99090022APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY -/'I 'j,
CITY OF CUPERTINO NUIIAING - ELECTRICAL PERMIT NO.
Nl1ILUING DIVISION APPI,ICA770N/PI?RMIT PLUM1IBINC-MEClIANICAI' -
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❑ Consultant Fees Paid by Applicant(initial)RLDGi
BUILDIN PERMIT INFO
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LICENSED CONTRACTOR'S DECLARATION
1 hrrcny afinm that I am licensed wader prrokiom of Chapter 9 (enmmcneing
with Section 701A)0T DIvisbin 3 ofthe Business and Profession% Cede, and my license is
in full 6rcc amt effect.
1.i¢nse CWsx 1 -ick
Date Cnntubmar
QTY ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SF L ❑ KITCHEN REMODEL
ErADDITION ❑PLUMBING RE -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
El INTERIOR ❑CHIMNEY REPAIR
IMPROVEMENT E]SWIMMING POOLS
❑ BATH REMODEIJREPAIR El DEMOLITION
Cl OTHER
PERMIT ISSUANCE
APPLIANCES -RESIDENI'[Al.
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ARCH] I' EM S DECLARATION
I understand my plans shall be amid as public accords
PANIiIS
UP'1021s1 AMPS
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Licenud Prefccsional
OWNER -BUILDER DECLARAr[ON
1 hereby affirm that 1 am exempt dont the Contractor's License law lin In.
following reason ISuclion 9031 5, Business and Professions Cade: Any city ter county
which requires a permit to consWct, alter, improve, demolish, or repair any structure
priormirs icxuance. ulsn requires rhmppllwm hnsucb prminn fileuvigncd sotemcnt
that he is licensed pursuant to the provisions aftbe Commemrs licence Law (Chapter 9
(commencing with Section 7lN)B)af Division Sof the Business and Pnafesxions Cadepen
but he is uxenrpl thercfmm and the naris for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a prh subjects the applicant to a civil penalty of
not more than five hundred dollars 195000.
ac ownerof the property. or my employees with wage% as their sole compensation.
w Bothe xnrk.andthe s0uclureisnot intended oroffarcd for sale (Sm. 70,14. Business
and Professions Code: The Conuactn''% License Law does nut apply to an owner of
pmprm, no builds or improves themon, and who does such work himself or Through
his awn employees, provided that such imprwemems am nm Inrendcd or alfcred for
sale. It. h;sever. me building- lntprovanem ixcnld xilhiture years(completion. the
201-1000AMVS
OVER 1000AMPS
SIGNS ELECTRICAL
SPECIALCIRCUITMISC.
'TEMP. MI?'Tlilt OH POLE [NST.
COMMERCIAL'
NEW BLDG/ADDITION [I DEMOLITION
❑'TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑OTHER
POWER DEVICES
1Wn;nz1pSEi7p L. ELECTRIC CVZZI
OUTLETS - SWITCHES-19XTURES
NEW RESIDENTIAL, CLECTR SQ Er
SQ. IT. FLOOR AREA
$/SQ. FT.
er-builder will have the burden of proving that he did nal build or improve for pur-
po. c of sown),
I, f owner of the progeny, am exclusively contracting with licensrd contractors to
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construct the project(See. 7014. Business and Proff essions Cade:) 9be Contractor's Id-
w Law dans nm apply it) an owner of property who builds or improves lhemon,and
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QTY. PLUMBING PERMIT /
who contracts for such prgeets with a contmcwr(s) licensed pursuant to the Contractor's
Lards, law.
❑ I am exempt under Sec. .B&YCfarthismamn
AUG 1 0 1999
PERMIT' ISSUANCE
Owner �' Dmc_ fry
WO : '. CObIPF-NSAI'1 ECLARATION
AMER -DRAIN &VEN"1'-W l7R(17A)
VALUATION
BACK PLOW' PROTECT. DE 1'
Ihereby nffir ter pewlly ofperju, onent'rhe l idlnwing decWrotlnns:
'lJ
;] Ihave eadwill maintain a Cenificam of Conserv toself-insure fur Worker's Compare
cation, as provided for by Section 3700 of the Lobe Code, for the performance of the
work for which this prate is issued.
DRAINS - FLOOR. ROOP,A EA. GOND.
