99080213 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY Q4 1006402-
~ CITY OF CUPERTINO BUILDING-ELECTRICAL. E ONO.
BUILDING DIVISION APPLICATIONIPRRMIT PLUMBING-MECHANICAL
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS:
$ANiTARY NO. APPLICATION SUBMITTAL.DATE
J v7S I SANTit Luc.IA PD. Cuv"-n.x.c CA 9S'0 i4r 9 . 7( ^
OWNER'SNAME: I'lI0N I?: CONTRAC IO�RNAME. LIC NO:
V ANTrr S,MADAN I+og-446-96` " NIC COM'ROLx
MR iCHITEC UUNGINBER: LIC NO: ADDRESS: ❑
CONTACT: vuONE: ' t. BUILDING PERMIT INFO
❑ Consultant Fces Paid by Applicant(Initial) t BLDG ELECT PLUMB MECH
o ret/ ❑ ❑
LICENSED CONTRACTOR S DEC1ARAnoN affirm QTY ELECTRIC PERMIT-. ,��-FEEI'-
1 hereby arm that 1 am Removed unit provisions f chapter 9(commencing . . )OB DESCRIPTION
WOO with Soeton 9000)of Division 3 mine Business and Professions Code unit my license is RESIDENTIAL:
FwdU
in full force and ellen. PERMIT ISSUANCIi
License Class v Liap ❑SFDWL ❑KITCHEN REMODEL
6 V APPLIANCE S-RESIDEWIN. ❑ADDITION El PLUMBING RE-PIPE
LZ Q W Date Contrenor
ARCHITGLTS DECLARATION [I MULTI-UNIT ❑STRUCTURAL
ZOyz I understand my plans shall M used as public records PANEMODIFICATION
OZ=� UPTO200AMPS ❑INTERIOR ❑CHIMNEY REPAIR
FW Licensed Professional 201-ILXMIAMPS IMPROVEMENT C]SWIMMING POOLS
ION
C C 6 1 hereby affirm ha N am lexelmlttFfr mFNe Contractor's
License Lew for the OVER I"AMPS ❑BATH REMODEUREPAIR ❑DEMO ON
pj3=E following ren on.(Section 7031.5.Businessand Professions Cdc:Any city or county SIGNS ELECTRICAL El OTHER
which require,a Permit to remover,alter,improve,demolish,m repair any nm adore 1 1315 ex
�; prior to its issuance,also requites the applicant for such permitto file u signed statement SPECIAL CIRCUIT/M ISC.
f } that he is licensed personal to the provisions of the Contractors license Law(Chapter 9
W QD (commencing wits Section 9000)of Division 3 ofthe Business and Professions Code)or TEMP MEIE.R OR POLE INST. COMMERCIAL:
a E o s that he is exempt therefrom me the basis for the alleged exemption Any violmimn of ❑NEW BLDG/ADDITION ❑DEMOLITION
^m Section 9031.5 by any applicant for a permit subjDEVICESs the applicant to a civil penalty of POWER DEVICESTENANT ❑FOOD SERVICE
not more Nm Five hundred dollars($500).
�_� ❑Las ownerof the Prnpeny.or my employees with xvgcs os their sole nsmpcnsation. SWIMMING POOL ELECTRIC IMPROVEMENT
L, will do the work,and the structure is not intended moment foraule(See 7 owBusiness ❑OTHER
IS:—m and de:Professions CoThe Cimmus ors License law does not apply man ner of OUTLETS-SWITCHES-FIXTURES
a 3 property who builds or improves thereon,and who does such work himself or through ate
his own employees,Provided that such improvements art not intended or offered for NEW RESIDENTIAL F,LF,CTR
sale.If.however the building or improvement issold withinone years(completion,theSQ.FT FLOOR AREA 5/SQ.FE
ownwebtfilder will have the burden of proving that he did not build or improve for par.
