99090137 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING ELECTRICAL PE o. 11
]BUILDING D}VISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: IN SANITARY NO. APPLICATION SUBMITTAL DATE
OWNER'SNAMF,: t PHONE: Y CO RACT R'SN II NO:
II1I��e0oUSa Nr 6Z NIC CONTROL#
CHITCC7LENGINEER: LIC NO: AI SDR SS: C } El0 ose// c
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fm Paid by Applicant(Initial) BLDG ELECT PLUMB .. MECH
60 ❑ O ❑
LICENSED CONTRACTOR'S DECLARATION QTY. - ELECTRIC PERMIT PEE
1 hereby of fin that I am licensed under provisions of chapter 9(commencing . JOB DESCRIPTION
FUS with
d0)mDZn3 of the Business and e'ro'sions Code,andmylicenu is RESIDENTIAL:
W 00 i ff
O L PERMIT ISSUANCE
s.UU Liven.)iyChess -Lie# ~ ❑SF'DWL ❑KITCHEN REMODEL
NGL Date-: L7_Comrazmr U JHv APPLIANCES-RESIDENTIAL . ❑ADDITION ❑PLUMBING R&PIPE
ARCHI'FEM'S DECLARATION ❑MULTI-UNIT ❑STRUCURAL
F. PANELS
Z p�NZ� 1 undersand my plans shall be used ac public records MODIFICATION
OZ-O UPT021KAMPS [I INTERIOR QPRIMNEY REPAIR
r4 t: Licensed Professional 201-I WIIAMPS IMPROVEMENT C]SWIMMING POOLS
9 y 5.'.a4l OWNER BUILDER DECLARATION
C 6 1 hereby affirm that 1 an,exempt from he Contractor's License Law for the OVER IOW AMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
WOCU following reason.(Secsion]031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
C I" which requires a permit ur connruct,elmr.improve,Jemnlish,nr rcpuir.ny.drucmre
ON prionoit issuance,also requires the applicant lorauch permino fileesigned staemcm SPECIALCIRCUIT/MISC,
.E y that he is licensed pursuanuo the provisions of the Connectors License Law(Chapter 9
(commencing with Section 100his'Division3m'the Businessand Professions Code)nr TEMP.METER OR POLE INST. COMMERCIAL:
C q m y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
iC 4-
Section 7031.5 byany applicant for a permit subjects the applicant mocivil ptrallyof POWER DEVICES
41^gym []TENANT ❑FOOD SERVICE
I-Zz cl not more than rise h ndredpidper ,or
em 6 IMPROVEMENT
F� ❑ 1.as owner of the progeny,or my employees with wages as Meir sole compensation, SWIMMING POOL ELECTRIC
will do the work,and the structure is not intended oroffered forsele(Sec.1044,Business .100
❑OTHER
and Professions Cafe:The Contractor's License Law does not apply to an owner of OUTLETS-SWITCHES-FIXTURES
6 3 progeny who builds in improves thereto,and who does such work hinaelf or through _
his own employees,provided that such improvements ore not intended or offered for NEW RESIDENTIAL ELE= SQ FT.sale.If,howevea are building or improvement is sold within one year of completion,the I' Q.PTTLOOR All \ S/SQ.ET.
o weer-builder whit have the burden of proving that he did not build or improve for pur-
Pose.f sale.).
