S 3169 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-KLEiC7RICAI. PE ITNO
BUILDING DIVISION APPLICATION/PF.RMIT PLUMB NG-MECHANICAL ' 3169
BUILIA NO PROJECT ID&Ni`p,CAL—
CATION
BUILDINGADDRESS: SANITARY NO. APPLICA'T'ION SUBMITTAL DATE
L l //1-2 1)-99
WNERE
I'fIONE: CON"1RACfIIR'S NAME LIC
NIC CON'PROLW
.� ARCHITECT/ENGINEER: LIC NO: ADDRESS'. S ❑
C i
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(initial) BhDO ELECT' ' PLIJMq! M1?CII
LICENSED CONTRACTORS DECLARATION QTY. ELECTRIC PERMIT FEE
1 hereby.ffinn That Ion b,enaed ander provision.mf chapter 9(amsencing JOB DESCRIPTION
ICy1WZ with Section 9(XIO)of Division 3ri Business and Professions Cale.and my license is RESIDENTIAL,
ENTIAL,
FUS in lull force von effect. PERMIT ISSUANCE.
y.W^ ❑SFDW[. ❑KITCHEN REMODEL
FaUZU License Class Lic.4 APPLIANCES-RESIDENTIAL ❑ADDITION ❑PLUMBING RE-PIPE
N G L Date Contractor
ARCH] ECTS DECLARATION ❑MUI.TbUNIT ❑STRUCTURAL
(.p m PANELS MODIFICATION
Z Z-Z 1 unJerstaW my plans shall be ural as public records
OZ— UPTO 200AMPS TF TOR CHIMNEY REPAIR
Liei, al Professional 201-1pWAMPS I VEMENT SWIMMING POOLS
.�.d'W I hereby affirms
OWNER-BUILDER aexempt
mECLARATION th the License Law for the OVER TBW AMPS BATH REMOUCIIREI'AIR C DEMOLITION
iWWi55 d U following rasson.(Section]1131.5,Business and Professions Coda Any city m county SIGNS ELF,CTRICAL ❑OTHER
n++3 y which tegaires a permit to consumer.alter,improve,demolish,or repair any swcture
�,0� prior to its issuance,also requires the applicant fmrsuch permit to file a signed statement SPECIALCIRCUFIMISC.
T� that he is licansen pursuum to oho provisions of the Contnamr's License Law(Chapler9
W e580 (commencing with S,ctinr 7000)of Division3 oflhe Business and Profesniom Code)or TEMP.tel OR POLE INS, COMMERCIAL:
lL y m C that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
NanSection 90315 by any appliwm for a permit subjects the applicantto a civil penalty of POWER DEVICES
t more than five hundred dollars(55001. El TENANT ❑FOODSERVICE
F.ZY / 1 PROVEMENT
Q awnerof the property.o,my employees with wages as their rale armpenmarou SWIMMING POOL ELECTRIC
SG .v(7i ldosen,ark.nothe orucwmisam intended oroRemd tarsale(Sce.7044.Business THER
ce and Professions Code:The Contractor's License Law does not apply to an owner of OU'I LETS-SWO'CHES-FIXTURES
pmpcny who builds or improves thereon,sal who does such work himself or though
his own employees,provided that such improvements are not intended or offered for NEW RESIOENT1AL ELECTR SQ IT.
sale.If,however,the building or improvement is sold within one year f completion.the
Sp.IT.FLOOR ARRA 95Q.Ff.
ser-builder will have the burden of Forcing that he did not build or improve for pur-
r sale).
I,as owner of the propeny,um exclusively contracting with licensed contractors to TOTAL: .
canoed the project(Sec.9044,Business and Professions Code:)The Commerce's Li-
nw. Crew docs not apply to anuwnerofproperty who hands or improves thereon.and QTY. PLUMBING PERMIT FEE
who cautions for such projects with u Oubrou(s)licensed pursmun Ira the Commeno's
License Law. PERMIT ISSUANCE
El I aim exern n
Sec B&P C for this teams 40—
AL'fl?R-UIIAIN&VIiNT-WATER WA) VALUATION
Owner Dae
OR nuclei
COMPtiNSATION DECLARATION BACK FLOW PROTECT.DEVICE
,JjI herehy affnn under penally at Perjury one of the following d,chnmfmar.
