99090124 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY cjLA o Q n ibL
CITY OF CUPERTINO BUILDING-ELECTRICAL
RUH.DINi•DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
IIIIIIAING PROJECT IDENTIFICATION
,i11i1.DING AD01lESS.. SANITARY NO. APPLICATION SUBMITTAL DATEoro a� q_a d- 8
NER'S NAMIr��� QN �^ I'IIONE/�,.1�//Y J RACTOIt'^N4 ML %elk LIC NO: N/C CONTROLIT
/iVN I` l4��/T INT ❑
111'I'ECI'1A1LEEIY 1.1 NO: AUDRE.
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) HiUG ELECT' PLUMB. MLCIJi
LICENSED CON] DECLARATION Q'PY ELECTRIC PERMIT' FEE C'-'J( L'9-11 mL-J/
TTkL/J{
I hereby arum to.,I am licensed ander pmvieinas of Chapter 9(i nmm"'Ong JOB DESCRIPTION
n ctIZ nh Seanion1Wh.f Division 3ofthc Businessand Pndeaians Cadc.undmy license is R 1 NTIAL
W p O w PERMIT ISSUANCE
F-W in full fosse unit c0'cet. ❑SFDWL ❑KITCHEN REMODEL
<-U License Class I.N. APPLIANCF'_S-RESIDENI'1 AL [I ADDITION ❑PLUMBING RIi-PIPE
F-z W Dam Coveor
nct
F�N ARCHI I'ECT'S DHCLARAI'ION PANELS
❑MULTI-UNIT ❑STRUCTURAL
Z p m Z I understand my plans shall he used as public record. MODIFICATION
N- UPTO 2W AMPS
OZ-0 C3 INTERIOR 0 CHIMNEY REPAIR
F�Ft-W L"mrad Isefesinnal 201.1000AMPS IMPROVEMENT (]SWIMMING POOLS
�Y2'� OWNER-BUILDER DECLARATION OVER 1(NXtAMPl rAATII REMODELREPAIR ❑DEMOLITION
'1 G 1 hereby affirm that 1 am exempt foam the Comoaaar'a License Law for the
dO following reason(Section 7031.5.Business and Professions Com,Any city or county SIGNS ELECTRICAI. ❑OTHER
p13
LLT- which require;;qre;a permit ,,commct,alley,improve,demolish,nr repair any structure
0 5 .rearm its izauanre.also tequims lhanpplicant far such pe—iva fileaxigled,lit mein SPECIALCIRCUTT/MTSC.
Eby that he is licensed pursuant o the pn,visions of the Contractor'%License Law(Chapter 9
Ael 0 (commencing with Section 10fXitd Division Bofthc Business andPrufessiunx Code)... EMP SIM Fit OR POLE INS'C COMMERCIAL:
e.a o'Y that he is exempt therefrom and the basis for the alleged exemption.Any violation of ❑NEW BLDG/ADDITION ❑DEMOLITION
kmLL Section]OI LS by any applicant for it permit wbJacu the applicant to civil penalty of POWER DEVICES
[I TENANT ❑FOODSERVICE
LL^N tome than five hundred dollar;($5110).
F-'Za
not
cam.asein. SWIMMING POOL IMPROVEMENT
C]
❑OTHER
F. will do the work,and the.nmcmre is not intended or offered for sale(Sea 70sbL Business
W
3 m and Profesxitax Code','I he Com mama ;Liccnee Law dao not apply e,an owns,of OUTLETS-SWITCHES-FIXTURES
property who builds nr improves thereon and who docs such work himself m through
his awn employees,provided that such improvements an,not intended or offctnd for NEW RESIDENTIAL ELECTR Q FT.
sole.It.however,the building or a lie warn(isxold within one y.,,if completion the SQ.FT.FLOOR AREA S/SQ.14.
wnerhuilder will have the burden of proving that he did not build or improve for pur-
pou of sale.).
