S0001 B0396 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CI TY OFCUPERTINO BUILDING-ELECTRICAL. PER ITND. 0396
APPLICATIONIPERMIT PLUMBING.MECHANICAL. 1
BUILDING DIVISION BUILDING PROJECT IDENTIFICATION SOOO 1
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL DATI
r7,5-,5G !en �r 6'Lt S-/.i_99
OWNERS NAME: HONE: C RACTOR'$NAME: LIC NO: NIC COM ROLA
ac 1ti 9&— S r/w
s�ARCHTIECT/F.NGINEER: LIC NO: ADDRESS ❑ —
Gcb?9-7
CONTACT, PHONE: BUILDING PERMIT INFO
��-� C] ConConsultant Fees Paid by Applicant(Initial) BLDG ELECT UM
PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Q•py. ELECTRIC PERMIT FEE
I hereby affirm that 1 am licensed under provisions of Chapmr 9(wmroeden JOB DESCRIPTION
ZWz th Seclinn7fM101 of Division3ofthe Business end Pmfasions Cade,wit mylicensc is RESIDENTIAL;
WOO in full foreeandeflbct. PERMIT ISSUANCE -
WO ❑SFDWL ❑KITCHEN REMODEL.
License Class Lion APPLIANCES-RIig1UENTIAL ❑ADDITION 99•4aFFIMBING RE-PIPE
I-QW Data Contructm
Fly ARCHITECTS DECLARATION p�Eyg C1 MULTI-UNIT ❑STRUCTURAL
y p to 7J I undersmnd my plans shell be used as Public records MODIFICATION
CZ-12UPT02�M1AMPS El INTERIOR ❑CHIMNEY REPAIR
1=EnFLicensed Pardivei...I 201-1AMPS IMPROVEMENT E]SWIMMING POOLS
SYF,� 0(IBOWNER-BUILDER DECLARATIONOVER IIXMIAMPS _J BATH REMODEUREPAIR [I DEMOLITION
d Q 1 heathy M.that I am exempt from the Contractor's License law for the
a'UyU following reason.(Section 0031.5,Business and Professions Code:Any city or county SIGNS ELECTRICAL COMER
3 W(" 'hut
requires a Permit m construct.ulcer,improve,demolish,or repair any structureN Pmmi.......ra,m...requires the applicant frrsuchpermit to file.signed stmemmt SPECIAL CIRCUIT/MISC.
�on that be is licensed pursuant to the provisions of the Contractors License Law(Chapter9
�GCy (commencing wishSection 70W)of Division 3ofthe Boainestrnd Professions Carrier 'TEMP.METER Olt POLE 1NST. COMMERCIAL
a :
kn � that he in exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/AUDITION [I DEMOLITION
ci Section 7031.5 by any applicant for apcnft subjects the applicant o a civil Penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
F Z>' not more than five hundred it.][.($500) IMPROVEMENT
E ❑
QQI,its owner ofthe propcny,or my employees with wages as their sole compensation. SWIMMING 1'OOL [1 OTHER
I3LF.CI'RLC
tz will do the work,.nd the stmnure is nm inuu eddroffered far sale(See7044.Business
G a a and Professions Code:The Convectors License Law does not apply an an owner of OUTLf:TS._S W ITCHES-FIXTURES
property who builds or improves thereon,and who does such work himself or through
his own employees,provided that such improvements are not intended or offered for NEW RESIDENTIAL.ELECTR SQ FT.
vale.If,heve,the buildingmiandam .t is sold whibinone yearofcompletion.tic Q.FT.FLOOR AREA SISQ.Ff.
mv
owner-builderwill have the burden of proving Nat he did.,it build or improve for put-
pnse m seta.).
