99120122 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY IoZ aa.
CITY OF CUPERTINO RUILDING-ELECTRICAL PERM
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL 50001
BUILDING PROJECT IDENTIFICATION
BQILUINO ADDRESS: SANITARY NO. APPLICATION SUBMI'PPAL DATE
1 ^
OWNERSµ9p�� PI{UNE: CONT T R'S Nroli A LIC NO: L
L /J N/C CONTROL#
CHITECDENGINEER: LIC NO'. ADDRESS —'P ❑
CONT Cr: PHONE: BUILDING PERMIT INFO
Ll0 _73q 051 /.r ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT UMB MEC
1•WLICENSED CONTRACTOR'S DIE/CL DECLARATION 1Y✓ V� QTY, ELECTRIC PERMIT FEE ❑ ❑
I herehy affirm Nnl1 am licensed under provisions ofChapter 9(commencing JOB DESCRI ON
Oa'z with Sedion711f1(p of0ivisinn3nftbe Business and roIeve as Code.and my license is RESIDENTIAL'
Wore, PERMIT ISSUANCE
Flyi` in full stiseand effect./� �k/� �/I ❑SFDWL ❑KITCHEN REMODEL
aVUE' Data �Cla I-��-OPV—Coop w APPLIANCES-RESIDENTIAL El ADDITION El PLUMBING RE-PIPE
tiW Date 1O] �L-!-! Contrnctor
ARCHITECT'S DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
z 000 I understand my Elans,aall be used as pablicpecoN, PANELS MODIFICATION
p,z,4-M UPT02MAMPS L1 INTERIOR [-]CHIMNEY REPAIR
Q[rJ f"pl Licensed Professional
OWNER-BUILDER DECLARATION aI201-IO AMPS IMPROVEMENT SWIMMING POOLS
C i1
W6 I hereby affirm that I am exempt from the Conte cmr's License Law for the OVER 1800 AMPS ElRATH REMODELMEPAIR ❑DEMOLITION
iqqi55 ti V following reason.(Section 70315,Business and Professinns Code:Any city ar,tormay SIGNS ELECTRICAL ❑OTHER
1++3 LL y which requires a permit to construct,alma impmm,demolish,or repair any seucmrc
I prior to its Issuance,also requires the applicant for such permit to fi le a signed statement SPECIAL CIRCUIOMISC.
999that be is licensed pursuant to the provisions ofew Contmdor'c License Law(Chapter 9
�8r (tarriming with Section 7mdpof Division 3 offie Business and Prof sionsCmk)m TEMP.METER OR POLE( L COMMERCIAL'
F e e' that ho is exempt Ennead..and the basis for the alleged exemption.Any sialaden o[ ❑NEW BLDG/ADDITION ❑DEMOLiTION
la• Sectien 70315 misubjects the any applicant for a pert subjthe applicant m a civil penalty of POWER DEVICES
�m 'O.IM ROT ❑FOOD SERVICE
key
put more owner
❑vehunoperty, rmyepl MP60VF.h N��
no ^
will
1,as
work,the moperty,ormyemntendes with wages as their sole wmpensudon, SWIMMING POOL T I N /
9(a will do the work,and theswaure is not intended oraffered for sale(Sec90no Business ❑0 ER.
and Professions Code:The Contractor's License Law docs not apply to nn owner of OUTLETS-SWIT IgXT I _l -
�' property who builds or improves thereon,and who does such work himself or through
his own employees, vided that such improvements proveents are not intended or offered far
proNEW RESIDENTI ELJC
sale.If,however,the building or improvement is sold within one year ofaxmpletion,the ae`�WSQUFLQ[ BA E/SQ.ET.
caner-builder will have the burden of proving that he did not build or improve for put-
pose of sale.).
