99100065 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL. PNiU
APPLICATION/PERMIT PLUMBING-MECHANICAL.
BUILDING DIVISION BBUILDING PROJECT IDENTIFICATION 50001 :
I1U11 J ADDR SSS' SANITARY N(l. APPLICATION)SUBMITTAL UA"
OWNH E: q CONTRA OX'S NAME: �/ LIC NO: 1
/ cX2 — ` NIC CONTROL#
CHITS /ENG N .R: LIC NO: A) IS': E]G
CONTACT; PHONE: as' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant I ,, BLDG ELECT PLUMB MECH
❑ ❑ ❑ ❑
LIC17NSED CON'TRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
I hereby affirm Inas 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
MWaZ rh$ectinn)INNB of DrvisionJolt ePusincas aoJ Profesv Code.cadmylicenvcis RESIDENTIAL:
)c wt PERMIT ISSUANCE.
E ly... n full tiros a c _ iFa- r ❑SFDWI. ❑KITCHEN RF.MODF.I
aUU hiansc Clss Lir.p' APPLIANCES-RESIDENTIAL [I ADDITION ❑PLUMBING RE-PIPE
i-a i D.m Contmcror
ARCIIIIT:C'PS DECLARATION ❑MULL-UND, ❑STRUCTURAL
F.,D m PANELS
Z Q rjj Z,7 I unduroan I my plans shall he mscd as pally ovandv MODIFICATION
OZ• -a IIP TO 2100 AS ❑INTERIOR El CHIMNEY REPAIR
licensed 11 t'...onal OWNER BUILDER DECLARATION201-1000AMPS xx IMPROVEMENT DSWIMMING POOLS
J
CY -1 OVIiR IINNIAMI'S ❑BATIi REh1ODELIREPAIR ❑DEMDLITI M
y Cy1 Q I herehy.(lion on I am exnnpt[ram he Contractor's Coal
A.,e Law for Ne
W 1 U following requires
a.(Section]o 1.5, t,alk®s vnd Professions Cade:Any city or county SIGNS EI-ECTRICAL DTIIB
W LL y which requires a permit w amstrva,alter,improve,demolish,or repair any structure
E':O� prior to its issuance,also requires the applicant for such Tremor to file a signed statement SPF.CIALCIRCUIT/MC.
Ey Ihm he is licensed pursuant m the provisions of Ne Comanors License Law(Chapter 9
(yC00 (eommencingwith5cction](M)of UivisionJoftha Bunincssand Professions C(de)or TEMP.METER)ALE INS COMMERCIAL:
e.2 that he is exempt therefrom and the basic for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W Section 7031.5 by any applicant for a permit subjects rise application a civil penalty of POW F.R DEV E.S
W
•-y ❑TENANT ❑FOOD SERVICE
not more than five hundred dollars 14500).
F Z Y .IPROVEh1ENT
_< wi Lo the work.the pestruct structure
emyemntended wiNwagesrevafei(See compensation, SWIMML 'POOL EL[CTRIC
ad�p.0 will dotheand the The wmisnm,Licens Law dos sal apply
Bu eines TIER
63 m and property
wh ons Cede;The Commcn es License Law does nm apply ro an owner of 01111 S-SWITCHES-FlXTURFS
property who builds or improves tbsuch i and who does such tints dee or or Nrough
his own employees,pmvideJ Nm such improvements are not intended or offered for NEW RESIDENTIAL ELELTR SQ FT.
sale.If.however,the building or improvement is sold within one year ofrompletion.tM SG�IT. 8/SQ.FT
er-huildcr will have the burden of proving that he did not build or improve for par. prP❑ I,as owner of the Sec.7W um exclusively contracting with )lice co.-vera, to TOTAL:
mnrvadproject(5cu.oair vipeBusr e.vsandrty who
or i The Comm�mon.Li- 1
xelawdoesrmehiapply mmr owmcrolpmpcns whosedpomant tothe thereon.and QTY, PLUMBING PERMIT FEE OCTlI 7Af1(J
who amuuctx finsuchp jeers with nmmvacmr(s7limnsed pursuant In rhe Cnnwanry 'JJJ
Luen.w Luw.