1,as owner of the property,am exclusively contracting with licensed commutators to TOTAL:
construct the project(Sec.0044.Business and Professions Codi The Contractors U-
cense law does not apply to an owner of Property who builds or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts forsuch projects with o contmnor(x)licensed pursuant to the Contractors
License Law. PERMIT ISSUANCE
❑1 am exempt under Sec. ,B&P C for this reason
ALTER-DRAIN&VENT-WATER(EA) VALUATION
Owner Dame -
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT,DEVICE
1 hereby affirm under Penalty of perjury one of the following drelarstions:
(have and will maintain a Cenlficate ofConsentno self-insure furwerames Comped- DRAINS-FLOOR.ROOF.AREA.COND. STORIES TYPECONSTRUCIOt
sation,as provided for by Section 3700 of the Inbar Code,for the performance of the
work far which this pemtit is issued. FIXTURES-PER TRAP
❑1 have and will maintain Worker's Compenaatird Insurance,as required by Section
3700ofthe labor Cole,forthe perfrrmanceofthe w.rkfarwhi,h thtapetmit is issued. GAS-EA.SYSTEM-(INC.4 OUTLETS OCC.GROUP APN
My War r'sC pens.' n nsuraric carrieroli ySRPol.,�yWh:S5KnI GAS-EA.SYSTEM-OVER4(EA)
Corded Policy Na_ <�f�Sw� —
CERT CA'IE OF :MPTION FROM WORKERS' GREASMNDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE BUILDING DIVISION MES _
(Thissection need not bmi
e completed ifthe pert is boards,hundred dollars H Hall GREASETRAP
or IessJ PLANCHECK FEE
I certify thin,in thepsommunce ofthe work for which this perom is issued.I shall SEWER-SANITARY-STORM EA.200 Ff.
nm employ any parson in any munncr su as m hunme subject to the Workers'Comped- ENERGY FEE
sation Laws of California.Data WATER HEATER WNENT/ELECfR
z Applicant I GRADING FEE
NOTICE TO APPLICANT.If,after making this Cerditcam of Exemption,you shouldWATER SYSTI3M?REATINO
SOILS FEF.
a ^ become subject m the Workers Compensation provisions of the LaborLaborCode,you must
� forthwithwforthwithcomply with such provisionsonsor nr this permit shall be deemed revoked. WATER SERVICE
(({❑��� CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.Flt PAID
U I hereby infirm that the. construction lending agency for the performance. Dm Reccipn
Lg the work for which this pe^nit is issued(Sec.3U97.Civ.C.)
ULenders Name TOTAL
Lenders Address TOTAL:
G I certify that I have read this application it .,a that Ne above inf immition is BUILDING P
r/1 correct.I agree to comply with all city and county otdimahces and start laws relating to QT•y. MECHANICALPERMIT FEE SEISMICEEF.
U Z building convection.and hereby uothorive mepresematives'IF this city m eater asm the
above-mentioned pmpeny for Impectioa inali acs.
(We)agree m save,indemnify and keep harmless Ne City of Cupertino-lional PERMIT ISSUANCE. ELECTRIC FEE
liabilities,judgments,costs and expenses which may in any way came against said City ALTER OR ADD TO MECH. PLUMBING FE
in consequence of the granting of this pe y
APPLICANT UNDE TA )S ANJ7��A.L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000CF14) MECHANICAL -
SOURCEREGUI ON // p
r � /��9/ AIR HANDLING UNIT(OVEN IO.oq)CFM) CONSTRUCTION TA
SignatureofA cant rnlraclop^ Date EXHAUST HOOD ONMUCr) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hnamdous material HEATING UNIT(TO 1110,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)^ HEATING UNIT(OVER 1(10.000 BN) D/
❑ Q D
Yes VENTr
ILATION FAN RESID) PAID Date Receipt
jai Will the applicant m future building ce ti,ml use equipment or devices which BOILER-COMP CHP OR TOR"BTU)
mit hururdous air contammunts as defined by the Bay Area Air Quality Management
Droned❑Yes Rlir�_ BOILER-COMP(OVER I(Xi BTU)
I have read the wourdous mineralsrequiremenb under epter 6.95 rf the Cali- AIR CONDITIONER ISSUANCE DATE
Ch
(ammo Health&Safety Crile,Savona 25505,25533 it 25534.1 understand that if the NEW RESIDEN'r1AL MECH. SQ.FT. l �•
or a, not m have a .Nat it is my responsibility to notify the oveopem 3 I /
must ct pti ssuan cafe CertiOcmc of Occupvnty. ���
y 1J
Own uthor ed agent Data
TOTAL: ISSUED BY: T Q
OFFICE