99090162APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY q q 0c) O 11,02
OFFICE /
INO BUILDING - ELECTRICAL
CITYL.AM
PERMIT N
'BUION APPLICATION/PERMrr PLUMBING -MECHANICAL.
BUILDING PROJF.CI' IIXENTIFICATION
BUILD
SANITARY NO.
APPLICATION SUBMITTAL DATE
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PHON��OI,S
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CONTRACTORS NAME: LIC NO:
NIC
❑
CONTROL#
CHITECT/ENGINEER: LIC NO.
ADDRESS:
CONTACT: PHONE:
-
BUILDING PERMIT INPO
❑ Consultant Fees Paid by Applicant (Initial)
BLDG ELECT PLUMB MECH
EL� ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that l am licensed under provisions of Chapter 9 (commencing
with Section]Il(Il) of Division 3 ofthe Business and Professions Code, and my license is
in full force and effect.
License Class Lia.#
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QTY ELECTRIC PERMIT PEE
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JOB DESCRIPTION
RESIDENTIAL:
❑S�FDWL [I KITCHEN REMODEL
E<IXTION ❑PLUMBING RE -PIPE
❑MULTI -UNIT ❑STRUCTURAL.
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
❑ BATH REM�OO^LDt elm AIR QDEMOLITION
❑ OTHER I D e n lJ
I
PERMIT ISSUANCE
APPLIANCES - RESIDENTIAL.
ARCHllITCT DECLARATION
beesSDECLARATION
I understood my plans shall be used as Public records
PANELS
UP TO 200 AMPS
Licensed Professional
OWNER -BUILDER DECLARATION
1 two by aftiet that I am exempt Intothe C.ntrum.r's License Law for the
following reason. (Section 7031.5, Business and Professinm Code: Any city or County
requires a permit in construct, alter, improve, demol'nh, ar mIxor any structurecis
prior to its is.cuance,al.n reyuires the applicant I ... Ch permit m file signed statement
he is licensed pursuant to the provisions.] me Contracmrs License Law (Chapmr9
(commencing with Section 7") of Division 3 ofthe Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031,5 by any applicant for a permit subjects the applicant to a civil penalty Of
no, more than five hundred dollars ($500).
Las owner of the progeny, or my employees with wages as their sole compensaion,
will do the work, and the structure is not intended oroffered for sale (See 9044, Business
2014000AMPS
OVER 1010 AMPS
SIGNS ELECI'RICA].
SPECIAL CIRCUCHAUSC.
,
TEMP. METER OR POLE INST.
COMMERCIAL
❑ NEW BLDG/ADDITION ❑ DEMOLITION
❑TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Code: The Contractor's License Law does not apply to an owner of
property who builds kr improves thereon, and who does such work himself or through
OUTLETS -. TCHES-FIXI ORES
his own employees, provided that such improvements are not iniende l or offered for
NEW IDFNTTAL ELECTR S FT.
sale. IL however. the building or improvement is sold within one year of completion.the
SQ. PIK FLOOR AREA
$/SQ. FC
owner -builder will have the burden of proving that he did not build or improve for put -
It.).
I, as owner of the property, am exclusively Contnmting with Tic oew c.nwemm m
TOTAL:
construct the project (Sec. 7044, Buldess and Profession, COdc:)'the Contractors Li-
c m se Lowdias napply to an ownerofpfopeny who builds or improves thereon. and
who Contracts for such projects with a enntmmkdpursuant s) licensed pursuano the Connector's
QTY, PLUMBI .RMIT FpWJ
iLSp IILJ., �[ u
PERMITISSUANCE
License Law.
1 am exempt under S_0__ 13 & P C for This reason
1 Q
Q 4
VA A O
ALTER-DRAIN&VENT-WATE.R(EA)
'ncr Date •�
WORK ION DECLARATION
I hereby affirm under penalty of penury One of doe following declarations:
RACK FLOW 1'ROTLCI'. DEVICE
/
DRAINS - BOOR, ROOF AREA, COND.
❑ I have and will maintain. Certificate ifConsent tuself-insure lis Worker's C.mpen-
smirk, az provided far by Section 3700 of the labor Cade, for the performance of the
—TVIC&CON5'Ht
Cf10N
FIXTURES -PER TRAP
'e.
work for which this permit is issued.
I have and will maintain WOfkets Compensation requiredbySection
Labor Qdationthe w rk for hi h his
surance Cancer and Polis fnumbir are: permit is issued.
