99080102 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY G Q
CITY OF CUPF,R'1'INO BUG NG-MECHANI:AI. PE TND.
BUILDING PERTIN APPLICATION/PERMIT 1'But]D:NG-ELECT ELECTRICAL
BUILDING PROJECT IDENTIFICATION
Iil11LDINGADDRlSS: SANITARY NO. APPLICATION SUBMITTAL'DAT(
C4,
OWNEWSNAME R 1'IIONE CONI RAC9ORSNAME: LIC NO:
Z N/C CON'TROL#
all,
IITECT/F.NGINIiIiR: ,IC NO'. ADDRESS ❑
CONfACr: PHONE: BUILDING PERMIT INFO
❑ Consultant Fres Paid by Applicant(Initial) BrLLEG/ ELLEECTT PLUMB MEECCHH
hICI.NSEDCONI'RACTOR:S DECLARATION QTY. ELECTRIC PERMIT FEE
I heresy affirm tote i ant licensed scrim provisions rf chapter 9(c tucndng JOB DESCRIPTION
O tYZ withSection7100)of Divrsion 3oftbe Businwsand pidessinns Code,and myli=enm is RESIDENTIAL,
LL O PERMI1 ISSUANCE
�LLO infull f,Class effect. 3b 3 ,❑,,�SF��DWI. ❑KITCHEN REMODEL
Qzw Datr Class Lica�-/ APPLIANCCS-RESIDENTIAL .tCRUO1T10N DPLUMBING REPIPE
Ha a Dam Comm<'115�.J
❑y ARCHITECT'S DECIAR ION / PANELS GMULThUNIT G STRUCTURAL
z Z ti Z 1 understand my plans shall be used as public records MODIFICATION
/ UP TO PXI AMPS C]INTERIOR [I CHIMNEY REPAIR
Uanwd ProRsional 201-100AMPS IMPROVEMENT [DSWIMMING POOLS
C C ECLARAT ION
Q I hereby uffinn tM1 uNlamledmp Cfrum the C tmmgnh License Law for the O\'IiH IINX)AMPS D BATH RIiMODY:IIREPAIR ❑DIiA101.IT10N
k 3 a F Billowing yawn.(Section 7131.5,Business and Ptnfes,lnns Codc Any city or county SIGNS ELECTRICAL D OTHER
LL LL H4 which requires a Permit b eorwrwl.aha impone.denewisb,or repair any vesture
J prior to its issuance.also requires the applicant for such p=rmitto file a signed.statement SPECIAL CIRCUIT/MISC.
f y that he is licensed punuantto the provisions of the Contracbh License Law(Chapter 9
�y'OD (commencing with Section 7gXB of Di vision 3 of the Bust nese and Profexsinm Code) TEMP.MET ER OR POLE INST. COMMERCIAL'
C.ke a thus he is exempt therefrom and the basis for the alleged exemption.Any violation of D NEW BLDG/ADDITION ❑DEMOLITION
W.„m Section 7031.5 by airy a,,I,canl for a ptnuil,what the npplicom ton civil Penally of POWER DEVICES []TENANT ❑FOOD SERVICE
not more than filebundrell dollms(b5W). IMPROVEMENT
Sp ❑Lnv ownerof Nc pntPenY,or my employees wish wvg=,mthcir,Mc utntpenxation, SWIMMINGPOOLELECTRIC C1 OTHER
F. will do the work,and thestmdure is not intended m offered formle(See.'IUW,Hisinexs
aim and Proac dW,Cade:The Contrecmr's License law Jots not apply to un owner of ON LETS-SWITCHES-le TURES
property w'her builds or improves thereon,and who docs such work himself or through
his own employees,Provided that such improvements am not amended or offered for NEN'RESIDENTIAL ELECTR SQ FT.
salc.If,however,the building or improvement is sold within one year ofcnmplction.the SG.FI'.FLOOR AREA LSQ.FT.
owner-braider will have the hurdenof proving that he dad not build or improve for par-
,,,,a of,a,) TOTAL
ar-,os<ofsa,) TOTAL
UX /V—
M I,use owner of the property,an,exclusively eonrn<fing with licensed continuous a) '.