SIOR&
,'['RUCT[ON
FIXTURES - PER TRAP
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37W of the Labe Cade,for the performance of the work far which rlux permit's issued.
OCC. GROUP
APN
GAS -IiA. SYSTEM -I INC. 40
GAS -IiA, SYSTEM-OV17R 4 ( EAI
My Worker's Compensation lnsurm¢e carrier and Policy number am:
Carlen Policy No.t
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GRIiAS1YINUUS'IAI. WASTE INI'ERCE OR
CER 'IIFICAT li 01' IJ(IiMPI']ON FROM WORKERS'
COMPENSATION INSURANCE
J
O
BUILDING DIVISION FEES
(This section need not be completed ifthe Permit is fortune hundred dollars19100)
or leu.)
GHIiASE ['RAP
PLANCHGCK IT:E 1 71/
// 40
SEWER - SANITARY - STORM FA, 200 Fr.
ENERGY FEE / S, �✓
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[ccnifylhmin thcprfnruncc ofthc work fmwhich thisprslis issucalshall
not employ any prom in any roamer %a m m become subject to the Workers'Cmupen.
ration Law, of California. Date
NOTICE TQ A1'PLICAN'1': If, alter nwking thl.. Cunificam of Exemption, You xhou4l
became subject to the Worker's Cnmpensatiun provision of die Labor Costs, You mon
forthwith comply with such provisions or this peril shall he deemed revoked.
COtJSTRUGcononc LENDING AGENCY
Ihareny affirm that there iso cnnArucpnn lending agency for the per(urmuncenf
the took for which this permit is issued (Sec. 3(197, Civ. CJ
Lcndeh Name
WATER HEATER W/VENTMLEC IR
WATER SYSTEMO BEATING
GRADING ME
SOILS PF3F,
WAT17R S17RVICE
PAID
Date Recciptp
NEW'R131UENI'IAI. PLMB. (0f SO 17.
TOTAL S O
11 'TOTAL:
I.andvAAddress
G FEE 41 Vt.
correct. I agree to comply with all city and county ordinances and state laws relining n)
building Cnnxlroctlaal,:Inrl hereby authorize representativesofthis city teener upon the
atnremantioned progeny for imspction purposes.
(We, agreem save, inderatify and keep hunnlexx the C,y of Cupriino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
of the granting of this permit.
in APPLICANT
AI'PhICANI' UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
QTY. MECHANICAL PERMIT FEE
n
SEISMIC FTE b0
b
PERMIT ISSUANCEELECTRIC
ALTER OR ADD TO MECH.)
PEG k7P
PLUMBING FEE /
AIR HANDLING UNIT frQ IO,BW CPM)
7^
MECHANI V
SOURCE REGULATIONS.
� t(1
AIR HANDLING UND'(OVER 10,00007M)
CONSTR 10 T
SignaturcNApplir; tl racmr Date
"HAUST'HOOD IW/DUCT)
HOUSING MI '[GATT Eli
HA" RIZiUS MATER[ LS DISCLOSURr:
Will the cep autor future buildingoccupam vnm or handle haeardouc mmedal
as defined by the Cupninu Municipal Cade. Chapter 9.12, and the Ilcallh and Safety
Code, Section 25532017
�Ycatu
Will the applicant or future Nilding occupant use equipment or devices which
it hazardous air contaminated, as defined defined by the Bay Area Air Quadly:Nanagcmem
I 1 IEATINGUNI'I'(IO10d.00B'IU)
IWA'I'ING UNIT (OVER [ill BTU)
PAID '
Date Receipt#
'
VENTILATION FAN(SINGLE RFSID)
BOILER -COMP CHIP OR 100,000 BTU)
TOTAL;
BUILER-COMP (OVER IW,M) BTU)
. neat
DYea �No
'7
AIR CONDITIOVER
I have rcaA the haennlous materials requirements under Chapter 6.95 of the Cels-
Orrin Health & Safety Code. Sections 25505. 25533 and 25534.1 understand Ilial if the
�/S� CP DAM
NEW RESIDENTIAL MECH. SU. FT
huilJingAces nm aurally haveusnunl,Jfhat it Isnsyecof.cend,ecid' theancupam
of the retmimnems which n�st M telt piiwrlq issuylfe of n Ccnitigam o((ycupattcy.
OFFICE