99090005APPLICANTTO FILL IN INFORMATION WITHIN RED LINES -USE SALL POINT PEN ONLY Odolll 4;r
CITY OF CUPE RTINO BUILDING. ELECTRICAL.
E T
BUILDING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
UILDINC )RESS:
it-il
SANITARY NO,
APPLICATION SUBMITTAL DATE
P F
OWNEWS NAME PHO>�: ^
1.
CONI'RACJjI�AMF
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415.50 ¢9
❑Consultant Feet/ P. It by Applicant (Initial)
RM IT INTO
BLDG ELECT PLUMB h1ECH
❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION
I hereby affirm Ihat 1 am licensed under provisions of Chapter 9 (commencing
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
with Seminn]OfXB.d Division3ofine Business and Potfcsxiuns Coee, ana my lieenm is
in lullfonce a ellal
License Cluss Liap
Dam Commcmr
RESIDENTIAL:
❑SFDWI. O NRRMODF.L
❑ADDITION ❑PLUMBIPLUMBING RR -PIPE
PCRMI'1'ISSUANCH
APPLIANCES - RE.SIDHNTIAL
ARCHITECTS DECEA ATION
I undersand my plans shall be used as public records
MODIFICATION 0STRUCTURAL
MODIFICATION
PANELS
UPT02MAMPS
❑INTERIOR [I CHIMNEY REPAIR
IMPROVEMENT [D SWIMMING POOLS
❑ BATH REMODEUREPAIR QDEMOLI'f10N
[]OTHER
Licensed PrMes.iunal
OWNER -BUILDER Ce Contractors
1 hereby .Rion that I nm eaenga train i the Contr o,C r License Law co the
followingream..(Section ] onstr Business Cara: Any city or county
201-11X0AMPS
OVI7R IOOOAMPS
SIGNS ELECTRICAL
mprve,dsinns
repair any atmetarc
which rtquirta a permit m construct alio improve, der.it
SP[CIAI. CIRCUIT/MISC.
fi cment
thovisiosafthecum such permit toicenslt,iie
aw(Chgned
,buthexlcensec No;hmmhuirts
thatheislicenced purxumn mthe provisions of the License law (Clap¢,9
'TI?MI'. METER OR I'Ol.Ii INS'[
COMMERCIAL:
(commas eBusinss Pr, Code) or
Sedion]O00) ofha,ik
Any
mat he is exempt therefrom and the dtsix for the allegeA exuntption. Any viobninn of
arrouh Ruda,.eB d Twain
Section 7031.5 by any applicant lin a panoit xubjeeta the appllcam m a civil penalty of
not are than five hundred dollars ($500).
❑Les owner.f the pmpcny, tar ntyemPloyees with wagcsmtheir wle rompensmion,
will do the work. end the swcmrc is not imendedorot ,mil for sale (Sec. 7614, Business
[I NEW BLDG/ADDITION ❑ DEMOLITION
/�
EJ PROVANT ❑FOODSERVICE
IMPROVEMENT
❑ OTHER
POWER DEVICES
SWIMMING POOL ELECTRIC
and Professions Cade: The Contractor. License law docs not apply to an owner of
OUTLETS - SWITCHES - FIXTURES
NEW RESIDENTIAL ELFLTR SQ FT.
Q.IT. FLOOR AREA
Q. FT.
progeny who builds or improves thereon, end who does such work himself or though
his own employees, provided that such improvements .arc out intended or 0tm d far
sale. If, however. the building or mproventent is sold within one year nfcmnplmian,the
ponerbuilder will have the burden of pawing that he did not huild or improve far put.
se ofmleJ.
-11, as owner of the progeny, am exclusively contracting with licensed contractors to
NOV - 41999
TOTAL:
onstmet the pre act (Sec. 7014, Business and Professions C,Aa:) The Cmdarame, Li-
- -
ecrocLaw does not apply toanownerofpmpenywho builds of improves thereon, and
QTY. PLUMBING pF.RMCT FEF.
_
who contracts for such projmts with a cuntmfmit licensed pursuant to the Contractor's
License Law.
❑ Iamexempt t 1• - - ,RatPCfo ti n
V
By
—
PERMITISSUANCE
ALN11- RAIN& VENT -WATER (EA)
Owner- -- Dam
VALUATION
BAC ' PROTECT. DEVICE
WORKER'S COM :NSATION DECLARATION
Iherch ono under penalty of perjury one of the following ealarutions:
DRAINS - FL ,Rf AREA, COND.