❑ 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL: 9
construct the project(Sce.16/4,Business and Professions Cale)The 199
Cmanse nra Li. ,r SEP J
cense Law does not apply to n ownerof properly who builds or improves thereon,and qI'Y PL.UMBINGPE.RMIT FEE -
who contracts for such projects with o comma rens)licensed purr......the Contractor's (f
License law. PERMIT ISSUANCE
]Into exempt under Seo. ,n&P C for he,reaatn Dt/
ALTER-DRAIN&VENT-WATER(EA)
Dwner Data --
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
I hereby affirm under penalty of perjury one of the fallowing declarations: 00
I haveaad will muinmin it Cedifcme of Consent m,elf-insure for Worker's Compete DRAINS-FLOOR,ROOF,AREA,COND. -
action,as provided for by Section 3100 of the Latter Cale,for the performance of the STORIES TYPE CONSTRUCTION
work for which this permit is issue, FIXTURES-PER TRAP
❑ 1 have and will maintain Worker's Compruction Insurance,as required by Swint
37M of the labor Code,for the performance of the work for which this femur is issued, GAS-EA.SYSTEM.I INC 4 OUTLETS OCC.GROUP /APN
M WorkedJ..sA nRensatintyt none r and Pnlic nt h ry / b P z
Cam'er. 0�aw /14Y1 Qnrlc policy No.Y \ -99 GAS-LTA.SYSTLM-OVER4(EA) 1�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE. GREASEIINDUSTRL WASTE INTERCEPTOR
(This section need not be completed if the permit is forone hundred dollars($100) BUILDING DIVISION FEES
orlcs.v.) GREASETRAP PLANCHECK FEE
(certify thein me perficarepubi,anymannro lifireas
work for which this the Wokt is ersued.I shall'Com,em. SEWER-SANITARY-STORM EA.200 FT. I
not employ any person in any manner so as m become subject m the Workers'Cnmpen-
,� pn ntes of Calilbmia.Dae ENERGY FEE
Applicant
7O O Applicaant WATER HEATER WNENT/ELECfR GRADING FEE
q NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEMORFATING
ai 7 become subject to the Workers Compensation Provisions of the Labor Code,you most SOILS P EE
[Z7 f.rthwithcoeplysvith such provisionsorthispermitshall hedecmed revoked, WATER SERVICE
5 iris
z CONSTRUCT'ION LENDING AGENCY NEW RESIDENTIALPLMB. SQ Fr. PAID
U O I herebyafftnn the, here iso construction lendingugemcy far the performacco f Uete
LLF the work for which this permit is issued(Sec.3091.Civ,C.)
c U Lenders NameTOTAL:
Lkl Lender's Address TOTAL:
11....,� 0. 1 cenify that I have read this application and save that the above information is BUILDING FEE
F-ih convert QTY MECHANICAL PERMIT PSE
U Z building construction,and hereby authorize representatives of this city to enter upon the SEISMIC FEE
above mentioned property for inspection purposes. PERMIT ISSUANCE ELECTRIC FEB
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgmems,costs and expenes which may in any wayaccme egmemolid City pf;1'1?R OR ADD'I'O MLCH.
in consequence of the grant go t is permit. PLUMBING FEE
APPLICANT UNDERSTAND. A.'D WILL C IMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 14000 CFM) MECHANICAL FEE
ZEeVZ.CE REGULATIONS,
AIR HANDLING UNIT(OVER M."CEM)
V,,,- �ZZ CONSTRUCTION TAX
igm ore of Applicant/Comractnr Date EXHAUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material HEATING UNIT U 011)0.000 BTU)
os defined by the Cupertino Municipal Cale,CTapter 9.12,and[be Health and Safety
Code,Section 25532(x)? HEATING UNIT(OVER Ub"BTU)
❑Yes E:1 No
VENTILATION PAN(SINGLE RESID) PAID Dae -eve,
Will the sit comm or future building occupant use ea Air Qu or devices which
ithmardous air contaminants as defined by the Be,Area Air Quality Management BOILER-COMP(JHPOR IIXI,000 BTU)
trn^
❑Yes ❑Nu BOILER-COMPfOVER'IW,IXNI BTU)
I have mad the hazardous materials requirements under Chapter 6.95 of the Call- AIR CONDITIONER
4 P ISSUANCE DATE
fomi.Health&Safety Cust Sections 25505,25533 and 25534.1 uudemnd Bun iT the NEW RESIDENTIAL MECH. SQ.F n
buildingdon,mornently vee ant.mot it is my mspnnsibility In notify the oecupem
cqu osmems win mr et print to i....nce of a CediL t of upancy.
Owner or authorized agent Date TOTAL ISSUED BY:
OFFICE