99080179 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT 1.-�Zf-�CrQD
lit
CITY OF CUPERTINO
BUIL ANG�EL90 1119
F.CTRIC� 9.3 NO.
BUILDING DIVISION APPIACATION/PERMIT PI.UMi11NG-MECHANICAL
RUILIIING PROJECT IDP:NTIF'ICATION
BUILDING ADDRESS: SANITARY NO, APPLICATION SUBMITTAL DATE
W R:S NAME: P ONE: CONTRACTOR'S NA E: LIC NO: (/(�f—�
m O, NIC
CONTROL It
C TECTMN'IN ER' I LIC NO: / ADDRESS: ❑
a. 62o6GS wooer !�.
r I'I1.0sNF� O BUILDING PERMIT INFO
� � Wf�N.L�� � ❑ Consultant Fees Paid by Applicant(Initial) BLU ELECT PLUMB MECII
GG ❑ ❑ ❑
LICENSE)CONT'RACTOR'S DECLARATION QTY. ELECTRIC PERMIT 17EE
hS1 hereby alum mol;]am fimnsed ander provisions or Chapter 9(economical, JOB DESCRIPTION
C=Z with 7000pd Division 3 mfthc Business and RafessionsCWe andmy license is RESIDENTIAL:
W O p PERMIT ISSUANCE
in full forecand corer. ❑Spil ❑KITCHEN REMODEL
aVV License Class Lica APPLIANCES-RESIDENTIAL DITION El PLUMBING R&PIPF-
NZLDmc Cnmmc -
O P. ARCED'PUTS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL
ZO0Z 1understand may plansshall beusedaspublic amid, MODIFICATION
OZ-O LJPT02MAMPS ❑INTERIOR C1 CHIMNEY REPAIR
1-Kf"u1 Licensed Professional 201-BNp AMPS IMPROVEMENT []SWIMMING POOLS
�s1f_z OWNER-BUILD17R DECIARA'I'[ON OVER ISAAMPS ❑BATH REMODEUREPAIR ❑DEMOLITION
9 C @ I hereby allinn that l am exempt from the Conavam'x License Law Sic the
xxa O i U following reason.(Section 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL ❑OTHER
W 3 W H which requires a permit tocanaln¢L.1w,immor e,demorxb.or repair any amelnre
F"u'G< Ed...1.it,i..uanon.also mature,the applicantforauch permit In File a signed statement SPECIAL CIRCUIT/MISC.
.hal he is licensed pursuant the pow ntons of the Contmdor s Licari Lmw(Chm IcV
�a�0 (commencing with Section700(oml'Division 3 of the Business:md Professions Cohn)or TEMP.METER OR POLE INST. COMMERCIAL'
a d e C mat he is exempt Therefrom and tic basis forme all exemption.Any violation of ❑NEW BLDG/ADDITION ❑DIiMOLIT[ON
XCn Section 7031.5 by any applicant for a permit mnject%the applicant to a civil penally of POWER DEVICES TE ❑FOODSERVICE
W-. t
FZQ more Than five hundred dollars S500).las owner of the norm byes with woes as their win compensation, SWIMMING POOL fiE,ECfBIC VEMENT
_ ❑ Cope y Yemp Y 6 Cnsa ❑0
F• will Jo me work,and Cush the h.ctumCont is nor,Lim
w Law doesed a.,apply n0ar own mess
W am anderty whio b Gale:'Imp Comtherma License Lawdiesnotrpply no himself or
OUI'L1515-5WITCIIES-PI%TURKS
prupeny who hailers onmprovcn thermal,and who Jos such work himself nr Through
his own dnployeas,provided into such improvements urn nal Imcnded nr offered for NEW RESIDENTIAL ELECTR SQ FT.
sale.If. Ih
ficamer, ebuildingomstaidr improveent taid within one year cfmnnplelinq the 'Q.Ff.PLO(IR AREA $ISQ.led.
owner-milder will have the burden of proving that he did oat build or improve far,,
five of sale.).
I,as owner of the property,am exclusively contacting with licensed contractors to TOTAL: 'Il A02.
conswct the project(Sec.70,14,Business and professions Calc:)The ComadnrI Li- /z
nue Law does not apply tow owner of property who builds or improves thereon,and QTY. PLUMBING PERM IT FEF.
wfio contracts for such projects with a contraction if licensed pursuant to the Contractor's
License Law, PERMIT ISSUANCE
I am exempt under Sec. ,B%P C lin this reason
ALTER-DRAIN d VENT-WATER(EA) VALUATION
Owner Due 3/010. 4/0
WORKER
made,
Catty of SATION DECLARATION milmoTON BACK FLOW 1'ROTIECr.DEVICE
1 herebyaffirmattention
tteunder CImM1y le perjuryone ormefmlmving declaraWorker s Ca
ns
Shave and will for bynen..37 c of dic Labor sclChadenwrcfnr Wmkcr's Ce of
UHAINS-I1,00R,ROOF,AREA,GOND. STORIES 'TYPECONSTRUCTION
tion,m providedh i for by Section 37011 of the Labor Cale,for tie performan<e of me
work have
illnpermiin issued, FIXTURES-PER TRAP ' \/.
