99080142 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY.OF CUPERTINO BUILDING-ELECTRICAL
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL ?
•' BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLICATION SUBMITTAL FATE
%Jp 'S NAME; �ONF.: CONTRACTOR'S NAME: LIC NO'. N/C CONTROLM
ARCHITECVENGIINEER: LIC NO: ADDRESS ❑
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG FLECT GIVE ECH
LICENSED CONTRACT'OR'S DECLARATION
QOZO QTY. "ELECTRIC PERMIT, FEE
1 nmeby arum mal I am hanged nnaer proviamna or Chapter 9(commencing JOB DESCRIPTION
with Section 90W)of Division 3of the Business and profefoois Cadgand my license is RESIDENTIAL:
�r
an full fora and eR PERMIT ISSUANCE ❑ SIDEFDWL CHEN REMODEL
C VZE+ License Cl Lic.9 APPLIANCES—RESIDENTIAL
<ydW Date$
Cc factor ❑ApDIT10N ❑PLD INO RE-PIPE
Fp>y> 1, '1 ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT L1 STRUCTURAL
Z O�A I understand my plena shall be used as public records MODIFICATION
O Z UP TO 200 AMPS
F=—W Licensed Pr..fessmnal Ll INTERIOR LJ CHIMNEY REPAIR
261-IOTU AMPS IMPROVEMENT SWIMMING POOLS
+y' OWNER BUILDER DECLARATION OVER I(KKIAMPS ❑
I hereby affirm that 1 am exempt from the Contractor's License Law for the ❑BATH REMODEVREPAIR El DEMOLITION
a F following reason.(SNLIOn 9031,5,Business and Professions Cole:Any city or county SIGNS ELECTRICAL ❑OTHER
which requires a permit to construct,alter,improve,demolish,or repair any somenco
rn Jd prior to its issuance,also requires the applicant for such permit file a signed statement SPEC IAL CIRCUIT/MISC
WNY that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9
CQ� (commencing with Section of Division 3 of the Business and Professions Code)or O O TEMP.METER OR POLE INST ^MMER
c is exempt therefrom and me basis for me alleged exemption.Any violation of
Se
YiCI Sectioio n 903156y any applicant torn DEMOLITION
ITNANT G/ADDITION ❑FOODSERVI
permit subjects the applicant loucivil penally or POWER DEVICES TENANT ❑FOODSERVICE
(„Z nal more man five hundred dollars($Sfq). IMPROVEMENT
SQ ❑ I,as owner Of the property,or my employees with wages as their sole compensation, SWIMM GPOOL ELECTRIC y will do the work,and the structure is not intended m offered forsale(Sec.]0,4,Business ❑OTHER
3 m and professions Code:The Combrox''s License Law does not apply to an owner of OUTLETS HES—FIXTURES
Property who builds or Improves thereon,and who does such work himself or through
his own employees,provided that such improvements are nut intended of offered for NEW RES] TIAL FLEfICk SQ FT.
sale.If,however,the building or improvement is sold within One year of comphoma,the SQ.FT.FLOOR AREA $/SQ.FT.
ser-builder will have the burden of proving that he did not build or improve for pur-
poveofeno.).
❑I,as owner Of the property,um exclusively contracting with licensed contractors to TOTAL:
,,.I'm.the project bee.7044,Business and Professions Codc)The Contractor's Li- -
se Law does not apply to an odder of property who builds Or improves thereon,and QTY, PLUIOEU ERbk FEE
who wmracts far such projects with a am rs m,O)Ilcensed pursuant m the Cond uctors
License Law.