5' N r
❑ I ten exempt under Sec. ,B h I'C on thi,v reason
p D ( ) VALUATION
Owner Dale
WllRK1.R'S COMPENSATION DECLARATION BACKP. P
1 hereby#Bion under penalty of perjury one of the fallowing dcclurmin is:
01.
l have and will maintain a Cenificate of Consent an self-insure for Worker's Campers- IAIN. ND. SlbRlliS TYPECONSTRUCTII
nation,as provided for by Section 3]W of the Labor Code,for the perfomance of the
work for which this permit is issued. 'R
❑1 have and will maintain Workers Compensation Insurance,as required by Section
3701 of the labor Code,for the performance of Ne work for which this permit is issued G - A."ITEnI &- OCC.GROUP
My WmlrLc o f nsaion Insurance carrierPoli yNoPol.:. )02n
Carrier. Policy Na.: YY IRk!�! .TCI:RTIFICA'IM OF EXEMPTION FROM WORKERS' f' BUILDING DD'ISION FEES
les.) GRIiASE'IBAY NCHECK FEE
I tcnify Nat in the pnlormanceof Neworkforwhich Nispermlr esissueJ.I shall SEWER-SANITARY-STORM EA.200 FT.
nor employ my peva m in any manner m as to become subject to the Workers'Container. ENERGY FEB
0z sminn Laws of Culifi,mia.One WATER HEATER WNEM'/ELECTR
z Applicata I GRADING FEE
.N. NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREA'TING
a > became subject to the Workers Compensation provisions of the Labor Cede,you must SOILS PEI?
❑ forthwith comply with such provisions.,,his porma,hall be deemedoevoked. WATER SERVICE
UO TT 'IFJ
CONS] LENDING AGENCY NEWRESIDEN'IALPLMB. SQ. '. PAID
I herehy allinn that them is v construction lending agency for the performance of Date Reecipt#
W py the work for which this pennif,,issued(Ser.3097.Cie C)
❑ULender's Name TOTAL:
Lender's Address TO'T'AL:
Fd I rectify Ihut 1 have readd...upplierhou vad state Nut the above inti nnmlon is BUILDING hili
m correct,l.gren ,cantply with.11 city ad ,,only ofinance,andmatc laws relming to Qw.. MECHANICAL PERMIT FEE
U building c......mminn.and ncrchyvmhmi,.c rcp[esemmlvcco(chis eivu'viterupnnlne SHISMIC ITE
move mentioned property(in inspection parpcnes.
Wel u• FERMI'I'ISSUANCE
( agree m save,indemnify rend keep harmless rhe Cip�of Cupertino.gain.. IH,IiC"TRIC PEE
(
liabilities.judgments,costs and expenses which may in any wayaccme against said City AI.TF.RORADDTOMECH.
inasmcii of the gmntin oftvisermir. PLUMBING FEE
APPLICANT ON : IJJ US AND WILL CON WITH ALL NON-POINT AIR HANDLING UNIT(To IL000CFM)
SOURCI RE R 16' MF.CHANICALFEE
AIR HANDLING UNIT(OVER 10.000CFM)
CONSTRUCTION TAXHA%ANIw
Signature of ppli[aAZVOUctor Umc EXHAUST D(W/DUCI)
IIUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Willtneapplicamorfummh'dingoccu tsmreor handle haesrdous mmerial HEATING UNI TO L00.0k)BTU)
as defined by the Cupertino Manic al Cal prat 9.12,and the Health and Safety
Cale.Section 2""ho' HEATING UNIT( VER 100.000 BT
Yes
VENTILATION FAN LNG ESI]) PAID Ilene Receipt#
Will the applirmir n u stag acu equipment or devices which
,if h,minrs air c am.minuntsrc cfincd by Nc Bvy Are.Air Quality Mmehoment BOILER-COMP OHP RIW,BW BTU)
tricl' TOTAL-
0 Yo,
OTAL❑Ytv BOILER-COM OVEAt 000 BTU)
I have read the barairl materials racumcmen¢under Chapter 6.95 of the Cali- AIR CON]' ONER
l p ISSUANCE DATE
harldnrria d...t .$Safe Cndu.Scdions 255115,2s my spoa5i 36.1 mWonlath that it the NIiW H.:IDIiNTIAh MECH. SQ.PT.
of itd-tax vI n' enllyhefCi(vionvi that it rreeponeinility wc.fy the rccuphm
of it�ra "cl uu»�net prior oissuance oft Cci �me ofJ*aaeuy:.
Ovois911urtWed.gem Date' TOTAL: ISSUED
OFFICE