ED I hove unit will maintain a Cenificme of Consem to self -insure far Worker's Compere
sumo. as provided I'ar by Section 3]1X1 ol'the Labor Code, fur the perfarmonca of the
STORE :
TYPE CONSTRUCTION
work far which this permit is issued.
FIXTURPS - PER T
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
37110 of the Laden Code, for the performance ofine work far which this permit is issued.
GAS - EA. SYS N,I OUTLETS
OCC. GROUP
APN
one(
NPIOIOMy rr
LLQ
GAS
1 1'CAMK SCamepolicy
F '
COMPHNSAHON INSURANCE
(Thisaectionneralmd be contplded ifthepermit is hu, c handreddollars(S 100)
tar less.)
Yl,
GREASUINDUSTRI, WASTE INTERCEPTOR
BUILDING DIVISION FEES
GREASETRAP
sw
PLANCHECK FEE /ay
SEWER -SANITARY -STORM EA. 200 Ff.
Icertify that in the performonccofthe work far whulado, permit is issued l shall
not employ any Person in any manner so as to benome x dapah m the Workers' Compen-
ENERGY FEE
WATER HEATER WNENTIELECTR
aorta Laws of California. Date
Applicant
GRADING PER
NOTICE 10 APPLICANT: If, after making this Ceniliwte of Exemption, you should
become subject to the Worker's Corwa satl.n provisions of mu Labor Cade, you must
WAT17R SYSTEMG BEATING
SOILS PEE
WAI ER SERVICE
fonhwhh comply with such provisinm.,,his permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
NEW RESIDENTIAL PLM. SQ. PL
PAID
I herchyeRrmthat there isoemstruction lendingagcncy for the performance of
as Receipt
the work for which this permit is issued (Sec. 309], Civ. C.)
Lender's Name
TOTAL:
Leader'. Address
'IfTTAL:
B�LTVG I> • . 3-1 al
I certify that I have read Chia application and state mat the alisi information is
QTY. MECHANICAL PERMIT FEE
0
SE 11C If
y
sect. ) agree it)comply with all city and county ordinances and state laws relating to
building csmetruhicn. and hereby authorix representatives of this city to enter upon the
above mentioned m,.y for inspection purposes.
(We) agree to save, indemnify and keep mrmlesx the City of Cupertino against
PERMIT ISSUANCE
ELEC R FEE
liabilita,.judginenb,c.su and expenws which they in any wvynmrue against sold City
lcnnscyuence of /
A U1 ER OR ADD TO MIiC R.
PLUM NGl ;APPLICANT
ABR HANDLING UNIT (10 I0,OM CPM)ME
NIC LE
UNDL OMPLY WITH ALL NO (P
SOURCEREC f _ /AIR
M�_
HANDLING UNIT (OVER IO,fMJO CFM)
CONS UCHON TAX
Si murc.fA 'c nVCm tanto, etc
HAZARDOUSM T-RIALSDISCLOSIIH
EXHAUST HOOD (W/OUCq
HOUSING ITIOATON FEE
Hi A'rING UNIT (TO 100,I100 B' TU)
Will theapplicantorfuture building occupantstoretar hurdle hazanduus.uncial
vi defined by the Cupertino Municipul Calc, Chapter 9.12, and the Health and Safety
Code, Section 2553200!
HEATING UNIT (OVER 100,EB(I BTU)
❑Yes E] No
( X511 me applicant or antra defined occupant use equipment or Marta which
emit hazardous air contaminants as defined by the Bay Area Air Quality ManagementROILF.R-COMP
District?
❑Yes - 7 N
PAID --
Dam Racipt p
VENTILATION FAN (SINGLE RESID)
(JHP UN 100,000 BTU)
'1'OTA p
I1O11.I1R- COMP (OV Eli 1110,000 OTU)
AIR CONDITIONER
I have mad the hazard. aerials regt't ahisnder Chapmr 6.95 of the Chi
ISSUANCE DATE
NEW RESIDENTIAL MUCH. SQ.
nd/bat' the
food. Health & Safety C. n on - 505 255) 2$$34.1 j��
building does not cu 0 av A m pon,ildldyl y!rent ofthe mcgui anS whi M pr' ora Cenifif p
l
ISSUED BY:
Ownersor authm ized agent pm
TOTAL:
OFFICE