❑ I oto exempt under Sec. ,R&P C for this reason PERMIT ISSUANCE
Owner Data ALTER-DRA NT-, 1'E (EA)
mss.E( / VALUATION
WORKER'S COMPENSATION DECLARATION BACKFLOW CT.D IC_$ - / �]/Ifj'�
I hereby affirm under penalty of pNjury,one of the following declarations: `i (�(/l,./
❑Ihvve anJ will maimoin aCertifiw¢of Consentm self-insure for Worker's Compen- DRAINS-PL ROOF,AREA,C ND.
cation,as provided for by Section 3710 of the Labor Code,for the performance of the STO ES TYPE CONSTRUCTION
workf hich this permit is issued. FIXTURES TR D )V
ave and will maintain Worker's Compensation himeo use,as required by Section
39W of the Labor Code,for the performance of the work for which this permit is issued. GAS-EA. TEM-1 INCA OUTLHTS OCC.GROUP APN
My Worker's Com eneaypp Incur neeearrier and Policy nye= s. I�Q r
Caries��po]icy No: �" RKEFFS LS GAS—EA. YET -OVER4(EA)
CERTI CA OF EXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE GREASFIINDOrTItICWA6T pR eU¢.DMO DIVISION FEES
(This section need nm be completed if the permit is ficamuhundreddollam($IW) GREASE TRAP
or taxa.) PLANCHECK FEE
Icomlythali ormanceorlhe waft or which Nis permit is issued,l shall SEWER—SANITARY—STORM EA.200 PT.
nolemploy any mi an mann s ec a hJyP��tmthe Workerk mpen- ENERGY FEE
,� smion Loewe alifomirIIe u 1
O �J, o WATER HEATER WNENVELECTR GRADING FEE
7 Applicant
a y NOTICE LFfifivide of Exemption,you should WATER SYSTEh1/TREATING
a ^' become subject m the K'orker's Cotopensutipro
revisions of the Labor Code,you must SOILS PEE
Wry forthwith comply with suchprovisione or this permit shall be deemed revoked WATER SERVICE
L A
CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SQ.FT. PAID
VQ kforwhichmmmmit i issued( ectioulending agency for the performance of Fate Receipt is
W the dark for which this permit is issued(Sec 309],Civ.CJ
Q Lender's Name TOTAL:
w Lenders Address TOTAL:
a I certify that I have read this application said.date that the above information is BUILDING F
VI comet,l agree to comply with all city and county ordinances and nate laws relating to QT'Y. MECHANICAL PERMIT FEE
V z
building conswdioo,and hereby authorize represenmlives Of this citymenmr upon the SEISMIC FIFEE above-mentioned property for inspection proposes.
(We)agree m save,indemnify and kap M1armless the City of Cupertino against PERMIT ISSUANCE ELECTRIC
liabilities;lad menta,caste and expenses which may in any way same against said City ALT ER OR ADD TO MECH.
Inco a if the grandog of this per ' PLUMBIN
(CANT INDERSTAND$ WI COMPLY WITH ALL NO POINT AIR HANDLING UNIT(TO 10,000 CFM)
OURCERF ULATIONS, MECHANI
AIR HANDLING UNIT(OVER 10.030 CFM) CONSTRUCTION TAX
re ofAppfcmWCmn WIV EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
- HAZARDOUS ERIALS DISCLOSURE
Will the app000d or future building occupant store or handle hazardous material HEATING UNIT(TO 100,000 BTU)
vs de0ncd by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safely
Code,Section 25532m)? HEATING UNIT(OVER 100,000 BTU)
El Yes VENTILATION FAN(SINGLE RESID) PAID
Da¢ Reeei
Will us air co applicant or furore building y the B use equipment Or devices Management
BOILER—COMP(3HP OR 100,000 BTU)
ch
mit hezallous air amfaminnnts as defined by the Buy Arca Air Qualify Management T L:
D hiet9 ^�
❑Yes s�O BOILER-COME(OVER IW,(NIO BTU)
rand the hamNous m is under Chapter 6,95 of the Cali- AIR CONDITIONER
NO 2555 en p Q 139U C1 DA
f a Hea it,Solely Code,S tons 25. 5,25533 and 25534.I mnderst that it the NEW RESIDENTIAL MECH. S FT.
uildin ono cumn0yn comm i at it ice'my resporchilily to noti me Nc and
of there iiremNte which ust rte me rinr eofn CNtifl al Occup ey.
i- er or authorized agentle TOTAL: ISSUED BY:
OFFICE