S 4223 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFCUPERTINO BUILDING-ELECTRICAL PERMIT NO.
BUILnING DIVISION APPLICATIONIPERMIT PLUMBING-MECHANICAL S 4223 _
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMIl9'AL DATE
'S M NTRACT ' N LIC NO:
77 lti� 99
NIC CONTROL p
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,CGENGIN E ' LI fl: ESS ^ ry 4 ❑
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1
CONTACT: PHONE: ' BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑
LICLNStiD CONTR CI' 'S F,CLARATION QTY. ELECTRIC PERMIT FEE
1 hereby affirm that I am licensed under provisions of Chapter 9(commerical❑ON g JOB DESCRIPTION
with Section
iande of DivismnJnfthe Business and Profcssiom Cute,ane mvlicense is PERMIT ISSUANCE ��
I-WON full force and efrher RESIDENTIAL
GUV Licenu CrossLic.k ❑SFDWL ❑KITCHEN REMODEL
H 4 a DateConation _ APPLIANCES-RESIDF,NTIAL ❑ADDITION ❑PLUMBING RT:-PIPE
ARC]II'1 ECT'S DECLA IO Oin PANELS ❑STRUCTURAL.
z o l understand my plans mall be uxJ as public records -/ MODIFICATION
oz- UP TO 200 AMPS
FL6!zW LicensedP.fessional [I INTERIOR ❑CHIMNEY REPAIR
201-LOWAMPS IMPROVEMENT C]SWIMMING FOOLS
yQ,cd a,� OWNER BUILDER DIiCLARATION
K Q 1 hereby affirm that 1 ata exempt from the Contractors License Law for the OVlik 1(100 AMPS ❑BATH RF.MOUEUREPAIR ❑DEMOLITION
following rcamn.(Section 911315,Holmes,and Plat"Itons Code:Any city or county SIGNS ELECTRICAL. ❑OTHER I _
LL O us which reyaires a permit ht construct,alter,improve,demolish,or repair any structure - fA_Q OUr.
Na prior to its issuance,also requires the applicant for such permit to rile a signed statement SPECIAL CIRCUIT/MISC.
EST— that he is licensed pursuant to the Provisions of the Commit License Law(Chapter 9
125 no (commencing with Section 70"n of Division 3 ofthe Business and Profusions Cade)or TL'1,1P.METER OR POLE INST. COMMERCIAL-
a 6 c that he Is exempt therefrom and the basis lin the alleged exemption.Any violation of El DEMOLITION
x4co Section 11DI 5 h 0 NEW BLDG/ADDITION
�,,,y y hundred
licanl fm550T, l subjMs the applicant to v civil pcnully of POWER DEVICES
not more than five h props,dollars my employees
❑TENANT ❑FOOD SERVICE
E=QO OLas he vok.er al propricam myemplendes a,offered
for smic compensation. SWIMMING POOL ELECTRIC IMPROVEMENT
F will dome work,and the amaum usual mmnded or offered for sale(Sec. Business ❑OTHER
l Yg1-m and Professions Cade:The Characters License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURESd 3- property who hailds or improvev thereon,and who does such work himself or through
his own s nBloyeev,pro,dral that such intprovenmms are sol imcaded or offered lin NEW RESIDENTIAL RLECTB .Q
sale.If,howcveglhe building or improvemem is sold within one ycmof completion,the SQ.NT.FLUOR AREA S/SQ.Fr.
mer-builder will have the burden of proving that he did not buil)or improve fm pur-
pamofsaleJ.
0 L as owner of the property,am exclusively contracting with licensed contractors to 10A
enact the project(sec.9014,Business and Professions Cade)The Contractors Li- 4,
cen claw docs not
each Elapply maa with
aofpmpeny whosedlorimproves Crossman, QTY. PLUMBING PERMIT F
If
whence Law. for such Projects wits aatn0actogv7licensee Cursuunnulhe Convvaor's ^
License Law. 10
PERMIT ISSUANCIi
G lamexempr under Sec. ,B&PC for this reams
ALTER VENT-WATER(EA)
Owner Date JUL 21 I99"JID.I I'
WOR order
f COMPENSATION DECLARATION BACK FLOW PR(YfEC'I'.DEVICE UU
M1cmby affnm wdur penally of perjury tine of the I'ollnwing dcelarutions�.
ave and will maintain vCertifteateof Consent teach-inI for Worker's Co.,.. DRAINS-FLOOR,ROOF,AREA,GOND.
