99090003APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPF.RTINO BUILDING - ELECTRICAL PERMI NO.
BUILDING DIVISION APPLICATION/PERMIT PLUM...r..atecxnN........
I hereby affirm thaTfim 1wemed under provisions of Chapter 9 (commencing
Z with Section INS))of Division 3 of the Business and Professions Cade, and my 11 cense is
WOOI � in full Torre :mei elf" us
Q V V Licence Class
I. a �
ZZW
Dale Cord II ,p
VI
ARCHITECTS DECLARATION
'on
Z I understand my plans shall be used as public records
)Z ay
-y
t:adLicensed Prom, Tonal
OWNER.BUILDFR DECLARATION
5 C W U ` , 1 hereby nlDrm that I am exe11gn from the Contraco is License Law for the
3 L following reason. (Section 7031.5, Business and Professions Code,, Any city or county
y which requites a Permit m consaucl. Ater, improve. demolish, or mpair any almalure
U. C)Q prior to its issuance. also requires the applicant how such permit to file a signed statement
e y s+l that he is licensed pursuantto the provisions of the Contractor'sLicense law (Chap¢r 9
]Eno (commencing with Section 7000) of Di vision 3 of the Business and Professions Cude)or
. W that he is mount mcmfmm and the Mitis for the alleged escnnption. Any vialminn o[
'K m h Section 70315 by any applicant lure punnit subjects the applicant m u cIv11 pnuthy of
W ; not more than live hundred dollars ($500)
f2 ❑ I. as owner of the property, or my employees with wages as their sole compensation,
p., will do the work. and the swaua is not intended or offered for sale(Sce. 0044. Business
a 3 m and Professions Calc The Commetor's License law docs not apply to an owner of
prop:ny who builds or improves flo mon, and who doe., such work himself or through
his own employees, provided that such intprnvements are not intended or otmo d for
lode. If, however, If, hnilding or improvement is ,,to within ono year of conflict 11,11, the
owner -builder will have the burden of proving that he did not build or improve Iia par.
pose of sale.).
❑ 1, as owner of the prnpnY, am exclusively contracting with licensed cootracmrs to
ondiden the project (Sec. 7141. Business and profession. Cade:) The Convectors Li-
u Law dow not apply to as owner of property who builds or improves themon, and
who contracts for such projects with u contratoons) licensed pursuant to the Commctor's
Licence Law,
❑ I an, exempt under Sec. If & P C lin this mason
ONT'RACfOR'S NAME: LIC NO:
DURESS:
q q1.1 Qf-A -'lia #IJ
W. WX q
❑ Consultant Fees Paid by Applicant (Initial) _
4Y. ELECTRIC PERMIT
PERMI I ISSUANCE.
APPLIANCES — RESIDENTIAL
PANELS
UP TO 200 AMPS
201-I0XIAMPS
OVER WWAMPS
SIGNS ELECTRICAL
SPECIAL CIRCUMMISC.
TEMP. METER OR POLE INST.
POWER DEVICES
Owner Date
\ WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of Perjury one of the following declarations:
` I have and will maintain a Cenifcme of Consent m self -Insure for Workers Compcn-
as provided Ruby Section 371X1 of the Labor Code, I'or the pumoccons. of the
.ork for ch ch doo pennit is twin d.
1 have and will maintain Worker'v Comlunaation Insurance, as required by Section
3700 of the Labor Cale, for the Performance of the work for which this pemnit is issued
Me=
��^a ti Ism ecemer and Policy nutnMra pp
Cartier
CI:RTIPICATE OF EXEMPTION FROM WORKERS'
COMPENS]ON INSURANCE
(This n¢linn scud nal hewinplcmJ if the Permit is funme hundred doll., ($ IIX))
or (etc.)
1 rem y that in the performance of the work for which this permit is issued. Island
not employ any person in any manner sit as to become sub act to the Walkers' mp
Coen-
rZ cation Laxxof Califomia. t
O Applicant_
z to NOTICE TO APPLI ANT: 11, after maks t n Ce licate of Exemption, you should
(~ become subject to the W ..for, Con.pn..... t + ms of the Labor Code, you nmol
forthwith comply with ouch pro ...inm 1,r this throut shall be dccmcd revoked.
d
CONSTRUCTION LENDING ngagerAGENCY
U 0 Thereby affirm that there is oconstmction lending agency for p:rformanc<of
U. P the work far which this Permit is issued (sec. 3197, Civ. C.)
Q U Lenders Nunn.
iW Lenders Address
0. 1... fify thin I have read this application and state than the above information is
Hh correct. l agree to comply with all city and county ordinances and state laws mating to QTY.
