99120114 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY girl �-nI J
XOWNERS
PERTINO BUILDING-ELECTRICAL T
APPLICATIONIPERMIT - PLUMBING.MECHANICAL �]I
IVISION I - 'BUILDING PROViLTIDRMOTICATION
IiSS. SANITARY NO. APPLICATION SIJIIMITTAI.DAU
Aow s D a 12zv
PHONE: CONTRACTORS NAME: LIC NO: CONTROL isoD
VIP INIiF.R: LIC NO: ADDRESS: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
�J�//�'J✓ P�o��S X98 -Y8/� ❑ ConsullantFees Paid byApplicant(Initial) DG ELECT P.uMB MECH
❑ ❑
LICENSED CONTRACTOR'S DECLARATION QTY EI.ECTRIC PERMIT FFB
I hereby affrm that I nm licensed under provisions of Chapter 9(commencing t JOB UESCRIP PION
Cy5]0Z with Section 9000)ul Ulvislo0ofthe Budiessmnd Profes'sio'ns Code,upndlny licunw is PERMIT ISSUANCE RR IIDF-NTIAL'
F00 in full force and effect. �6B ❑SPDWL KITCHEN REMODEL
aUF Lmrnu Cl 4ss�LiC.M
¢ U /p_q G-96 APPLIANCES-NISIUIiNTIAL C1 ADDITION PLUMBING RliI'IPE
F Z W Dane Cnmmemr
rq¢y <� ❑MULTI-UNIT ❑STRUCTURAL
ARCHITECTS DECLARATION PANEI S
I'D Ver IunJersmnd my plans zhell beuudapub'at rtamds MOD1171CATION
CZ4 UPT0200AMPS ❑IN' :RIOR ❑CHIMNEY REPAIR
`:,rrnF�j Cleansed l'ndessinnul 201-111011AMP5 PROVBMHNT SWIMMING POOLS
�Se OWNER-BUILDER DECLARATION OVER 1000AMPS 'H REMODEUR17PAIR ❑DEMOLITION
C w¢ I hereby anirm that 1 oro exempt from the Contractors License Law for the
gyp(,O y U following reason.(Section]0315,Business and Professions Coda Any city or county SIGNS ELECTRICAL ❑0TH.R
If i+W y which mquous a permit to amepvcr,alter,improve,demolish,or repair any souclurc
F��� pdorains iasuance,also customs Ne applicantfor such pemminn filevsigned statemcnn SPECIAL CIRCUIT/MISC
� } that he is licensed pursuant to the provisions of the Contractor s License Low(Chapter 9
Hca (commencing with Section 90smof Dlvi,ii Sof the pusinasm trod Pmfessbns Chic) TEMP M HTER OR POLE I NST. COMMERCIAL,
a a C dint he is csempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDGIADUI'fION ❑DEMOLITION
Section 7031.5 by onyapplimMufor it pemtiwuhjst. he applicant o acivil Penalty of POWER DEVIC&S'1 ❑THNANT FOOD SERVICE
.F,2q not romeden fire hundred dollar,($500). IMPROVEMENT
Sp El as owner of the property,or my employees with wages as their sole compeamtion, SWIMMING POOL ELEC'T'RIC
will do the work,and tllesrvaurc is not intended or offered for sale(Sec.9044,Business ❑OTHER
ID 3 m and Professions Code:The Compatriot's License Law does not apply to an owner of OUTLETS,-SWITCHES-FIXTURES L_
property who builds car improves Meeme,and who dors such work himself or through %
his own employees,presided that such Impmvemcns are not intended or offered fur NEW RESIDENT 1,L ELECTR IT.
sale.If,however,the building or improvement is sold within one}caret campktion.the �I SQ IR.FLOORARErA'r S/SQPf.,
.
owner-builder will have the burden of proving that he did not build or improve for par- t f.J
pnseofsale.). TOI'AU O EC 2
I,as owner of the property,um exclusively contacting with licensed cnnuactors m O
1 conswtn the proper(Sec.9B4L Business and Professions Cede:)Ino Contractors 999
nee Law does not apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PERMIT', FEE JJJ
who mmurecs hor'such projects with a wnpacmr(s)licensed pursumao Nc Commowr's ❑
License Ww. PERMIT ISSUANCE ❑V
1 am cartma under See .B&P C for this reason is ��..,
AL'flili-DRAIN&VENT-WATER(1>A) VALUATION
Owner Umc
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE LSA i
I hereby anion under penally of perjury one of the fallowing declarations: lam.✓
I have and will maintain a Certificate ofComent to self-insure for Worker's Cmnpem- DRAINS-FLOOR,ROOK AREA,CON D. S'PORIES TYPE CONSTRUCTIOr
sation,a provided for by Section 3900 of the Labor Code,for the performance of the -
war
su
kf which this Permit is ised. FIXTURES-PER TRAP
hmva mnJ will ode,fon Workers Cumutifth is l kfor which
h his per by South,.