,anon,as provide for by Section 3900 of the Labor Code,for the fieRormance of the STORIES TYP CONSTRUCTION
work for,hich this .it is issue. FIXTURES-PER TRAPV
0 I have and will maintain Workers Compensation Insurance,se,required by Section J
3900ofthe Lobrjr Code.for the performance ordain work for which this permit is issued. GAS_tip.SYSTEM-1 INC.4 OUT OCC.GROUP APN
My Wnrak!cldrf' Carnp}��s-yton It ace eerier anA Policy
Ca"r / Policy No GA5-EA.SYS'TEM-OVF,k4(EA)
I RTIFIC l OF E MMION FR M WOR CERS'
COMPEN.ATION INSURANCE GREASFANDUSTRL WASTE INTERCEPTOR
or less.)(This section need not he completed ifthe permit is for one hundred dollars(S 1001 GREASE TRAP BUILDING DIVISION FE-ES
YhANCHECK PEE
Ioyany that in the anyromunceo the asit)f coonk for subjectch to permit ikirs Confilhull SEWER-SAN]'FARY-
nmcmploytinyCalifonintiny manner so as ext Mammsubjecnn the Workers Gtmpcm STORM EA.200 PT.
z ALaws at California Dm a
ENERGY FEE
zO nion Applicant - WAFER HEATER W/VLNT/EL[CfR GRADING FEE
y NOTICE'TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMOREATING
Become subject to the Worker's Compensation provisions of the LaMar Code,you must
foMwitM1 comply with such provisions or this 't shall be devoted revoked. SOILS FEE
� Q M^nr WATER SF,RVICF,
a
Uz CONSTRUCTION LENDINGAGENCY NEW Hf:SIUENTIAI, LMB. I SQ.EL PAID
UQ Ihereby dhrm thatthemissued(Sec.ion lending agency for the MRomtanee of Data Receiprp
0f^ Ihework far which this Cermil is issue(Sec.3097.civ.C.)
Landers Name
� W Leaders Address TO 'IYYTAL:
.ey pr I artily that 1 have trial this application and state that the above information is, BUILDING
Z) correct.I agree ext comply with all city and county ordinances and state laws relating ro QTY MECHANICAL PERMIT
U Z building construction,and hereby authorize representatives of this city to enterepsn the FEE SEISMIC FEE
abave-mentioned property for inspection purposes.
(Williagree to save,indemnify and keep harmless the City of Cu PERMIT ISSUANCE."penins igainst ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way aceraeagainst said againavid City
in anseyncnor of Ne grunting nfmiv 't ALTER(Ift ADD'IY)MECH.
Mom PLUMBING FEE
APPLICAN INDERSTANUS AND WILL COMP.Y WITH ALL NON-POINT qIR{{ANDLING UNIT LTO IO,L00CI'M) f
SOURCE 0/
IULATION MECHANICAL FEE
/ AIR HANDLING UNIT(OVER IO,o(O C1.) CONSTRUCTION TAX
Signa m ,",cmads-m woo, Date EXHAUST HOLD(W/DUCq
fIAZ RDOUS MATERIALS DISCLOSURE HOUSING MITIGATION FEE
Will theaffiicamor loom hmldingereupam Satre or handle hazardousntd"ad HEATING UNIT(TO 1011,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)1 HEATING UNIT(OVER 10,000 BTU)
O Yea No
VENTILATION FAN(SINGLE RESID) i4t
_.
Will the applicant or future building occupant use equipment or devices which
emit buiardnuv air con ponwann as defined by the Buy Area Air Quality Manngenscm BOILER-COMP LIHP OR 1114100 BUD
Distort?
O Yes ONo BOILER-COMP(OVER 10,0011BTIB .
1 have mad the hazadeus materials AIR CONDITIONER
re,25533 and
Chapter Cali-
forma Health,@ Safely Code..Sections 25505,255]1 and 25534.1 undersand Ilial if the NEW RESIDENTIAL MECH. SQ.FF
of'hengdtws nn oil which
hi 0ybuvuu roan'@mltisaamf ConsiM1ility lotwtifytheoanpunt of the reyti nw whichm met once uta a a¢nfOccupancy.
Ow ?,5)
agent pare
_ TOTAL: ISSUED BY:
OFFICE