99090176 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OFERTINO
BUILDING-ELECTRICAL
BUICDING DIVISION APPLICATION/PERMIT PLUMBING MECHANICAL
BUILDING PROJE,C9IDENTIFICATION
BUILDING ADDRESS: SANI'T'ARY NO. APPLICATION SUIIMI Ah )ATI
F04", �,� �,�>G 9---z - c7,,9
'WN.RS NAME: PHONE: CONTRACTOR'S NAME: LIC NO,
1 N/C CONTROL#
CIULECI'MISGIN1iEW LIC NO: ADDRI-Sy: EJCON'T'ACT: PHONE: N BU ILDING PERMIT INFO
rJ-..,,_1 , �q/ �IG1 ❑ Consultant Fecr Paid by Applicant(Initial) BLDG ELECT PLUMB MI-EyC{(f
TGWW�.•1� r7 I 11 0— R E- GJ
LICENSED CONTRACTOR'S DECLARATION QTY ELECTRIC PERMIT FEE
1 herehy of ce mat I ala licen,nt amal,...coimm of Chapmr,9 hentuncenc lig JOB DESCRIPTION
WOO with Section 7#p)af Division 3ufine Businessman]Pmfesxi...Gd,mad my license is RESIDENTIAL'
WOO q PERMT r ISSUANCE ,�,
F in full force W cffc "5_1?wyA ❑SFDWL 9'KtTCHEN REMODEL
aUW license Clue. - Lic.a l 1 APPLIANCES-RESIDENTIAL []ADDITION El PLUMBING RE-PIPE
tF C i Umc Conuactor
FO,� AR611TECTSDECLARATION PANELS
❑MULTI-UNIT ❑STRUCTURAL
Z O h,Z, I understand my plans shall be used as public records MODIFICATION
OZ-0 UPT02MAMPS [I INTERIOR [I CHIMNEY REPAIR
Liccmed Professional 201-INX)AMPS „..,,IMPROVEMENT SWIMMING POOLS
OWNER-BUILDER DECLARATION OVER 1010 AMPS 14AIM�TH REMODEUREPAM El DINGLE I[ON
IY C Q 1 hereby affirm Na'1 am exempt from The Cnmmnor's License Law Port The
1 O d V following roxson.St 7031.5.Business and Professions Code:Any city or county SIGNS ELECTRICAL DOTTER
+f LL O y which requires a permit to conmfan,alter,improve,demolish,or repair any stmclare
c❑ }� Mor it)is issuance.also requires the applicam for such permit to file a signed statement SPECIAL CIRCUIT/MISC.
that he is licenwd pursuant to the phoWonr ofthe Conrado[.,License Law(Chdpmr9
y1�0�0 (commencing with Secaion7f)(Knof Division 3af The Buxines..nJPm1essions Codvd.r TEMP.METER OR POLE I,NST. COMMERCIAL:
That he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
W oat See, x7131.5 by any applicam fimaonnit subjects the applicam in a civil penally of POWER DEVICES ❑TENANT ❑FOODSERVICE
=O
not mnce'han rive hundred dollars S500). IMPROVEMENT
1 1.as owner of the Inept or my employees with wages as their sole compensation, SWIMMING POOL ELECTRIC
F+ willdu the work,md,tor,o Oue is nal inteadedo,mifeed forsale(Sec.9044.Business []OTHER
L 3 m and Professions Cade:TM1e Comrdcmh License Law mos not apply In um owner of OUT'Llil'S-SWITCHES-FIX
'f . ~• t
property who build,or improves thereon.and who does such work himself or through II A \ »I I I•
his own employces,provided that such imtprovamcnks are not intended or offered for NEW RESIDENTIAL ME 1TVAet
g or improvement yearn p 'SQ.41':PLODR AREA 1 $/SQ.EL
sola-builwe"ep Nevethn lis saW wild none improve
Nc
Pa”of uile.) will have TM1e burden of proving that he did not build or improve fur par- I /
F11of"ale.'. G'T . S[P 2 1994' „
❑ Las owner of The Sec.prolp,it,am eadusi and contracting with licensed ntradcmrs i- I
Li-
scow
La the e,ma (Sec.o(an Business and Py,the ons Ccsdcd-,i The Commc ....Li- V
e ¢lawdtsforsch plymnn with
aofprnpenywhohullJxm intpro the mcn:on,and QTY. PLUMBING PERMIT FEE
who contracts for such proleax wim a eantmdngs)licenced punuan'm the Contmnora _
License Law. PERMIT ISSUANCE
❑ I oro exempt under Sec. .B&P C for this le"no
ALTER-DRAIN&VENT-WATER(EA) VALUAI ION
wor, Dam
WORKERS COMPENSATION DLCIARA1 ION BACK FLOW VROIUC'I'.DEVICE —( 0
OOQ
1 hereby aRrunder penalty of perjury e of the following drsT
cclai urt
I have and wi 11 mointm.a Cenitievcof Consent m,elf-insure for Wnrkcrs Campen- DRAINS-FLOOR,ROOF,AREA.COND. STORIES TYPE CONSTRUCTION
smion,as provided fm by Section 3700 of The Ltmo,Gide.for TM1e pemarneuvr of the
work for which Nis permit is issued. PIXTURES-PER TRAP
1 have and will maintain Worker's Compensation Imurame,as required by Section
371M of the labor Code.me Performance work for which Nis permit ix issued. GAS-1fA.SYS'll?M-I INC.40lITLE'I'S UCC.ONOIIP AYN,� •�
My Work smion lnsu(a�na�carric/and Policy number are: D 6
Cartier: jG�L1RIlRpolicy No.: GAS-IiA.SYSTEM OVER 4(L'A)
CER I'IIICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WASTE INTERCEPTOR BUILDING DIVISION FEUS
U1c,w,,u nneMnnl be completed it he, it isfmnne hundred dollars SIN) GREASETRAP
or less.) PLANCHECK FEE
Icenifythat inthe performance oOhe wmkfor which Nis permit is issued,[,hall SEWER-SANT TARY-STORM EA.200 FT.
