S 0599 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE SALL POINT PEN ONLY -
CITYOFCUPERTINO nnn.nwr,-Pas.<rrxlrpLPERMIT No.
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING-MF.CDANICAL S 0 99
,BUILDING PROJECT IDRMI'IF'ICATION
ILUINGADDRESS: SANITARY IN APPLICATION SUBMITTAL DATE
7Sd3 "f--1vclwr GT g 'Ll 4
RTAME COMJ OR" AMG: CNG: NIC COM'ROLM
-/� ARCHIf(6KC";1,'/I,NGINEFIR: LIC NO: !Consultant
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Fees Paid by Applicant(Initial) I ELECT PLUMB M"
ICENSED NTRACTOR'S DECLARATION QTY ELECTRIC PERMIT
mFEE JOB DESCRIPTION
I li by l Erm Im
hm I am IicenuA under prnrisions of Chepmr l(nsmencing
q�Z wi,h$emion](NXllrf Division Sof the Business and l'rofessionsCase,and my licencis PERMIT ISSUANCE RESIDENTIAL.
aWF in full loreeund elfec �/J ❑SPDWL ❑KI'I CHEN REMODEL
QUU Licen Cm APPLIANCES-RESIDENTIAL ❑ADDITION El PLUMBING RE-PIPIT
FZ W Date Commnnr
m6 ❑MULTI-UNIT ❑S'fIDIFIC TIO
AL
ARCH[11 ac trae UEGublic c ON PANELS
�7 .I u � -n d mY s II be u.tl m Public mcordx - � MODIFICATION
ZOZ UPT02MAMPS C1 INTERIOR ❑CHIMNEY REPAIR
rt3 eased rt e..mnul - 201-IINTAMPS IMPROVEMENT SWIMMING POOLS
g w V I � VNER-BUILDER DECLARATION OVER HXXIAMPS REMODEUREPAIR El DEMOLITION
.it
I hereby amort that 1 am cxemPt from the Cnmmnnrs License Law far the El OTHER
iq5 d U following reason.(Section 9113 L5,Itusinesx and Pndessionx Cndc:Any city nr cnun,Y SIGNS ELECTRICAL
w W y which inquires a permit so cnnnwn,slur,impmre.demolish,or.repair anystmemm
t-ii:0 Friona its isstiance..E.oyuireathc eplifrmit forsuch emit file.signed statement SPECIALCIRCUIT/MISC.
Q TI'm he is licensed pmstri ,m The proviaaas Tribe Contractor's Licemu Law(Chapter 9 - COMMERCIAL,
W SCO (commencing with Section 7")of Division J ofthe Business and Profession Cadc)or 'TEMP.METER OR POLE INST.
a q m pd that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC {L
Station 703 1 5 by any n 111icant lin a panni,mhjccts T he.pplicmil mu civil ponalry of POWER DEVICES El TENANT ❑POO[)SERVICE
not mom than five hundred dollars($5001.
Fz0 Ci,is owner ofnhe property,or my employees with wages as their sale compensation, SWIMMING POOL ELECTRIC IMPROVEMENT
HER .
will do Tic wink,and(Tic sanctum is not immtded or offend Curtain(Sec 7044,Business ❑OTHER
and Professions Cade:The Commewn,Liecnse Law does not apply m an owner of OUTLETS-SWI"I CITES-FIXTURES
L .. property who builds or improves the,zmn,and who does such work himself n Through
his own ormo,ca,provided thin such impnrvmnems are nnI intended or offercJ on NEW RESIDENTIA EU!CfR SQ FT.
sale.IL however.the Wilding at impmvemeTa is sold whbim one yearofcompletion the SQ.M.FLOOR AREA USQ.Cr.