❑I have and will maintain a Certificate of Content to self insure for Work,' OR AREA,COND. STORIES TYPECONSTRUCfION
satinn,as provided for by Section TOOK)of the Labor Code. or
the pert ce of the n
work for which this permit is issued. /-� FIXTII '-PE
❑1 have unit will maintain Worker's Cospcnsaion Insurance,as req.i Secti t
J7W of Ne Lobar Cale,fonhe performance of the work for which this if issued. GAS-EA.SYST AtI NC.40UTLETS OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy naMe,ma fSnO
Cartier: Polley Nm.: S ST ER 4(EA)
CERTRVCATE OF EXEMPTION FROM WORKERS' GRIiASF/INUUS ASTEIMF:HCEPTOB
COMPENSATION INSURANCE BUILDING DIVISION FEES_
(This secdmn newt not M1ecompincd ifthc lentil is for one hundred nllars($11X1) GRI3ASETRAP
or lees.) PLANCHECK FEE
I eenilythm itnhe psfnrmm�mnflhe work for which thispermit is ss6fd, _ Y-STORM EA.YOB FL
not employ any penal in any manner an as to become subjectto the Workers Compel- ENERGY PEE
ZZ satinn Lawsof Califomia.Data WNFER HEATER WNENT/ELECTR
Q Applicant GRADING FEE
On NOTICE TO APPLICANT,If,after ranking this Certmi to of Exemption.you should WATER SYSTEMO BEATING
a seems,subject to the Workers Compensation f the Labor Code,you must SOIIS FEE
3 e, rocu lonx u
4k1 Lmhwhh comply withsuch provisions nr this p,nnil shall he demWrcvnkeJ. WATER SERVICE
Q
.�7. Z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PCMB. SQ,FT. PAID Date ReceiptX
L) Thereby uflinn thanherc isannnwction lending agency fnnM1e perfurtnancc of
the work for which this permit Is issued)Sec.3099,Civ.C.)
0F' Lendefs Name POTAL:
{ULender's Address TOTAL
IJ . BUILDING FEE
1 certify That 1 have read this application and Stam that the above momentum n
Zi correct.l agree to comply with all city and county ordinances and state laws relating to QTY. MECHANICAL PERMIT FEE
U building construction,and hereby aulhonce representatives of this city to enter ups the SEISMIC FEE
aNne-mannan!property far in Nano n purposes. PH RMIT ISSUANCE?
(We)agree us save,indemnify and keep harmless the City of Cupertino against ELECTRIC FF:
Hahn ores,jud encs,cosh and expenses which may in any way acerae against said City ALTER OR ADD'10 MECH. PLUMBING FEF.
is cmnsequ t the gramin6 of thL permit.
APPLIC U ERS NDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL FEE
SOUR .0 'fit
AIR HANDLING UNIT(OVER IB,(XN)CFM) CONS'IRUCTION TAX
/- Signature of A,hctim/Croaralor Dae X EXHAUST HOOD(W/DUCT) HOUSING MITIGATION IEE
l HAZARDOUS MATERIALS DISCLOSURE
Will.ha.,licantor future building arrepaat arm or handle hreftel smmen0 HEATING UNIT('11)100.0X1 BTU)
as defined by the Cupertino Municipal Cade,Chapter 9.12,and the Health and Safety
Coda Section 25592(x)? HEATING UNIT(OVER Hr BTU)
L]Yes Fl No PAID
VENTILATION FAN(SINGLE RESID) Dam Receipt
Will the applicant nr furore hnilJieg occupant use equipsent or devices which BOILER-COMP I311P OR I W,(MX)RTU)
emit haysnfous air contaminants as defineArm d by the Bay AAir Quality Management TOTAL:
DcanetP
❑Yen 0 N BOILER-COMP(OVER 100.000 BTU)
I have roan the hazardous materials requirements under Chapter 695 of the Cali- AIR CONDITIONER JJJ ISSUANCE DATE
forms Hwllh&Safety Cale,Sections 25505,25533 and 25534,1 understand that if the NEW RESIDENTIAL MSCI I. SQ.FT.
huilding does sol cuncnlly have a tenant that it is my mspsnsibilily s notify dna recupant /
of the nal ieements which must be mel prior to issuance of a Certificate of Ccropawy
Ownerormlim od!.gent Dare 'ITOI'AI ISSUED BY:
OFFICE