nnnmct Ne project(Site.9194,ITusiness and Profession,Code:)The Crnawb 1,U-
nseLaw does not apply toan owner ofpmp=ny who builds or improves therene.and QTY. PLUM TNG PERMIT FEE
who contracts for such projects with a contracmo%)licensed pursuant o the Contractors
Liccnm law. I PERMIT ISSUAN E
D 1 am exempt under Site .B&P C(or this reason
ALTER-DR__ -WATT IEA) VALUATION
ower Data
WORKERS COMPENSATION DECLARATION BACK E 'AS PROTE I: E .�5 afls
T I and waflinnunder penaltyof perjuryoneeltheinvarm mg Worker's
���/// 'EY�l
Inavc and will mamiy Section
37tenf Commato rCode,,warefor
arfiaw,Cnmpcn- DRAINS-IT,(1(3R,ROOP.A .C()NU. SORIES TYPHC.ONSTRUCI'IDN
cation as Provided for by Section 37 W of Ne IaMn Code,for the perfonnunce alone
work for which this permit is ixsuW. FIXTURES-PER TRAP
D 1 have and will oommin Worker',Com P,nsation Insurance,as required by Section
3700ofmc labCode,for nieIEA
e pehmoremse line walk for w'bith this pens issued. GAS- .SYSTEM-1 INCA
or OCC.GROUP Sw AP/S•
My Worker's Compensation Insurance cancer and Policy number are GAS-IEA.SYSTEM-OVER4(EA)
Carmen Policy No.: Z
CERFIFICA'IF OFEXEMPfION FROM WORKERS' GI1EA51%INDUSTRI.WASTE INTfiRCIiPTOR
COI PENSAI ON INSURANCE BUILDING DIVISION F13E5
(This,edinn need nrn heatmplamd it lbs lennit is for ane hondmd dnllnrx l5l W) GRI'.ASI:'T'RAP
nr lcsv.l PLANCIfECK FEE O
I ccmfy that imhc Mrfo rite worA En which this pcnnit i,icwN,lshall SEWER-SANITARY-STORM IEA.301 FT.
nm employ any peWp. �yypy m nosy so os b become subject b the Workers'Cnmpen- ENERGY Il3B�.,-�-
2 satins Las a li✓ WATER IIIiATER wNCNT/F.L[CE'R \
O O ApplicumY ,7��� - JI GRADING 1 rLl �n
z 2 NOTICE OA I,ICANI': L nfmr making this Cenifmae of Exemption,you st=aid WATER SYSTEWIREATING
(~ become vubjam to the Worker's Cumpenmtion provisions of the Labor Code,you must SOILS FEEJILil r-�
WQ Ionhwhheomplywith"Oroovistoniorthispcnnit,hallbedcemulrevoked. WAIHRSHRVICE II 12. u
OCTl/ O 9
0. CONST RUCHON LEN DI NO AGENCY NEW RESIDENT IAL PLM B. SQ,PT. PAID II )ate RecciptN -t-v s7
V O l hereby affirm that is a construction lending agency:D zfor the performance of
the walk for which this Permit is issued(Sac.3097,Ci,C.)
W U Lender's Name TOTAL:
O V TOTAL: i 1^f_
} W I.cnJcr',Address
y I cenify that I have read this application and state that the above information is BUILDINGP i
E' to correct.)agree to comply with all city and county on inners and state law%mlio ng to QTY. MECHANICAL PERMITFEE
U Z th dingeonamnction,anal hereby nothorim mpresontatives of this city to enter upon lire SEISM IC IT
ubo r-memionW property for in,pe<timt follows PERMIT'ISSUANCE
1 Wc)agree m save,malcmndy and keep hanalca the City of Culvabou against P.LECTR T'
finnllittc,judgmenu,costs and expenses which may in anyway allow against laid City ALTER OR ADD TO MECH, PLUM TNG �Bi
con=uenec of the granting 0f this permit.
APPLICAN UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICAL FE
S(Ill .E FPUULAT N.
SN AIR HANDLING UNIT(OVER IBM)CFM) CONSTRUCTION TAX
Signature of Appl4.ndCn ruatfor Uam ! EXHAUS'I'HOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will the appllcata of future building reenpnnUtore tit handle harmines material I U7AYING UNIT(TO 1(0,(00 BU)
as defined by the Cupertino Municipal Cole,Chapter 9.12,and Ne Health and Safety r
Code.Section 25532(tl? / HIiA'1'ING UNIT(OVER 100.000 BTU)
D Yes GNo VENTILATION FAN(SINGLE RESID) PAID
Dec Receipt N
Will the applicant or furore building occupant use equipment or device,which BOILER-COMP(31AP ORBTU)
BTU)
hazallous air contarmawas as defined by the Bay Area Air Quality Management TOTAL
7 BOH.lilt-COMP(OVER RO,NX)BIU)
❑Yes [-]No
I have read the hvuNou.s materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
m in Health&Starry Civic.Sections 25505.25533 and 25531.1 understand Nat if the NI?W RESIDENTIAL MECH. SQ.t•T. ^Q
building xswr rrcntly haveammn4 Nat it is my responsibility to nmify the sxcupant l� s 2 �7/
I
the o u icchh nnu�est M met pnonn issuance nfa CenificutI d`kcupa`p C
6 or amhoriecJ agent u Dom s1 / TOTAL: ISSUED BY:
OFFICE