99090139 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-F,LECPRICAL P
a BUILDING DIVISION API'LICATION/PERMIT PLUJtBING-MECHANICAL '
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: - SANITARY NO. APPLICATION S UBN.
l ►E LAuW- 23
"R'S NAM PHONE: CON'TRACTOR'S NAME: LIC NO:
�g NIC CON'1'ROE.p
AR'HIT,CTII;N�NEER'. K LIC NO: ADDRESS: ❑
CONTACT: `•• PHONE: - 6UILUING PERMIT INFO
❑ Consultant Fcev Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑. ❑
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 hereby ammo that 1 am licensed under provisions of Chapter 9(commencing JOB DESCRIPTION
Woo with Section 700)of Division 3 of the Business and Professions Cole.and my license is R T
W O PERM I ISSUANCE f
F W m lull torccund uff.al. ;I'DWL- ❑KITCHEN REMODEL
C J F Liccnsc Class Lic.e
IQ-ZUNI Das Commcmr APPLIANCES-BESIDENFIAL ❑ADDITION ❑PLUMBING RILPIPE
,Q ao ao ARCHITECTS DECLARATION ❑MULTI-UNIT ❑STRUCTURAL
~h Z I undercut I mY plans.ball be mail as public ratters PANELS MODIFICATION
Oz 4-a UP 1'0 210 AMPS A ❑INTERIOR [D CHIMNEY REPAIR
Licensed Prof..imed 201-IIXIDAMPS IMPROVEMENT []SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER I"AMPS C1BATH REMODEUREPAIR [IDEMOLITION
1 C W Q I hereby affirm rm th t 1 Pt fromtheC t ter. 1 1 for the - ❑OTHER
if Ot1V follow 8 (S.eun 711115 N ten dP f:. 'Csd A Y ty ounlY SIGNS I?LECfRICALY
W 3 LL N which req Permit t construct,alter, P demolish, pa Y tructure J��r n'�� "`-••fFF///'�I-lll.���
i prior to its.. atm requires the applicant for such permit t file a Signed.trement SPECIAL CIRCUR/MISC. —that he he is licensed pursun
uno the provisions tithe Contractors License Law(Chapter 9
W�QOO (commencing with Section 70)0)atD......s3efdre Br,nmutord Pnufeysions Code)a, TEMP,METER OR POLE INS'T. COMMERCIAL
0.d c C That he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
�:2 Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of POWER DEVICES ❑TENANT ❑FOOD SERVICE
,.?a
tmore Nun five hundred dollars($500)
5 . IMPROVEMENT
�=QOf,ns ownernl the proryny,nr my unployces with wages as their sole mmpansauon, SWIMMING POOL ELECTRIC [I OTHER
will do the vv k,aalfluitmcmreisnot intended or offcead for sale(Sec.71W,Business
L 3 m and Professions Code:The Contractors License Law does no apply 1tt as owner of DO 11.ITS-SW'1'FCHES-FI%TURES
property who builds or improves thereon,and who docs such work himself or through
' his own employees,provided that such improvements aro not intended or offered for NEW RESIDENTIAL ELEC IO SQ FT.
sale If.harvest,rbe mildine o i.npou am is sold emionna yalrof,omplelion,the SQ.FT.FLOOR AREA ASQ.let.
suns-udder will have the human of proving that he did not build or improve for pur-
Puae of sale.).
C] 1,as owner of the property,am exclusively contracting with licensed contractors to TOTAL
nsni an the now(Sac.7044.Busir ass and Prufaesi ins Cods:)The Conlrazmr's Ll-
cerise"a does not apply ni an owner of property who builds or improves thereon.and QTY. PLUMBING PERMIT 'FEE
who comma for such projects with a ctmmmcmr(s)licensed pursuant to the Contractor's
Liccnsc Law. PERMIT ISSUANCE.
