99080099 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F,LEC'PRECAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
BUILDING PROJF,CF IDENTIFICATION
BUILDINGADDRESS: SANITARYNO. L TE
H1IT'NErR eAMI:: � PHONE: CfI��G�IJ M��� 1 �Ir ;bjIICN t,1 NIC CONTROLN
µtCHITECCCDENGINN/EEE LIGN(T t 10I,( ADDRESS: 4 ❑
CONTACT: PHONE: LIl BUILDIN RERMIT INFO `
1'.01.0 J-`D ❑ Consultant Fees Paid by Applicant(Initial) BLDG EL PLUMB MEC
LICENSED CONTRACTOR'S DECLARATION I ❑ ❑
t
I belch form that um licensee under provisions of Chapter n(commencing Qom' I ,' GLCCTRIC PERMIT,; ,PEE
hereby prov' P g I JOB DESCRIPTION
�00 with Section 700(dif Division Sof the Businessand P...m.im,Cop, dmylicemeis RESIDENTIAL'
,,r in full force enJ cRcc. I1_ (I PERMIT ISSUANCE
U Liven, �{paI� tic.If WQ 'W-
E-
W— y—�— ❑SFDWI. [3 KITCHEN REMODEL
E-zW Dam V +sa Contmcmr�e" APPLIANCES-RESIDENTIAL []ADDITION ❑PLUMBING RE-PIPE
ARCED'1'ECTS DECLARKPION ❑MULTI UNIT []STRUCTURAL
Z p sq A'ir PANELS� [understand my plans sh:Jl be used as public rarNs MODIFICATION
5 40 UPTO200AMPS [I INTERIOR El CHIMNEY REPAIR
<� ; Licensed Professional 301-10X0AMPS IMPROVEMENT [3 SWIMMING POOLS
OWNEILBUILDER DECLARATION
a C C 6 1 hereby affirm that I am exempt from the Comracmrs License Law for the OVER UWAMPS ❑BATH REMODEIIREPAIR ❑DEMOLITION
k 6 U fallowing tenon(Section 70315,Hosier.and Professions Code:Am,city mommy SIGNS ELFCfRICAL �OTHER
which be,firea a Permit to mnStNCL me,inmo,,dcm0116h.nr repair eny aINCWre Wj
groan it,Nvamce,als.requires lhcupplicam Tor.vnchpermilm file axigncdamemem SPECIAL CIRCUDUMISC. -
Hy. that he is licensed pulaconto the provisions of the Connector's License Law(Chapter 9
CO� (commencing with Sretion]mXO of Division 3 of the Business and Prolessions Code)or SURE EI'ER OR POLE INST. COMMERCIAL:
a a p C that he is exempt therefrom ant]the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�y Section 70US by any applicant for a Permit subjects the applicant o u civil Penalty of POWER DEVICES
EE-- not more than live hundred did... S500). []TENANT ❑FOODSERVICE
p' Q 1,as owner of the norm mloees with woes as their sole cont nsation, SWIMMING PLOL ELEC`TR IMPROVEMENT
AA ❑ Pro Pe Y Y e P Y g le
0 'll du the work,enJ the srcucmrc is nnlimended nr nllcred for sale(SecJ(W4,Business ❑OTHER
P�i2 and Professions Code.The Contmdur's License Law Ares not apply Io an.caner of OUTLP.TS-SWITCHES
63 pr.peny who builds or improves thereon and who Jres such work himself or through
his own emPloytts,provided that such inn m vemems art nm intended or oRemd for NEW RESIDENTIAL ELECTR Pf.
sale.If,however.the building or improvement is sold within one year of completion,theC SQ.ET.FLOOR AREA $/SQ.FT
owner-builder will have the hurJmt of proving that he did not build or improve for pur-
Ieseofsaled.
❑ 1,m owner ollhe property.ata exclusively contracting with licensed cor macmrs m T(yl'AL:
construct the project(Sec.7144,Business and Pmfcssams Cade:)The Contractor's Li- -
u Law does not apply to an owner of progeny who builds or improves menton,and QTY PLUMBING PE IT PEE
who contracts for such Projects with a commissions)licensed purounuo the Conlmcmrs
License Law. PERMIT ISSUANCE
❑ I am exempt coder Sec. ,B&1'C for this reason
ALTER-DRAIN&VENT-WATER(EA7 VALUATION
Date y
WORKER nder COMPENSATION DECLARATION RACK FLAW 1'HOTF.CT.DP.VICF.
