. PERMIT FEE
BUILDING FEE
SEISMIC FEE
.PERMIT ISSUANCE
ELECTR IC HE
habilities,judgments. costs and expenses which may in any way accrue against said Cay
sagocncc nl the gmario, of thou permit.
ALTER OR ADIJ'10 MIiCfi.
PLUMBING HE
AIR HANDLING UNIT (TO IU.pCFM)
IX
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU Ii REGULATIONS e
MECHANICAL FEE
AIR HANDLING UNIT (OVER IO.(IOO CFM)
CONST RUCTION TAX
Pi�
Signature of Appllcant/Contratun Data
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD(W/DUCT) -
14OUSING MITIGATION FEE
HEATING UNIT CED JBIL,W B' FU)
Will the applicant or future building Occupant store or handle hramalosmawtia)
as defined by the CuNraro Municipal Code. Chapter 9.12, and the Health and Sidmv
Code. Steelton 25532m)?/
HEATING UNIT (OVER 100j)(I) BTI!)
❑Ye' .o
Will the applicant or future Molding occupant use equipment or device, which
ithnmeouaair coma min:atwmdctinedI, t he flay All Air Qwlhy Managancnt
tic/
❑ Yu �N
C)
PAID ' A1�
/_ A t W
Date Receipt x / on
(n
VENTILATION FAN (SINGLE RLSID)
BOILER- COMP IMP OR IM.0o) BTU)
TOTAL
BOILER- COME (OVER EW,WU BTU)
AIR CONDITIONER
I have read the moodooxmu¢nuly is under Chirpier of the Cal,
cquiremrn p
ISSUANCE DATE
NEW RESIDENTIAL MECH. SQ. FT.
orma 11.1, Safety Calc. Sermons 255113, 25533 tad 25534. 1 understand that it the
Jbitildinga ntly have a tenant, that itis my rmpormbillty to notifyii¢ism:mix
of a Ce t nc
a
SSUED BY 9,
"'amhsr_ agent Dam
1'O TAC:
OFFICE