m exempt under Sm. B&P C for this reason
_ ALTER-DRAIN&VENT-WATER(EA) VALUATION is/f
WORkER'SCOMPENSATION DECLARATION BACK ROW PROTECT.DEVICE }s lTpe
I hereby affirm under Penalty of perjury nue of the following declarltions: 00g
I hove and will maintain a Certificate of Couwnnowlf--iwure iiasic k,,,Conmpen- DRAINS-FLOOR.ROOF,AREA,GOND. STORTf.S TYPE CONSTRUCTION
cation,as provided for by Section 3710 of the Latour Code.for the Performance of the
work for which this periil is issued. FI 71 URES-PER TRAP
F1 I have:md will maintain Workers Compensation Insurance,ns inquired by Section
_ 37110 of the Labor Code,for the peroanionce offhc work for wh'mhthis pcmdt is issued. GAS-EA.SYSTEM-1 INC.i OUTLET'S OCC.GROUP APN
_ My Workds Compensation Insurance curierand l'olicynumMrare:
Carica Policy No.: GAS-
EA.SYSTIiM-OVER 4(EA)
CERTIFICATE OF EXEMPTION FROM WON KERS' GREASFIINUU$'I'RL WASTE INTERCEPTOR !�
COMPENSATION INSURANCE _ BUILDING DIVISION FEES
Ohlsscatin 0 need atm,hecomplemd iflhcpcnnit isfornnehundreddollnrs(8110) GREASETRAP
or less.) PLANCHECKPEIi
Ioyany than in the any manner of the work for which this per mit is is Cooper. SEWER-SANITARY-STORM EA.200 FT - y T- 7
nmemployany person in any manner so aswhemme subject to Wariest Cooper. ENERGYFEL's�N _ us
0 z scion Laws of California Uma WA'1'17R HEATER W/VGN'1'IIiLECTRal2ADIN sG PGE J IIs
Z Applicant s
q NOTICE TO'APPLICAN'f:If.after making this Ccnifiame of Exemption,you should WATER SYSTENVEREATING j SOUS F,Ei6 tnf C�
I--' become subject to the Worker's Compensation provisions of the Labor Code.you most ,r- l f D l 9 l'i1y 1
WionhwiN comply with ma h provisirnsor lois Pcnrit shall he [armed revoked. WATER SERVICE - t � L
= z CONSTRUCTION LENDING AGENCY NEW RESIDENT IAL PLMB. SQ.FT. 1 AN Dole Re eipt b
L) C) Imarch,affirm that them is aconsauanart lending agency for the performance
w F" the work for which this permil is issued(See30D.Civ.C.) _ k.i - TOTAI: 'J
0 V larder's Nana
Iandcrs AddressTOTAL:
} 0. I cenlfy that I have mad this application and dual at the above information is BUILDINGFEE
, correct,l agree to comply with all city and county ordinances and state laws relming to QTY. MECHANICAL PERMIT FEE
I.) Z buildingponurctimrand hereby amen,ampmscrotives of diisca,to enter upon the SEISMIC FEE
above-mentioned properly for inspection purgmsea PERMIT ISSUANCE
(We)agree to cute.internally and keep Enol time City of Cupcnino against GLRCTRIC FGG
liabilities,judgments.costs and expenses which miry in any way accrue aguinn said City ALTERORADDTOMECH. PLUMBING IEE
in nsequeneu of the Starting of this Talent.
APPLICANTUNDERSTANDS AND WILL COMPLY WI'T'H ALL NON-POINT AIR HANDLING UNIT('TO 10,00007M) MECHANICAh
501yffA4 TI VS. /t _ �
C I J,t� AIR HANDLING UNIT(OVER I0.0(IO CFM( CONSTRUCTIONTA
Signature of Applicanl/Cantoctir Dat. EXHAUST HOOD(W/DUCI) HOUSING MI'FIGA'1'ION FEB
HAZARDOUS MAI ERIAI S DISCLOSURE
Will the applicant or future building reception score or handle haziudous material HEATING ON IT(TO 100.0)9 BTU)
as defined by the Cupcnioo Municipal Code,Chapter 9.12,and the Health and Safely
Call,,Seen 0255320)0 HEATING UNI'I(OVER I00,000 BTU) ,
p Ycs ei 11IDateReceipt
VENTILATION PAN(SINGLE RESID) PAID
Will the applicant or future building occupant use equipment or devices which BOILER (3HP OR 1 W,000 BTU(
snit h-ardnus all mnmmninants m AeEncd by the Ray Aru Air Quality Management TO"
Oisnicm?
AD OLD
C]Yes r1P"n/) BOILER-COMI'(OVER 101,0111 BTU)
- '
I r.nd the hmnNnm mwcrials menu under Chert 6.95 of the Cali" AIR CONDITIONER ISSUANCE DATE.
require par //,�� b
fnmiu Health&Safety Gda,Sections 25505,25533 wd 25534.I undersand thm ifIM1e NEW RESIDENTIT.
IAL NATO 1. SQ.
building dos not currently have a mtlnanl.Nat it is my re,wasihiliy as notify the occupant E
' ofOtsnFDapn fa Canfivf ,
Uwr ouw�tMdw,a
TOOL: p
ISSUED BY:
OFFICE