U Z building construction, and hereby authorim representatives of this city to enter upon the
aMve-mentioned property for inspection purposes.
(We) agree to as. indemnify and keep harmless the City of Cupertino against
liabilities. judgments costs and eateries which may in any way accrue against said City
he ... umccof she 8 amin, of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Willnbe uPPlinm or fumrc builAng acupam store 1,r handle hmmokaw material
us refined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Calc,Smon 25532(1,)!
E3 Yes 'KNo
Will the applicant or future hnilding acupam use equipment or devices which
emit hazardous air comeminants redefined by the Bay Area Air Quality Management
/
E] Yes ANu
1 have and the hmardous material., mquircmems under Chapter 6.95 of the Cad -
forma Health & Safety Code. Sections 25505. 25533 and 25534. 1 understood that If the
building does not currently have a Lamm. that it is my responsibility to notify the occupant
PLUMBING PERMIT
PI3RA11'I'ISSUANC'
A1rER—DIA .NT—WATER (EA)
BACK I1�V1�ItOT/: _
FIXTURES—PER TRA('
GAS — EA. SYSTEM -I INC. 40ETS
GAS — EA. SYSTEM -OVER 4(FA)
GREASE IINDUSTRL WASTE INTERCEPTOR
GREASE TRAP
SEWIER— SANITARY — STORM EA. 201 FT.
WATER HEATER WNENIDELECTR
WATER SYSTEM/rREATING
WA'I ER SERVICE
NEW RESIDENTIAL PLMIL SQ. IT.
1—C
FLOORAREA
/d dAoz'
STORI . TYPE CC
OCC. GROUP
t
BUILDING DIVISION FEES
PLANCHECK ITE
ENERGY FEE
GRADING FEE
SOILS FEB.
PAID
Dam RccelptN
MECHANICAL PERMIT
FEE
i I1
r S 1 1C-6ce I I,
Fe 6-4
BUILDING PERMIT INFO
BLDG ELECT ,Y ❑MB ME❑CH
ES'
1;1
ALTER OR ADD TO MECH.
FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION ❑ PLUMBING RI; PIPE
[I MULTI -UNIT ❑STRUCTURAL
MODIFICATION
❑INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT []SWIMMING POOLS
El BATH REMODE EPA( [DDEMOL 10
El OTHER _
s+
AIR HANDLING IINITT1010.000 CFM)
LMGCHANIGAI. N141i
AIR HANDLING UNIT OVER 10.000CF1,0
CONSTRUCT ION TAX
COMMERCIAL' /q x/r1
[I NEW BLDG/ADDITION ❑DEMOLITION
❑TENANT ❑17001) SERVICE
IMPROVEMENT
❑ OTHER
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.010 BTU).
FLOORAREA
/d dAoz'
STORI . TYPE CC
OCC. GROUP
t
BUILDING DIVISION FEES
PLANCHECK ITE
ENERGY FEE
GRADING FEE
SOILS FEB.
PAID
Dam RccelptN
MECHANICAL PERMIT
FEE
i I1
r S 1 1C-6ce I I,
IIs
PERMIT ISSUANCE
ECTIHiIi 1 IJ II
1;1
ALTER OR ADD TO MECH.
nPLUMBING FEE
s+
AIR HANDLING IINITT1010.000 CFM)
LMGCHANIGAI. N141i
AIR HANDLING UNIT OVER 10.000CF1,0
CONSTRUCT ION TAX
EXHAUST HOOD (W/DUCT)
HOUSING MITIGATION FEE
HEATING UNIT (TO 100.010 BTU).
HENT ING UNIT (OVER 11101X10 BTU)
PAID
VP.NTILA9TON FAN (SINGLE RESID)
Date Receipt at
BOILER —COMP (311P OR 1 MOM BTU)
TOTAL
1
HOILP.R —COMP (OVER I f10.IXM) BTU)
Ak CONDITIONERJ$S=ANCE,
ATE
NEW'RCSIDENTIAI. MECH. SV. FT.
TOTAL
OFFICE