pcaner-builder will have the burden of proving that he did has(wild or impnsae for put- P p N`1 I
ate of rale.). - -
❑L, is owner of the property,am exclusively contracting with licensed contractors to TOTAL
cansaum the project(Sec.7044.Business and Professions Cd,The Comrucusrs l.,
cense law does not apply h)an owner of property who builds or improves Immon,and QTY. PLUMBING T FEE
who eanmacas for such projects with a commemrG)Il caused pncmannn,he Cumruemr's �y� /�' U
/1
License law. PERMIT ISSUA Uf L (�
C] I'
I am exempt tinder Sec. ,H&1'C far this moron j)
ALTER-DRAIN&VE ' - ATII (EA) IAI'ION�
Owner [).,aWORKER'S COMPENSATION DI!CLARATLON BACK PLOW YR[TfECT.DF,VICIi
P hereby of irm under penalty of penury one of the I'Nlnwlng declarations:
❑ [have and will maintain a Certilicam of Cometh mael6mure for Workers Compact- DRAINS-FLOOR.ROOF,AREA,GOND, STORIES TYPE CONSTRUCT ION
senior,as Provided for by Section 37(X)of the labor Cone,for the performance of the
work for which this Permit is issued•. 1:1 STORES-I'IiK'fRAI'
❑1 have and will maintain Workers Compensation Insurance.as required hyamtion
3700 of the Labor Case,for the performance of the work In which this permit is issued. GAS-ITA.SYSTEM-1 INC.a OUTLETS OCC.GROUP APN
My Workers Comp usalion Insurance carrier and Policy mmaMr am'
Carver: Policy Na: GAS-EA.SYSTEM-OVER 4TEA)
CERTIFICATE 01'EXEMPTION MOM WORKERS' GREASOINDUSTRL WASTE INTERCEPTOR
COMPENSATION INSURANCE (BUILDING DIVISION FEES
(This section need not be compleiesl lithe Ismnit is foram,hundred dollars(SIM) GREASETRAP
or less.( PI,ANCHECK PTF.
I artily Than in the performance of The work for which This permit is i.sawd.P shall SEWER-SANITARY-STORM HA.200 Fr
not employ any Person in any m a t 6 uyccnn the Workers Campen, ENERGY FF,Ii
App?
Paw ifo Dat• %% WATER HEATER WNF.NT'IF.LECfR
O anti '_ J GRADING FEIi
Z p nPNie.. . .
.N. NOTI APPLICANT:Ir?"r mating this ' rilicmc tilExemption,yon should WATER SYSTEM/fREA'1'ING
abecome subject m the Worker Compensation provisions of the Labor Carl you must SOILS FEE
W fonhwithe rply with such prnvWantser this permit shall lin Jeemd revoked. WATER SERVICE
Q
]Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL"An SQ.FT. PAID L c Reacipl p
UQ Iherehy infirm That there is a contraction lending agency for The perfnm.nce of -
E~- the work for which this lernth is issued(Sec 3097,On,CJ
4' lender's Name dY1TAL: TOTAL.:
U lenders Address
's FIJ I certify that 1 have read,his application and slate That the above iufnrnanim,is BUTLDIrt II
correct.l agree to comply with all city and county ordinances and state laws mlmingm QTY, MECHANICAL PERMIT FEE
7
U w7 building construction,and hereby authorize representatives of1hiscily treater upon the SEISMIC .E
above mentioned property for inspection purp..a,. PERMIT ISSUANCE
(We)agree m save,indemnify and keep harmless the City of Cupertino against ELECTRIC tli
Imbilitiesjudgmetns,costs and expenses which may in any way acerae against said City ALTER OR ADD TO MECIL
In consequence of The grunting of This permit. - PLUMNI THE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(1010.M)CFM) MECII NICAI.FEE 1
SO' B.AT S.
AI K HAN OILING UNIT(OV ER 10,00 CPM) CONTRUCION TAX
nemm of Applican omrector CCS/ Dme - EXHAUST HOOD CW/DUCT) HO ISING MI'T'IGATION FEF.
AZARDOUS MATERIALS DISCLOSURE
Will the app eater fuwr btildingswcupamamreorhaodlehamrdous material HEATING UNITT(TO I OO,IXq BTU) ss
as defined by the Cuperino Municipal Code.Chapter 9.12,end the Health and Safety
Cade,Section 2.5532(.)', - HE.AUNG UNI'p R)VER HNLBM B'I'G)
❑Yes
El - VENTILATION FAN(SINGLE RISIDI PAID
Du Re Ips IT
Will the applicant or future building nuuPTnn um equipmern or devices which
Iharardous air commmhicars us defined by the l{ay Area Air Quality Management BOILER-COMP I3HP OR IW,000 BTU) TO L:
DislneYl BOILER-COMP(OVER I(XLMO B'TU)
Cl Yes E]No
AIR CONDITIONER
have read the hazardous nationals mqui......ucr Chapter 6.95 aflhe Call.dISSU NCE DATE
fnmin Ilwlth&Safety GsJe,Sections 255115,25511 nnJ 25534.P undersand Ihm if The NI!W RESIDENTIAL MECll. SQ.ET.
building does nm currently have a tenant,that it is my responsibility it;notify mo overpant
of the uquirencnts which must bemet pries 1.asuarm of.Cerificam of Oxuprsel
Ownerarauthmized agent - - Data - TOTAL: ISSUHD BY:
OFFICE