❑ oner I,as wof the property,am excluvively contracjl ,with licensed contractors to TAI- R V
construct the es nota(Sec.]fano Business and rty who
builds
Code:)The Contractor's Li-
cause
i-an owner and QTY. PLUMBING PERMIT FEE
who contracts for such projects wiEtpconeocmr(s)licensed pursuuntm the Contractor
License Law. + PERMIT ISSUANCE
❑ I am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Data e�
WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT.DEVICE 6OI O r��
1 hereby off mi undo penahy of ofCon ono of the following declarations: V
(have and will main mina Cion fic37 to of the Labor
Code,for therarrom'e Camper- DRAINS-FLOOR.ROOP,AREA,CONK STORIES TVPE CONSTRUCTION
satior,as hick this
for by Section J]00 of the Lahor Code,for the perfnrmanca of the -
Wo
tor which Ibis pemtit ie ismer'. FIXTURES-PER TRAP
have and will maintain Workers Compensationhi required by Section 1
3700 of the Labor Code,for the performance of the workrk for for which
IM1is permit is issued { GAS-h;A.SYS"fEM-I INC.4OUTLETS OCG GROUP APN
My Worker'4�ao p�yPif Insurance copper and Policy nu�P1)Gf /�-
Carrier: 14f9�/r LS Policy Na: 1(JMC- 7aJ GAS' EA.SYSTEM OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE CREASEIINDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
IT section need not be completed lithe pemtit is forone hundred dollars($100)
T
or less) GREASE TRAP PLANCHECK FEE
I certify that in Cheperformanceoflhe wmk for whichthis permit is issued lshall SEWER-SANITARY-STORM FA.200 FT.
not employ any person in any manner so as to become object to the Workers'Compeer- ENERGY FEE
z ,Z Indian Laws of California.Date WATER HEATER WNENT/ELECTR
Applicant \ GRADING FEE
h NOTICE TO APPLICANT:IL after making Otis Ceniparm of Exemption,you should WATER SYSTEMUREATING
a �+ become subject to the Worker's Compensation provisions of the Labor Code,you..it SOILS FEE
W ,may fnnhwithcnmply wat...ch provisions or this perreashall be deemedrevoked. WATER SERVICE.
CD O
CONSTRUCTiso [ON LENDING AGENCY NEW RESIDENT[AL PLMB. SQ.Ff. PAIL)
V 0 (hereby ulEnn NNm at eiso construction lending agency for the Performancef Date ReselptM
W the work for which this permit is issued(See,3097,Civ.C.)
O Lender's Name TOTAL:
U Lender's Address TOTAL:
�' a I certify that 1 have read thin application and store Nvuhe above iuformmion is BUILDING FEE
rF-t fn correct.1 agree it)comply with all city and county ordinances and state laws adding to QTY. MECHANICAL PERMIT FEE
V z building construction,and hereby authorize representatives ofthis city to enterupan the SEISMIC FEE
w-t above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep hamtless the City of Cupertino againa PERMIT ISSUANCE ELECTRIC FEE
liahilities.judg costs end expensec which may in any way acerae against said City ALTER OR ADD TO MECH.
msequence f segmntie'tEdi"mit. PLUMBING FEE
APPLICANT DDRSTANDS COMPLY WITH A .NO -POINT AIR HANDLING UNI'1'(TO 10,000 CFM) MECHANICAL FEE
U EREG ATIO l �S p
'(//, I AIR HANDLING UNIT(OVER IB,BIHa CFM) CONSTRUCTION TAX
Nreof App] 'anl/Contmctor Date EXHAUST HOOD OVIDUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the ap liantorfnumb Idingswcupam sum or M1ardle hazddous material HEATING UNIT(1010G."BTU)
as defined by Ih uper ino Man pal Code,Chapter 9.12,and the Health and Safety
Cale,Section 25.200 HEATING UNI'E(OVER 100,000 BTU)
❑Yes No VENTILATION FAN(SINGLE RESID) PAID -"
Date Receipt#
Will the
us applicant or fuwrc building by them use equipment or devices which BOILER-COMP(3HP OR 100,000 BTU)
nit hazardous air wnmminams de0nnl by the Hoy Area Air Quality Management TOTAL:
acil BOILER-COME(OVER 180.000 BTU)
i
El Via, Nn
1 reaslt nzudoas materials rcquiremens under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Emiv H h&Sof y ode,Sections 25505,25533 and 25534.1 orders d 1h t if Ne NEW RESIDENTIAL.MECH. EQ.PT.
bui]din enol ea 11,have a lanvnt, tat it is my responsibility to noel tl engin
off _, x hi nl et or In issuance ofd Ctlrtifra a
orauthori ogre a TOTAL: ISSUED BY:
OFFICE
can
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