{e-n' r of the property,vat exclusively contracting with licensed contractors to TOIA
'canswct the project(Sec.9Mq Business and Professions Code:)TTe Ct)nlracior's cemi, build or improves thereon.and QTY. PLUMBING PERMIT FEE
who contracts for such prnjen ithar,man (,)licensed pursuant to the Contractor's
License Law'. FERMI lISSUANCE
rCIT oto exempt under$ .B&P C for this rerson
ALTER-DRAIN&VENT'-WATER IEA) VALUATION
net [)an
'OI - 'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
Iherebyani der penalty of perjury one of the folio wing declarations: ` (�
Ihm'eandwll i nwinu Certifieamnf Consent oself-insurefor Worker's Con:pen- DRAINS-FLOOR,ROOF AREA,CONO STORIES "TYPE CONSTRUCTION
nation,as provided far by Section}000 of the Labor Code,far the performance of the
work for which this permit is isxoe& FIXTURES-PER TRAP
1 have and will mainion Worker's Coortmortion Insurance,us required by Scotian
3700of the LaM,,CrJe.for We performanceof 0e work far which his permit is issued GAS-PA.SYSI17M-I INC,4 OUTLIGS (JCC GROUP / APN/J
My Worker's Compensation luxuriance career and Policy number are: 4 L
Coad,: Policy No.: GAS-EA.SYSTEM-OVER q(EA)
CERTIFICATE OF EXEMPT TON FROM WORKERSGREASI%INUUSI'RL WASTE INTI3RCEProN
COMPENSATION INSURANCE BUILDING DIVISION FEES
(This vection need not be completed if the permit in for true hundred dollars IS 100 OREASIi'1'RAP
PLANCIIIiCK FEE
Is,,,)
locen'yital inthe patiormamcemme weakfmwhich this pemtitisismed.[shall SEWER-SANITARY-STORM EA.200 FT.
employ any person in any manner so av to bee re suhp,n to the Workers'Co.,.- ENERGY FEE
Z, talion Lawsof Calif in Data WATER IIIA ERW/VEN'HITLECI'It
ZO Applicant GRADING PIA:
N NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM TREATING
a ; rec»nm subject to the Worker's Cmnpcnsation provisions of the Lehor Crile,you must SOILS FEE
forthwith comply with such provisions or this permit shall bedcemedfevoked. WATER S17RVICL
V O CONSBII(.TION LENDINGAGENCY NEW RESIDENT IAL I'LMIi. gQ.FT. 4PAID1 herebyoffrn Ihm there isa cmcmm,;km lending agency for the performance ofIL F the work for which this permit is issued(Sec.3091,Civ.C.)OULendeh Nanta :
LendersAJdre;v I(YfAI..1 certifthat 1 have read this application andstate Ibat the aMre information is sorest.l agree to cotmply with all city and county ordinances and stare mws,datingto QTY. MECHANICAL PERMIT FEE U Z. budding conswnion.and herby amtharim reprexmtmivecnf this city mcmeTupan'he
above-mentioned property for inspection import v. PERMIT ISSUANCE(We)agr<e m note,indemify and keepharmless the Cny of Cuper ino again
liabilities.judgments,ensu and expenses which may in any wary accrue against said City ALTER OR ADD TO MECT I. P UMBINGHE
onuqueme of the sting of this comet.
APPLICANT OND" S' )WILL COWLY WITH ALL NON-POINT AIR HANDLING UNIT(TO I0,000 CFM) STECHANICALPEE
SOURCE RIiGl11
AIR HANDLING UNIT(OVER 10,X10 CIM) CONSTRUCTION TAX
Sign:num nl Ap dConrncto, Date EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEB
HAZARD
MATERIALS DISCLOSURE
W eupplicanwrfumre building rccupamsmm lir handle hazardous material HEATING UNIT(TO I W.(Iod BTU)
as Aalinc by the Cupertino Mnn'¢Ipal Cndc,Chapter 9.12.and the Eleallh and Safety
Code.Section 255321t0P HEATING UNIT'(OVER 100,UBB BTI])
❑Yes ❑Nn VENTILATION FAN(SINGLE,RESID) PAID
Dale R.ip
Will us applicant or lattice no building by the Bt use ea Air a of devices which BOILER-COMP CHP OR 100.0(10 BTU)
mit hazardous air comaminnnu¢s defined by the Bay Arca Air Quality Management T
I
M id'I BOH.Fn-COMP(OVER I WJMNf BTU)
❑YCa ❑NaI have read the Th of t mamrial>r,mucatenu under Chapter 6.95 of the Cali AIR CONDITIONER ISSUANCE DATE
ornix 1211h&Safety Cr $egnro255115 5599 and 255.141 mulcmmnd that if the NEW RESIDENTIAL MIECH. SQ.PP.uildingdoesootcutten away resprrobilityto notify dreaccuTem,ftherequiranenrs t m issuance yf a Certificate of(kcpancy.wner or autM,rizW tram 1 Date TOTAL: ISSUED BY:
OFFICE