99120110 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY '
aU , W�
CITY OF CUPERTINO BUILDING-ELFCTRICAI. �T-IPE Nb'Fe
BUILDING DIVISION APPLICATION/PERMIT PLUMB NG-MECHANICAL
IIt111,DIN0 PltOJEC'1'IDENTIFIUATION'r' dgwp
BUILDING AUDRE.SS: - SANITARY NO. APPLICATION SUBMIT-1"AL DATE
OWNpJk;SNAMIi: YHONI?; 4RpR'6 AM': LIC NO:
T ' NIC CONTROL#
CHI= INFER: LIC NO ADDRESS ❑
CONTACT: PHONIi: BUILDING'PERM IT INF
❑ Consultant Fees Paid by Applicant(initial) BLDG Ii1.liCf 1'1, 1 MECH
❑ ❑ ❑
LICENSED CONnsed under Provisions
CON QTY ELECTRIC PERMIT I PEE
I hereby nllirm that 1 oro Ifthc B under provision..of Chapter 9(commencing JOB DESC PTION
O=Z
with Section 9TXXq ofDivisi.n3 of Me Business anJ l'ndessions Cale,and mylinnsc is RESIDENTIAL
in bill force and.thee. PERMIT ISSUANCE
�FUU License Class Lic.# CSFDWI. CKITCf1EN REMODEL.
NQWIt, Date Comommr APPLIANCES-RESIDENTIAL CADDITION El PLUMBING RE-PIPE
ARCHITECTS DECLARATION PANELS El MULTI-UNIT CSTRUCTUkAL
Z O rnz„ I understand my plans shall be used as public records MODIFICATION
CNFW Licensed
UP'TO 21l0AMP5 F1 INTERIOR ED CHIMNEY REPAIR
r�,. Licensed Pr.les.anal iIMPROVEMENT'
201-1(XX)AMPS
C`cmj
OWNER-BUILDERexemtDECLARATION ❑SWIMMING POOLS
tY�'6 1 hereby.form that I am exempt from the Contractors License Law for the OVER IfX10 AMPS L1 BATH RF.MODF.VNEPAIR C DEMOLITION
aW V following reason.(Section 9131,5,Brous and Pmfesalore Gale:Any city re county SIGNS ELECTRICAL ❑OTHER
a+y which requiren n permit to cnnetmet.alter,improve,demolish or repair any someone e
prior to its issuance, Ne applicant fn such Permit file a signed �/�. C
y gee SPECIAL.CIRCUIT/MISC.
that he is licensed Pursuannn the provisions of the Contractors Licence Law(Chapter 9
5p0 (commencing with Section 9000).17Division Sof Ne Halt....and Prole{,Ions Cooll TEMP.METER OR POLE INST COMMERCIAL'
d m that he is exempt Iheraf cut end the ba,i,for the alleged exemption.Any 0o noon of ❑DEMOLI'T']ON
Section]0315h any for permit subjects the applicant to a civil
E:1 NEW I{LOO/ADDI'T'ION
Y P p pp Penalty of POWER DEVICES
H z} at mare Nan five hundred dollars($500). - c❑TENANT ❑FOOD SLI VI
Q ❑1,ns owner of the progeny,or my employees with uages as theirsnle compensation. SWIMMING POOL ELECTRIC .IMPNOVEh
will do the work,and The stmenm o
is not intended forsaln(See 9044,Hasings
m ❑ ^ryT/)--^/-�,
and Profession.Code:The Contractor's License Law docs nm apply m an owner of OUTLhI'S-SWITCfIIIS-FIXSTJRF.
proper who builds ar informational and who does such work bountiful...top,
his own employees,provided that such improvements ore not intended or offered far NEW RESIDENTIAL F,LEC R US
sale.lf.however,lite building ser impmvenum is snlA wiThin one ycarnfcompleti�n,the SQ,IT FLOOR AREA $ISQ,4T.
owneebuilder will have the burden.f proving that ha did not huild or improveor por- '�"�.�s,� -•.
,,,a.1 sale J.