MyT
Worker's
My Worker's Cmnpensmion Insurance currier and y N.: number are:
Carrier: Policy NO.:
GAS -EA. SYSTEM -1 INC. 4011TLLTS
OCC. GROUP AI'N
CAS- EA. SYSTEM -OVER 4 (BA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
"
Zi
COMPENSA'T'ION INSURANCE
(This section mission, be Completed tithe permit is (.rune humboaddollae ($T W)
fless)
Iretail, that in the performanCcrfthe work for which this per mit is issued. T shot)
no, employ any person in any manner xk as m m
hecre subject In the Workers' Compact.
storm Law sat California. Date
Applicant
GREASFIINDUSTRL WASTE INTERCEPTOR
DING DIVISION FEES
GREASE. TRAP
PLANCHECK FEE
SEWER
SLWER- SANITARY - STORM EA. 20d FT.
FEE
HEATER WNENT/ETR LEC
GRAVING FEF.
ID
.OTICE TO APPLICANT: If, after mak'mg this Certificate nl Exemption, you should
become subject m the Workers Compensnion previsions of the Labor Code, you must
forthwith comply with such previsions or this permit shall be deemed revoked.
WATER SYSTIiMITREATING
-
ZWATER
h
Uj
SOILS FEE
WATER SERVICE
a0
PAID
NEW RESIDENTIAL PLMB. SQ, IT,
Uz
CONSTRUCTION LENDING AGENCY
Date Rtteiplp
til0
w
euhathereisaconswai.nlending agency forth¢ performanceof
work
thework for which this permit is issued (Sec.3W], Civ. C)
Landers Name
TOTAL:
Q U
IxnderI Address
I certify that 1 have mad this state that the above information
TOTAL:
BUILDING FEE
QTy. MECHANICAL PERMIT FEE
V)
TA
C.)z
y and counand
to
combuilding agree to comply and here alldryand cxpmxcnty rdlnances Ofand sura lawsnnotipia the
building Consuvd hereby to ¢merupon the
SEISMIC FEE
famert in,etic.Frepreunutivesofthiscity
for inspectionpurposes.
above-( e)agr Cut
(We) agree m save, indemnify and keep harmless the City of Cupertino agar
PERMIT ISSUANCE
ELECTRIC FEE
ALTER OR AVD TO MECH.
PLUMPING PEE
Iiabilhlev,juJgmems. costs ileuses which may in any way acme against said City
in on"imaree nl'Ihe gra li-a,,cthis permit.
ALR HANDLING UNIT (TO 10.000CFM)
MECHANICAL FEE
APPLICANT UNDERSkNrAAND WILL COMPLY WITH ALL NON -POINT
SOURCE ULATIONS.
AIR HANDLING UNIT(OVER 10,0(10CF14)
CONSTRUCTION TAX
EXHAUST HOOD(W/DUCD
part aPAp lis dtl7ompiaom Date
HAZARDOUS MATERIALS DISCLOSURE
HOUSING MITIGATION FEE
HEAPING ONO CTO I0d000 B' IU)
Will the applicant or future building rwcupam stare kr handle hazardous mate, al
us defaced by Ibc Cupedink Municipal Code. Coupler 9. 12, and the Health and Safely
Crile, Section 25532(1)1
HEATING UNIT' (OVER 100,001 BTU)
❑Yes ❑Na
ordevices ch
Will he usair Contaminants
or Poem building by the B useea Air
emit hazardous .ir amuminan[s as defined by the Bay Arca Air Quality Management
ement
Owner'
PAID
VENTILATION FAN (SINGLE RU)
F_SI
Date ReceiptM
BOILER- COMP(3HP OR 100,000 BTU)
TOTAL'
❑Yes No
BOILER - COM P(OVER I00,01110T1)
AIR CONDITIONER
I have madth It Maus nctc.lsreyuiremenB undcf Chapter 695 at the Cali.
ISSUANCE ATE
NEW RESIDENTIAL MECH. SQ. If.
forma Health & Safety , Secliona 8505, 25533 and 25534. 1 uadeeund the if the
buildin netcufrtnt have amnant,Uwtitisfn its nsibilaymmanymercmpant
of requ hadpore m issuance of a Certificate f Ocapanry.
9_
7`
ISSUED BY:
O rauthmt. Ore
TOTAL..
OFFICE /