1900 of the Luton Cmxlc,for the perlormdnce of the work for which this permit is issued. GAS-IiA.SYSTIiM-I INC.4OUT'LIi TS OCC GNOUP APN
My Work�(s��y Te tan naunncec rand Policy yml1yyr 91�l�
Currier:.}/ � g✓ c
Policy No:P(TO G(3 GAS
-EA.SYSTEM-0VER4(BA)
CERTIFICA9'11 OF EXIIMPPION FROM WORKERS' GREASU1NDU5TRL WAST F:INTERCEPTOR
COMPENSATION INSURANCE HUILIIING DIVISION FT ES
PThis section need not lccompleted ifthe permit is Pursue hundred dollars($1000 GREASH'TRAP
ar loss.) PLANCI3ECK PCF.
I comity that In the perfornwnce of the work for which this Permit is issued,l shall SEWER-SANI'T'ARY-STORM EA.200 FT.
not employ any pe�}1n in any manner sous to become mthnot to the Workers'Coinpen- - ENEROY FEE
0 ssaimi La Calff�grmaiwate WATER HEATER W/VENT/ELECfR GRADING PFE
7
AC
a' ((111111 �{l'
G rjI NOTICE TO AP CANT:IL alter making Nis Cenifcme of Exemption,you should WATER SYS'fliM/1'REATING
f+ ; Mame abject m the Workers Csmpla setiom provisions of the Isbor Code, commit SOII S FEE
Wforthwith comply with such provisions or this permit shall he deemed revoked. WATER SERVICE
Q
0.
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMIi. SQ.FT. PAID
U � Ihercby anion Nnnhere isaconstmnion lending agency fm Ne performance nP Date Receiptp
H the work for which this pemdt is issued(Sec 3099.Civ.CJ
TOTAL:
C) ti Lender's Name
LU[1 Lenders Addfess TOTAL:
I really that I have mad this application mad cam that the above information is BUILDING F17117
fa/3 emrren.I ngreemcnmPly with all city and county nrdinanscs and mem lows relating m QTY. MECHANICAL PERMIT '1 FEE
V Z building conswction,undhereby authorize representatives of Nis city toentcrupon the SEISMIC FEE
idsor-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupenimo against ELECTRIC FEE
ludilities,maigmentn,comsond expenses which may Mary way morin againsaid City ALTER OR ADDTO MECH,
PLUMBING FEEin consequence of the graining of this pcatri
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CITE) MECHANICAL FEE
SOURCE,REGULAI IONS.
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature id Applicant/Conwcmr Date EXHAUST HOOD(W/DUC'D HOUSING MITIGATION FTE
HAZARDOUS MAI FOALS DISCLOSURE
Will the applicant or future building occupant store or handle hanrdns material HEATING UNIT(TO 100,000 BTU)
as defined by to Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Suction 2553200? DEAL NO UNIT(OVER 100,000 HIT LE
El Yes ED No VENTILATION FAN(SINGLE REST DI PAID perm Raeipp
Will the applicant or home building occupant use equipment or devices which pO1LPACOMP(3HP OR 100,000 111 U)a hamMsus air contaminants us defined -
by the Play Area Air Quality Management 'TOTAL:
I ismer❑Yea ON. BOILER-COME(OVER 1110,000 BPut
I have read the haaam
nloms uterulsfolam
egens under Chapter 695 of Ne Coli- AIR CONDITIONER ISSUANCE.DATE
forma Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.FE
building does non currently have a normal.that it is my responsibility to notify due comfort
of Ncrequo,smdwlmichmosibc stprain.liaesail Ccnificate f(kcuponcy.
2-�o-Q y
Owner o hurised agent Date TOTAL: ISSED BY:
OFFICE