❑I,e.x owner of the progeny,am exclusively connecting with licensed comments to TOTA
nnn.uvct We project(Sec.704y Busing,and Professions Code:)The Control Li-
•.e Law does nm'lot applyon owner of prr imre
opewho builds or preves theon,and QTY. PLUMBING FEE';
Li-
colter,
contracts fol such projeetx with acomentn(s)licensed pursuant to the Cordial - DEC
License taw. PERMIT ISSUANCE 1999
❑Iota exempt under Sec. ,B&PC(.obis reason
OwnerDom ALTER-DRAIN as VENT-WATCH(EA) VALUA'1'B
WORKERS COMPENSATION DECLARATION RACK PLOW Pk(H'ECI'.DEVICE
1 hereby affirm unJer PcnalTy of perjury one of the following declarations:
I have and w 11 maintain.Certificate ofComemb,set Nimure for Workers Catnpen- DRAINS-FLOOR,ROOF.ARBA,COND.
sailor,as provided for by Section 3900 of the Labor Code,for the Performance)I The STORIES -T PE CONSTRUCTION
weak far which this peomit is issued FIXTURES-PER TRAP
❑1 have and will maintain Workers Cooperation.[overall as required by Secaan
3900ofthe Lothar Code,for the pert once ofthe work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OIG LETS OCC.GROUI' APF
My Werke' m alit Insure .carie.and Policy nur9bgr nm:
Crrriee Policy Nn `•rpt Z/ 4 y GAS'_HA.SYSTEM.OVER 4(EA) ..
CERTIFICATE OF EXEMPTION FROM WORKERS'—
COMPENSATION INSURANCE GREASIJINDUSTRL WASTE INTERCEPTOR
(Thi,section need not he completed if The permit is fomoe hundred dollars ISIW) - BUILDING DIVISION FEES
err Icee,) GREASH TRAP
Iccnif,that In Nc rfomnnceofllevarkfor which Nis 1'LANCIIECK FCC
Y an Permit is isx'Cour erll SEWER-SANITARY-STORM EA.2W FT.
not employ any person in any mm�ner so as t.become suhjecnn the Workers'Compen-
O z ssubject m Worker's Compensation
laws of C.lifamia.Date
yyP O Applicant 1 WATER HT/EL
EATER W/VENIiCTR ENERGY PEf:
GRADING PEE
t•-t M NOTICE TO APPLICANT:If,atter making Nis C'rtiUnfairme of Exemption.you.chnaiJ WATER SYSTEM/I'RIiATING
become subject the WorkCompensation prov s of the IaCade,you moa SOILS FEE
[[7 forthwith comply with such provisions or his permit shall be deemed revoked. WATER SERVICE '
z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAI,PLMB. SQ.PT. - PAID
V 0 Thereby affirm that there is a constmcoion lending agency for the perfornance of Date Receipl#
The work far which Nis Permit is issued(Sea.301.Ci,C.)
Leader's Name
L) Lender's Adl TOTAL: 'TOTAL:
G1 certify That I have rend this application load state That the aMrve information is BUILDING FEE
H cefrect.I agree In comply with all city and county ordinances andstate laws Telating To QTY. MECHANICAL PERMIT FEE
U Z building cemnuction,and hereby audience representatives oRhis city To enter upon the SEISMIC FEE
ahmo-menl9oned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Catarina against PERMH ISSUANCE ELEC'T'RIC FEE
Iiahilities,judgmentx.emotional expenses which may inaay saynecrueagaamt said City ALTER OR ADD TO MECH.
in consequence of The gmming of this permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,(1011 CFM)
SOIIRCF.RC` �. MECHANICAL FEE
�d•,��9I AIR 14ANDLING UNIT(OVER R),(XI1)CFM) CONSTRUCTION TAX
Si o pplicanTlCo mcum - Date EXHAUST HOOD(W/DUCT)
a l 2DOUSMATI?RIALSDISCI.OSURI? HOUSING MITIGATION FEE
Will the lm rfumre building tnconalmorem handle hawNnumatedol HEATING UNIT M1 I doW01{'1'tl)
as cleaned by the Captain.Municipal Cate,Chapter IL 12.and the Iieahh and Sall
Code,Sell 25532nd? HEATING UNIT(OVER 1 WdXXI HTU)
❑Ye. ❑No
VENTILATION FANS I NGLE RlIS l ll) PAID -_
Will Then affliction of future building occupant equipment or devices which Dote Recelpt a
Pp gbcca muse.ui
ntThemarroll air wmamm
inas as defined by Nc Bay Arta Air Quality Management BOILER-COMP CHIP OR 100,000 BTU 1
1 strict?lrict?ict?
TOTAL
:
CY.. CN. BOILCk-UDMP,(DVER 100.1NI11BTU)
1 have read the haroNnus matelots mryiremnaks under Chapter 6.95 of the Cali- AIR CONDITIONER
form Health&Safety Cade,Sections 25505,25533 and 25534.I understand That if The ISSU ATE
building does not currently have a renant that it is my responsibility In notify Neaccupnnt NEW LIPS[DENTAL MECH. SQ,FT.
of the rermina nT.which most ho met prior to issuance of o Cedificam of OeO punct'.
Owner or automated agent Data TOTAL:
ISSUED BY.
OFFICE