The URL can be used to link to this page

99090060 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES•USE BALL POINT PEN ONLY CITY OF CUPERTINO BUILDING-ELECTRICAL ArlPE NO. & BUILDING DIVISION APPLICATIONITERMIT PLUMBING-MECHANICAL ,BUILDING PROJECT IDENTIFICATION 19 BUILDING AU0RE55: SANITARY NO. APPLICATION SUBIchind,DATE D 4 Ve �- OWN R'S NAME: PHONE: CONTRACTOR'S NAME: / LIC NO: Zrv tirolrAL NIC CONTROL# RCHITECT/ENGINEER: LIC NO: ADDRESS'. ❑ CONTACT: PHONE: /_ia/9 BUILDING PERMIT INFO. 7 C7 ❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PLUMB MUCH %N �f�rG 1 - EI Z ❑ ❑ ❑ V� LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE I hereby alarm that I am licensed made,provisions of Chapter 9(commencing . ]OE DESCRIPTION �QZ with5edion]000)of DMusumn3oRh iciness and Pryfyxi n e,and myli.ense is RESIDENTIAL' in full forced �'j PERMIT ISSUANCE ❑SCOWL El KITCHEN REMODEL �U License Class # y< Gonhanm APPLIANCES-RESIDENTIAL ❑ADDITION EI PLUMBING RE-PIPE nam ARCHITLLT'S DECLA ATION El MULTI-UNIT 11 STRUCTURAL Z FO n ZU I understand my Plans shall ba sed as public records PANELS MODIFICATION OIL-C UPT0200AMPS _ El INTERIOR El CHIMNEY REPAIR P...i Licensed Professional 2 y„00 1 IMPROVEMENT SWIMMING POOLS a • OWNER-BUILDER DECLARATION 1 [I BATH REMOD ERZR ❑ EMOLING P C d 1 Masa affirm that 1 1 5axasin Gam the Contrncmr's License Lew far the LPyS O d U following reason(Section 70315.Rsiness and ProfessionsCode:Any city or county I ❑OTHER W 0 y which requires.permit to construct,alter,improve,demolish,or repair any stmdure Tad Placid it issuance.also requiresme applicant forda,P",to file a signed statement SPECT CI / }..1 tbut he is licensed p.rsuem to'he provisions of the Contmoar's License Lew(Chapter9 W[Ld�O (commed.ingwith Section 9000)of Division 3 ofthe Business and PmfassionsCode)ar BMP RORP T. COMMERCIAL' a Qo y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION ti Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of E ❑TENANT ❑FOOD SERVICE not more than five hundred delta,,($50d, IMPROVEMENT C Q I..,owner of the property,army employees with wages as their sole compensation, I a dd will do the work,nnd thexwcmre is ratintended proffered forsale(See 7044,If ❑OTHER end Professions Code.Ton Contractor's License Law dues not apply to an owner o U B 9 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 otTered for NEW RESIDENTIAL ELECTR SQ ET. sale.If,however,the building or improvement is sold within one year ofeompletion,the SQ.IT.FLOOR AREA $/SQ.FT. neolander will have the burden of proving that he did not build or improve for pur- pose of,.IeJ. ❑1,as owner of the property,am exclusively contracting with licensed contractors to L: construct the project(Sec 7044,Bsiness add Professions Cale:)The Contmators Li- cense Law does ma apply to an owner of property who builds or improves thereon,and QTY, PLUMBING PE who contracts for such Fri with a corm emHs)licensed pursuant to the Contractor's License Low. PERMIT ISSUANCE F, 1 i m exempt under Sec. ,R&P C for this reason ALTER-DRAIN&VENT-WATER(HAD VALUATION Owner Date WORKER'S COMPENSATION DECLARATION BACK PLOW PROTECT DEVICE I hereby affirm under penalty of perjury one of the fallowing declarations: .9 ❑ I have and will maintain a Cenificateof Consent msclf-insure for Wo,ker's Compen- DRAINS-FLOOR,ROOF.AREA,GOND. O .S TYPE CONSTRUCTION ration,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. FIXTURES-PER TRAP ❑ 1 have and will maintain Warkers Compensation Insurance,as required by Section 3700mfthe LaloorC ,fortheperfo..one of the work for whichmis permit is issued GAS-EA.SYSTEM-I INC.4 OUTLETS DEC.GROUP APN M Works' ti nlnsu ler and Polis GAS-EA.SYSTEM-OVER ..S Z C► C.m'ec a. ��-Policy No.Y / S CERTIFICATE OFEXEMPTION FROM WORKERS' ~Q/ GREASFIINDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE 1AHLbING DIVISION PEES (This section need not be completed Hire permit is for one hundred dollare($IM) GREASETRAP or less.)(This FEB - Icerifythatinthe performance lithe work for which this permit is issued.Ishall SEWER-SANITARY-STORM EA.200 FT. not employ any person in any manner so us to become subject to the Workers'Compen- ENERGY FEE ,Z satin.Laws of California.Date WATER HEATER WNENT/ELECfR z 0T GRADING FEE fn NOTICE TO APPLICANT:It,.(In,..kid,this Certificate of Exemption,you should WATER SYSTEM/fREAT1NG SOILS FEE F become subject to the Worker's Compensation provisions of the Labor Code,you must — tiforthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE G A CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID I hereby affirm that them isaconstruction lending agency for the performance of Date ReeaiptN U0 the work for which this permit is issued(See.3097,Civ.C.) 0 F^ Leader's Name L: WLenders Address TOTAL: I certify that 1 have read this application and state That the above information is BUILDING FEE ycorrect.l agree to comply withal]city and county ordinances and sate l.voi ndi m,cc QTy, MECHANICAL PERMIT FEE V building cmnstmction,and hereby authorize representatives ofthis city to enter upon the SEISMIC ME above-mentioned property for inspection pmprsus, PERMIT ISSUANCE (We)agree to save,indemnify and keep harmless the City of Cupertino inst ELECTRIC MEaga liabilities,judgments,costs and expenses which may In any way accrue against said City ALTER ORADD TO MECH. PLUMBING FEE in consequence of the Seaming of this permit. APPLICANT U D STAND'AND WILL COMPLY WITH ALL NON-POINT pIR HANDLING UNIT(TO 10.000 CFM) SO C I)NS. MECHANICAL FEE ♦/i AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX Signature o[ pplicamAdurarm VN EXHAUST HOOD(W/WC1) HOUSING MITIGATION FEE HAZSM RIALS DISCLOSURE ARDOU Willthe applicant.,future building occupant stmem handle hazardous material HEATING UNI'f(TO IMXI BTU) Q.e as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely 66 3-3 Code,Section 25532(x)? HEATING UNIT(OVER 100,000 BTU) DYes ❑No VENTILATION FAN(SINGLE RESIO) PAID Date Receipt# Willthe applicant ufuture building occupantuseequipmento,dManaement BOILER-COME(THE OR 100,000 BTU) mit haamdous air cnnmminanls as Defined by the Ray Area Air Quality Management TOTAL Dlstricft BOILER-COMP(OVER IM."81 IT ❑Yes ❑No 1 have read the hazardous materials requirements under Chapter fi 95 of the Cali- AIR CONDITIONER ISSUANCE DATE fomia Health&Safety Code,Sections 25505.25533 and 25534.1 understand that if the NEW RESIDENTIAL MECH. SQ.ET. building doe ..in n lyheveat ant,thafit is my M,,Ou ditytoglairydreentpart m /7 oft i i um Ipoort I eofaCe ' 7 �� Ownero out mise agentDae TOTAL ISSUED BY: OFFICE