99120037 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY iL I Q0 0_:q_
CITY OF COPERTINO BUILDING-ELECTRICAL. ERMIT NO.
BUILDINGFCUPERTIN APPLICATION/PERM[T PLUMBING.MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING AIIDRF:SS; mm
SANITARY NO. APPLICATION SUBMITTAL DATE
LO-73G - I.L_00 pfiv€- cop6 .1/NO y501 �G-G' �p
pW �NIMS PH�� 3-I CONTRACTOR'S NAME: F -7 LIC I��
1 NIC CONTROL#
SRCHITECf/ENGINEER: LIC NO: IADDRESS1: qWMft ' ^^ ❑
CONTACT: PHONE: 6 CrELOWF' BUILDING PERMIT INFO
❑ consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ r� ❑
LICENSED CON'TRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
I hereby aBirm that I am licensed under provisions of chapter 9(commencing JOB DESCRIPTION.
osIZ with Section 900n)nf Division 3ofthe Business and Professions Crde,and my license is RESIDENTIAL
WOO PERMIT ISSUANCE
FW in full farce an,[effect. ❑SFDWL [I KITCHEN REMODEL
Fnzu License Cinss Lic.# APPLIANCES-
rGW DateContractor RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCHITECTS DECLARA'T'ION ❑MULTLUNIT ❑STRUCTURAL
zoD.
,aiz l understand my plans.shall be used as public records PANELS MODIFICATION
OZ4p UPT02MAMPS [_1 INTERIOR ❑CHIMNEYREPAIR
F4.F.BJ1 Licensed Professional 201-1000AMPS t�t,IMPROVEMENT E]SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER IBM AMPS M REMODEL/REPAIR DEMOLITION
LAA`
.¢.41 I hereby affirm that i am exempt from the Commerce's License Law for the
7qc7�55 O O Ellowfng mason.(Section 0031.5,Businessland Pmfesomo Cale:Any city or conte, SIGNS ELECTRICAL ❑OTHER
which requires a pemtit to mmswcr alter,improve,demolish,or repair any structure
�� prionoils issuance,also rcyuircslhe epplicom for aimh permit to fileaaigneJ vWlement SPECIAL CIRCUIT/MISC.
jw that he is licensed puomm to the prnvivionsofthe Commerce's License Law(Chapter 9
(commencing with Section 90(10)of Division 3 ofthe Business and Professions Code)or TEMP.METER OR POLEell
COMMERCIAL:
6pi5�o y
had he is exempt therefrom and the basis for the alleged exemption.Any violminn of ❑NEW BLDG/ADDITION ❑DEMOLITION
W m'rn Section 7031.5 by any applicant forapermio subjects the applicantt1 4
wt civil penaltyof POWER DEVICESor ❑TENANT ❑FOOD SERVICE
not more man five hundred dollars(5500). 6;�
E Z Y IMPROVEMENT
ODI,as owner of me property,or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC 110
will do the work,and the strvctum is nm intended n Wend forevlo(See.]044,Business ❑OTHER
d ' and Professions Code:The Contractor's License Law does not apply In an more of OUTLETS-SWITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself car through -
his own employees,provided mat such improvements are not intended or offered for NEW RESIDENTIAL.BLECTR I") SQ FT. �T
sale.IL however the building or improvement lscld whhin oncywr of ecmpletior, he I� � S IT FLOOR AREA YSQ.FT.
me -bb�uuiilder will have the burden of proving that be did not build or improve far par- u
D
r eaan)e
r of the property,em exclusively contracting with Ileetscd cmnanerors to
consumer the project(Sec.](44,Business and Professions Code:)The Contractor's Li619 .2
-
nse Law does not apply to an owner of property who builds or improves Forced,add QTY. PLUMBING PER FEE
who contracts for such projects with a commands)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑ lu---in der B&P C for this reaarm V _
Owns Date ALTER-DRAIN&VENT-WATER(EA_)"-" VALUATION
RKF.R'S CO ATI ARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under pe clary one of the following declarations: O
I have and will maintain a Certificate of Consent mscIparrm for Workea Cmmpen- DRAINS-FLOOR,ROOF,AREA,GOND.
cation,as provided for by Section 37mI of the Labor Code,for me performance of the STORIES TYPE CONSTRUCTION
work for which suis permit is issued. FIXTURES-PER TRAP
I have and will maintain Workers Compensation insurance,as mquacd by Section
37W of the Labor Code,for the performance of the work for which this permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP
My Worker's Croup emntlon insurance carrier and Policy number are:
Cartier: Policy No.: GAS-EA.SYSTEM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WORKERS' V
COMPENSATION INSURANCE GREASEANUUS'TRL WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not beromplcted ifthe permit is for me hundred dollars($1POP GREASE TRAP
or less.) PI.ANCHECK FEE
I certify that in thencifrrearre ofhe work for which this pennitis issued,Ishall SEWER-SANITARY-STORM EA.200 Ff.
not employ any person in any manner so as to become subject to the Workeri Comped- ENERGY FEE
,Z colon Lawn mf California.Data WATER HEATER W/VENT/F.LECfR
Z Applicant 1 GRADING FEE
NOTICE TO APPLICANT:If,afire ti making this Coa final of Exemption you should
WATER REjR
E , becomeh comply who Worker's Compensation Permit slul of the Labor Cade,yon most SOILS PF,R
LkJ forthwith comply with such provisions or this permit shall be AeemeJ revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL Pf.MB. S I
L) 0 l herahy affirm that hem is a construction lending agency for the performance of --, eceiplM
the work for which this permit is issued(Sec.3097.Co,C)
01"t Lender's Name N TOTAL:
0 V Lender's Address OTAL: t � �
Fa 1 certify that 1 have read this application and sat¢ilial the above information is I ' ''�t, it k R 1 fLzzl
Vl mored.l agree to comply with all city and county ordinances and state laws reining to QT\', MEC L IT FYTH3 I
U �
building cnnetmninn,and hereby aumoriu representatives of this city mentor upon the Sb
kldlrl
abate-mentioned property for impartiun purposes. PERMIT ISSUANMrst
(We)agree m save,indemnify and keep harmless the City of Condition against F.
Iiabilums,jud mems,ousts and expenses which may in any way accrue aguinstsaid City ALTERORADDT( MECH.
in corseeo the printing (this mit.
APP
LI ASTU F COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHA
SOUR F. h'
AIR HANDLING UNIT(OVER 10,II0JCFM) CONSTRUCTION TAX
Si AppDate EXHAUST HOOD(W/DUCT)
ZARDOUS MATERIALS DISCLOSURE Date MITIGATION FEE
Will the applicant or future building occupant atom or handle hazardous material HEATING UNIT(TO I00.000 BTU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and the Health and Safety
Code,Semlan 25532(a)'I HEATING UNIT(OVER Iflu"BTU)
E]Yd, ❑No PAID
VENTILATION PAN(SINGLE RESID) Dam Rece' #
Will the applicant or future building occupant use equipment in device,which BOILER-COMP OHP OR 100AX)BTU)
emit h ve rdnms air comaminants as defined by the day Area Air Quality Management
District? TAL
❑Ver No BOILER-COMP(OVER 100,00I BTU)
OH
reardous m'erials req mems under Chapter 6.95 of to Cali- AIR CONDITIONER ISSUANCE DATE
to
e, c n. 505,255- . d 25534.1 understand that if the NEW RESIDENTIAL MECH, SQ.Fr,
hulldnil hit anuli responsibility rc notify me rocupan,' t t sofa Certificate of Occupancy. L/G
O Per Date TOTAL; ISSUED BY:
OFFICE