1 have and will maintain Workers mance ofthe w Insurance, h required by Section �rrV
37(0 of the LaorCode,for the performance ohhe work for which this permit is issuM. GAS-G.SI'S'TF.hhI INC.40UTLGrS OCC GROUP APN
My Warkmh Cpnqunfalinn Invarunmc currier nnsl Policy number arc:
Camey: Policy Nn: GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OP EXEMPTION FROM WORKERS' GRL'ASF/INDU$THL WASTE INTERCEPTOR COMPIENSAI']ON INSURANCE BUILDING DIVISION FEES
(His attfnnnmdam be completed The permit is forest,hundred dollars($100) GREASETRAP
ur lass) PLANCIIECK ME
Imr-hythal intbe pe rlbrnumuccafthewook leawhich(lik,rmil iv i.oned.Ideth SEWER-SANITARY-STORM IA.2N)PI'.
not employ any person in any manner w as to become subject the Workers'Ci mpcn- (ENERGY FEE
�Zsari....Lao—of California. /
a.Data WAI'I7R HEATER WNENELECI'R
Z O Applicant GRADING PCI:
NOTICE ED APPLICANT:IL after ranking this Cenificam of Esemptimn,you should WAT1ER SYSTEM?BEATING
j penia provisions o you mush SOILS INCE
C hcmmc object m the Worker's Gsm tion ofthe hnhur Coat,, /t•
W forthwith comply with such provisions or this permit shall an,deemed avoked. WATER SERVICE
Q
7z CONSTRUCTION LENDING AGENCY NEW NESIULNI'IAI.PLMR. SQ.PI', PAID Data acceptn
L) O I hcmbyoffirm thmticrc isacnns0uction lendim,,emcy forthe perfo.....f
the work Tim s Iro
which thimnit ix.....I(Sa:.3097,Civ.CJ
C) [,Me,'a Namc TOTAL:
V Lender's Address TOTAL:
} 1BUILDING FEE7040 .
Q a
I ccnify that I have real Ihls application and stoic Combe move ininrnmtinn is
Ftq correct.I agree to comply with all city and county ordinances and stare laws relaJngto QTY. MECHANICAL PERMIT FEE
UZ molding construction,and hereby amhoiee memas,neuivice oflhin city to enrerupom the SEISMIC ME
move"mentioned property far inspection .,I've,, -
ISSUANCE
(We)agree to nave,indommfy and keep harmless the City of Cupertino agaimt IELEC'TRIC F[E
I'molawb.Erdgmcne,cmua..dmxpcmes whichnmy funny wuyuccme anninsi-int City ALT ER OR ADD TO MECII. PLUMBING FEE
in asequence of the lamming ofmis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL.FEE
SOURCE .GULATIONS.
AIH HANDLING UNIT(OVER 10.010CPM) CONSTRUCT ION TAX
Signature of Applicam/Cammcinr Date EXHAUSTHOODfWA)UC) HOUSING MITIOA'I'ION FEE?
IIA2ARDOUS MATERIALS DISCLOSURE
WIIlmenpplicanl or lumnc bnilJin6neenPa^t,fore or handlchwallous arawmai BEATING UNIT(TO bill BTU)
as defined by the Cupertino Municipal Calc.Chapter 9.12,and the Heaph and Safely
Credit,Section 25532(a)7 HEATING UNIT(OVER 100.010 It My
/ 0Ycs � VEN'1'ILA'I'IONfNN(SINGLERI?SIO( PAID Dmc Receipt
Will the applicant or future huilding accupom use equipment nor devices which� BOILER-COMP CHP OR 80,000 BTU)vil hasardnus air conmminanrs as ddha d by the Be,Mea Air Quality Management TOTAL
smd'I Yes Ste
BOILER-COME(OVER 100,000100,000BTU)
I have ad c hazvdous marenah uircou"a soler Chat me,695 of the Cali AIR CONDI'TIONEiR ISSUANCE ATF:
mor Ilcul afdy Cnde,Scan a -511 25594 mW 255W.1 u mond mm if the NEW RESIDEN'[At,MIECH. SQ.FI'. 9
building ecu ntlyhav t, my rcspnrnibiih madythe occupant
non n, earaee ,in nor ap.rte.
ta, mort:.ee engem Uu TOTAL: ISSUED BY:
OFFICE