1 hereby a0irm under pcwhy of perjury one of the following dednredons:
❑l have and will maintain a Certificate ofComcnt to self-insure for Workers Complain- DRAINS-E'LOOR,ROOF,AHEA.GOND.
sation;as provided for by Section 37M of the Labor Code,for the Performance of the STORIES TYPE CONSTRUCTION
work fill which mix permit is issued. FIXTURES-PER TRAP
❑ 1 have and will actinium WnrIn,,Compensation In...men,an required by Section
37WMthe Lienor Code,for the performance of the work for whichthis mm 1. is ued. GAS-HA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AB'N 10
My Coat tion lnsuranm cam Policy His; 2� GAS-EA,SYSTEM-OVER 4 GEA) O
CF.R RCATE OF EXEMPTION PROM WORKERS'
COMPENSATION INSURANCE, GREASLONDUSTRL WASTE INTERCEPTOR �.
IUILf)ING DIVISION FEES
(This.section need not Mt completed if the permit is for ane hundred dollars($100)
or less) GREASE TRAP PLANCHECK 19iE '
Icenify that in the pofurommea.f the work I..whichmispereatisi...ed,l shall SEWER-SANITARY-STORM EA.200 FT
not employ any person in any manner so as m become subject to the Workers'Carlen- ENERGY FEB:
Z sation Laws of California.Dae WATER HEATER WNENT/IX(TR
Applicant GRADING FEE
N NOP10E TO APPLICANT(If,after making this Certificate of Exemption,you should WgTRR SYS,1iM(fREATING SOILS "
ai 5 1mv.me suhju3 m the Worker's Compensation provisions of the Lahor Cuda,you must
forthwith comply with such provisi.nsorthis permit shall be deemed revoked WATER SERVICE
UZ CONSTRUCTION LENDING AGENCY - NEW RESIDENTIAL PLMD. SQ.Ff. PAID
wo l for
rwhich affirm thin isaed(Sec.3097lending agency for the Mrformunm of Dot crit
W Fy the work for which this permit is issued(See.7TN7,Civ,C.)
C) U Lenders Name 'TOTAL'
Lender's Add.... - TOTAL:
1 certify that I have rcuJ this application and stem that the uM,vc information is BUILD G PEE
fconcoct.B agree to comply%im all city and county ordinances candidate laws relating to QTY. MECHANICAL PERMIT - j FEE
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMI
nMve-mentioned property for inspection purposes.
(We)agree to one,Indemnify and keep harmless the City of Cupertino agairnt 4
PERMIT ISSUANCE ELECTRIC FEE
IaMI'nies,juJgnicnts.costs call expenses which may in any way acemc agidastmid Cd, ALTER OR ADD TO MECH.
in consequence of the gmming of this Permit. PLUMBING FEE
APPLIC T UNDERSTANDS AND WI(COMPL WITH, .L NON-POINT AIR HANDLING UNIT(TO 10,(X0 CFM)
SOU C EGULAT ON MECHANICAL FEE
AER HANDLING UNIT(OVER Initis CFM7 C0NSTRUCf10N TAX
Signor riodAPplic onuaclr Dam EXHAUS'1111OOD W/DUCT) HOUSING MI'HGATIO FEE
HAZARDOUS MATERBAI S DISCLOSURE
Will the applicant or future building occupant store or handle hnmrdous material HEATING UNIT LTD 100.00 BTU)
as fined by the Coleman Municipal Code,Chapter 9.12,and the Health and Safety
Code Section 25532m)7 HEATING UNIT(OVER 100,000,BTU)
Fl yes E]No
VENTILATION FAN(SINGLE RESID) PAID
Doe Rece'
ex
Will the aa,conte or future buildingytheoccupant use equipment or Micas when BOILER-COMP(3HP OR HXI,0)BT!TmL
I ex
emit huurJnus air contaminants m defined by the[toy Area Air Quality Management TO
District)
❑Yes ❑No ILER-COMP(OVER 100.000 BTU)
I DLI In
1 have read the humdous anncdm remircmenD under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE
- forma Health&Safety Code,Sectio a,25505,25533 and I rade land that if the NEW RHSI)TWIAL MEC((. o /�
huile ngd not currcnllY haventmm�0 then it is Ponsihil' tonolit'ytheeccuporn �r / r `/
of ten t,nor t nota came 1 cy.
�e �—
Owner rauthorir m Dam ISSUED BY.
OFFICE