99120034 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL P61NT•PEN ONLY
CITY OF CUPERTINO - BUILDING-ELECTRICAL I
BUILDING DIVISION APPLICATICIVPERMIT PLUMBING-MECHANICAL
• BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - ITARY NO. APPLICA'T'ION SUBMITTAL DATE
-i L -4✓�' Gni Cif 9501 f'L--L z�
OWNERS PHONE. CONTRACTO 'S A : r LIC NO:
/9p NIC CONTROL#
4RCHITECP/ENGINEEIC LIC NO: ADDRESS;: ❑
CONTACT: PHONE: BUILDING PERMIT INFO
N�o;G '40
C 0 /�Q� ❑,Consultant Fees Paid byApplicant(Initial) BLDG EILECCTT/PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby aRrm that I am licensed under provisions of Chapter 9(commencing _ JOB DESCRIPTION
�04Z with Section p(NM)ofDivision 3ofthe Business and Professions Coda-e�,and mylicense is RESIDENTIAL
F W F" in full force and force and e� L PERMIT ISSUANCE ❑SFDWL ❑KITCHEN REMODEL
�U$ Cleanse Class Lia# APPLIANCES-RESIDENTIAL. El ADDITION ❑PLUMBING RE-PIPE
D.
oto Dom Contractor
ARCHITECTS DF.CI RATION ❑MULTI-UNIT ❑STRUCTURAL
PANELS
Z p'/r Z I understand my plans shall h useJ as public records _ MODIFICATION
OZ=� UP TO 200 AMPS 11 INTERIOR C1 CHIMNEY REPAIR
AMPS BATH RF,MODFa./RF.PAIR DEMOLITION
C=Jj Licensed Professional - 201-IOMAMPS IMPROVEMENT SWIMMING POOLS
Sid ...4I CAN
DECLARATION 1000
C 6 I hereby affirm that 1 am exempt from the Convector's License Law for the OVER
O d U following reason.(Section 7031.5,Business and Professions Code:Any cityor county SIGNS ELECTRICAL OTHF.
'3
66F` which requires a permit in construct,alter,improve,demolish,or repair any suucture
�0 poor to its Issuance,also requires the applicant for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
y that be is licensed pursuant to the provisions of the Computers License Law(Chapter 9
W(.L OO (commencing with Section 7")of Division 3 of the Business and Pmfessiove Cade)or TEMP.METER OR POLE(NST. R 1 '
6 y o a that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W W Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of POWER DEVICES
18'"w ❑TENANT ❑FOOD SERVICE
�x0not more than rive hundred grope dollars y amp. IMPROVEMENT
❑Lashe owner k,the property,or remyemntended with wages Bred bosalei(Se compensmion, N T C '
will dothework,and the he Core Is pots License
offered for sale(Sec.o aBusiness ❑OTHER
and Professions COJe:The Contractors License Law does not apply to an owner of ^U S H � '
tL 3.. property who builds cmimproves thereon,and who does such work himself v through
his own employees,provided that such improvements are not intended or offered for EW RESIDENTIAL.ELECTR
sale.If,however,the building or improvement is sold within one year of completion,the SQ.FT FLOOR AREA - $/SQ.Fr..
ovemer-lbuilder will have the burden of proving that he did not build or improve for par-
pose of se1,),
❑1,as owner of the properly,am exclusively contracting with licensed contractors to
onstruct the project(Sea.7044.Bosinesa and Professions Cw1c0 The Cono-remrs _ 5)
cense Law does not apply to an owner of property who builds or improves thereon,and ( PE FEE
who contracts for such projects with a contractors)licensed pursuant to the Contowas a
License Law. S
❑ 1 am exempt under Sec. ,B&P C for this reason
Owner Dom ALTER-DRAIN&VENFI-WATCIt(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLOW PR0d=DEVICE
1 hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Cenifcam of Consent o self-insure for Worker's Comon- DRAINS-FLOOR,ROOF,AREA,GOND.
sstion,as provided for by Section 37W of the Labor Code,for the performance of the STORIES 'TYPE CONSTRUCTION
work for which this permit is issued. - FIXTURES-PER TRAP
❑I have and will maintain Workers Compensation Insurance,as required by Section
3/W of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP AFb
My Worker's Compensation Insurance comer and Policy number no: - V
Carrier: ' Policy No.: - GAS-EA.SYSTEM-OVER4(E,G - -f1 3
CERTIFICATE OF EXEMPTION FROM WORKERS' V
COMPENSATION INSURANCE GREASFJINDUSTRL WASTE INTERCEPTOR
(This section neednot bpermit ecompleied if the peit is torose hundred dollars($10p)
BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
I certify that in the performance of the work for which this permit is issued,i shall SEWER-SANITARY-STORM F.A.2W FT.
not employ any person in any manner so as to become subject m the Workers'Compen- ENERGY FEE
ential Lyy ofC to
WATER HEATER WNENTIELECTR
z Applica \ t L �j GRADING FEE
y NOTIC TO APPLICA�41:haft 6aCmg this�ficam_rrmMFtmm you should WATER SYSTEMITREATING
become subject in the Worker's Compensation provisions of the Labor Colo,you must SOILS PEE
W G
Forthwith comply with such provisions or this permit shall be deemed revoked. WATER SERVICE
Q
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ.Try. PAID
(hereby affirm that there isaconstruction lending agency for the performance of
Fr the work for which this permit is issued(Seo.309?,Ci,CJ
O ULeaderts Name _ _ (TOTAL:
W Lender's Address TOTAL:
dy 1 certify that I have read this application and state that the above information is B WING FEE
0 correct.I agree to comply with all city and county entrances and state laws relating to QTY. MECHANICAL PERMIT FEE ��-'' 19 9 99 U
U building conservation,and hereby authmiae representatives of this city m ether upon the SE MICE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree to save,indemnify and keep harmless the City of Cupertino against E TRIC FEE
lishilities,judgments,costs and expenses which may in any way acme against said City ALTER OR ADDTO MECH. PL JM4 GFEE _
in consequence of the granting of this pemtit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000CFM) MECHANICAL FEE
SOURCE,REGULATIONS.
AIR HANDLING UNIT(OVER 10,0010 CFM) CONSTRUCTION TAX
natured pp a acmr Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE.
nAMDOUS ATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material BEATING UNIT(TO I Our)(01 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cade,Section 25532(a)? HEATING UNIT(OVER'1 00,000 BTU)
Fl Yes [I No VENTILATION FAN(SINGLE RESID) PAID --
Date Receipt#
Will the air commitments
mitmet in nturn behold oxectilby,hc Bay Aegripm unlit JManaement BOILER-COMP OR IW,000 BTU)
e,which
mit huzallous air ronmminants as Jefinetl by the Bay Area Air Quality Management TOTAL:
District?
F-1 ye, ❑No BOILER-COMP(OVER 1(10.00(1 BTU)
AIR CONDITIONER
1 have recd the h ode,Se materials requirements under Chapter 6.95 of to Ceti- - ISSUANCE DATE
famia Health ne Safety Code.Sections,than i,25533 end 25534.I understand that i(the NEW RESIDENTIAL MECH. SQ.FT.
building doe not curtentiy haveatenant,than it is my responsibility to notify the cecupnnt
of th vwhich sl be met pdurmissrance of a Certificate of Occupancy.
Ownernr theP Dam TOTAL: ISSUED BY:
OFFICE