not employ may lxrom in any rammer so as to become subject m the Wnrkcrs'Conlpen- ENERGY FEE
QZ roti#.Law"of California.Dam WATER HEATER WN6'NTE-LECTR GRADING FEE
z 2 Applicant
NO ICE TO APPLICAN'1':If,audounkingthlx Ceniliculeol Exemption,You should WATER SYS'I'HMU'RHAT'ING SOILS FEE
I--' 5: accountsubject to the Worker's Compensation provisions of the labor Code.you most
forthwith mnmly wird such pnou,inn,no ho permit"ball be seemed revoked. WATER SERVICE
a �
CONSTRUCT ION LENDING AGENCY NEW RESIDENTIALI'hMB. SQ.En PAID
UQ 1M1erehy affirm the there isaconstruction lending agency for Ne performance of Date Receipt M
P the work line which this permit is i...ed(Sec.NN7,Civ.CJ
0 U Lcndcr's Name TOTAL:
r D-I Lender',,AJd¢,v TOTAL:
a 1 cenily Thal 1 have rend'i i,application and acme that the above infonnmion is BUILDING FEE
E^- h correct.l agree to comply with all city and county ordinances and stale laws relating to QTY. MECHANICAL PERMIT FEE
V z Toddling ennaracfnr.and h...byand rite representatives at this city In enter urym the SEISMIC FEL
above mentioned propcny on inspection purposes PERMIT ISSUANCE
(N' m care,indemnify and keep harmless the City of Cupcninn it a m, ELECTRIC PIiE
ii PPl� qua.Em fntl'Ccopli^�I cxOc", �h¢h may in any wuyxrerue uguins.vaiJ City ALTIiN OR AUT)TO MGCfI.
PLUMBING T§iE
Nf ND T S AND OMPLY WITH ALL NON-POINT AIR HANDLING UNIT RO TO."CFM)
MECHANICAL FEE
SOU RC' X UI 10
AIR HANDLING UNIT(OVER 10.000 CFM) CONSTRUCT ION TAX
Signuwm . mm Dam EXHAUST ITOO[) W/DUCT) HOUSING MFFIGA'UON FEE
a ltAlARI US TER[ALSDISCLOSURE
Wi Neapplieant or future bantam,occupant score nr handle hmanue,material HEATING UNIT(TO IN."BTU)
ax det'med y the Cupertino Mt idpal Code.Chapter 9.12,and he Ilcahh met STT,
Cole.See' 255321x)^ DEAL NG LINT F(OVER 100,000 BTU)
Yeen
VENTILATION PAN(SINGLE RESI)) PAID Dec Rccciplp
Will the applicant or future hatilJing occupant use equipment or devices which
mit limanloul,air comemiman's a.,defined by the Puy Area Air Quality Munagemem BOILER-CUhIP III{Y OR 100,10MBLU) TOTAL:
)isuidBOILIiH-COMP(OVL'R 100,M)BTU)
❑Yet '�Y"�'N 0 3 *s
have) therr `corm,requirements under Coupler 6.95 ellhe Cali AIR CONDI'OONER ISSUANCE DATE
to as healed r S u anal and 25534.1 understand N.if the NEN'RESIDENTIAL,h1ECH. SQ.IT. �� �Tx 11
"Id' n u Ilyla aalruu,m, it ry re,,ndhilily mnmify Nu lKcupam (/ -(
e realm esu hich ist h7st pitssuanec nl i enificxm of(kcupancy.
I L
O,ucr orr 1,agent "co. TOTAL: ISSUED BY
OFFICE