st W
r of the property,am exclusively contracting with licensed contractors to Ai.: Ae
construct Ne project(Sec.1144,Business and Professions Cole:)The Contractor's Li-
cense
i-c se law does not apply to an owner of property who build.,or improves thrcon,and QTY. PLUMBING PERMIT I
who contracts for such projects with a contracturEd licensed pursuant m the Comramor's - - r AUG 3 1 1 gg
License Law. PERMIT ISSUANCE
lam exempt under Sec. ,B&P C far this raamn Ic
10
- �J ACDiR-DRAIN&VF.NI'-WATER(EA) VALUATION
^• WOk 'SCOMPENSATIONDECLARATIO�— Ely
BACK PLOW PROTECT'.DEVICE
I busby affirm undo Penalty nfperjury one of the following Aalamdnns: ��—'
I have and will maintain u Certificate of Con.senrto self-insure for Workers Compcm DRAINS-FLOOR,ROOF,AREA,COND. STORIES TYPE CONSTRUCTION
satton,as provided for by Section 3700 of the Labor Code,for the po forrourec of the
work for which this pc,,air is issued. FIXTURES-PER TRAP
E] 1 have and will maintain Worker's Compensation Insurance,as required by Section
370Ml of the Labor Code.for the performance of the work for which this permit is issued GAS-IiA.SYSTEM-I INC.4 ours-El'S DEC.GROUP ��A N
My Workers Compensation Insurance carrier and Policy number are: `J
Carrier Policy No.: GAS-F.A.SYSTEM-OVHR 4(EA) /
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE GRFASLJINUUS'TRL WAS FE INTERCEPTOR yAsa
(Thls'emtianneed nal brcompletedit lbe ITnnitls 0aaoc hundred dollars it 10 10 J ffltl c BUILDINGDIVISION FEES'i
or lees) GREASE T'I1AP PLANC IECK FEE
I certify that In the performance ofthe work fa which this permit is isocd.I Null SEWER-SANITARY-STORM EA.200 FT.
u
not np
loy any penton In eny n inner sv us m heatme,addr,t m tan Worker,'C...gwa- ENERGY PEE
smsivn Laws of California.Dam WA9'131t III?ATIiR W/VENT/F.LECTk
0 Applicant GRADING FEE
'Zh NOTICE TO APPLICANT:It,alter making this CerdOcum of Exeription,you should WRPFIi SYST,M/TRHXTING SOILS PfiE
Nc,,.c-object m the Workers Cmnpmma0on provisions of the Labor Cn I,you ain't
forthwith comply with such provisionsor this punit shell reiterated revokaL WA'G?N 517RVIG7
Q
CONSTRUCTION LENDINGAGENCY NEWRESIDEN'UALI'LMIL SQ.FT. PAID
I huehy off m dutthere is u conaruction lending uguncy forthe perGtmmuccolDate I k'eiptit
W the work for which this permit is Issued(Seo.3099,Civ.C.)
O Lenders Name TOTAL:
U
Lenders Address TOTAL:
Ly, 1 citify the,i have read this oppliewit n and'uue Nal the above information Is - - f - BUILDING FEE
y street.1 same,tic comply our all city and county ordinances mad stem Iaws relating to QTY. . MECHANICAL PERMIT'on FEE ' t
U Z building construction,and hereby authorize representatives of Nis city treater upthe SEISMIC FEE
above-mearmnal property for ir",fion parisrses.
(We)agree auave,indemnify and kcep hom levs the City of Cupertino aguind PERMIT ISSUANCE ELECTRIC FEE
liabilities,judgmen,s,costs and expenses which may in any way aummtgainst said City ALT ER OR ADD TO MECH.
in asequence of the granting of his permit. PLUMBING FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALI.NON-POINT AIR HANDLING UNIT(TO 10,000 CFM) MECHANICALFEE
S 'RCE REGULATIONS. p
' 3 9/. AIRHANDLINGUNIT(OVERIO.OWCFM) CONSTRUCTION TAX
Ssgnaalreof Appli VCoatmmor Dem IiXI1AUSTHOOD(W/DUCT) HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE
Will Neapplicam or fbmre building occupant store or handle hauNmns material HEATING UNIT(TO IW,000 BTU)
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health end Safety
Coda Section 25532(0)? ���� !MATING UNIT(OVER 100.0,X1 BTU)
!]Yes 17Na PAID
VENTILATION FAN(SINGLE RFSID) Dam Receipt 4
Will the applicant or future building occupant use equipment or devices which
Lit hamNous air contaminants as defined by the Buy Area Air Quality Managemcm BOILER-COMP(3HP OR 1 W,00(i BTU)
TOTAL:
istrin?
❑Yes [�/ BOILER-COMP(OVER 10LODO BTU)
I have read the mem oms materials requ ircomms under Chapter 6.95 of the Cul, AIR CONDITIONER ISSUANCE DATE
fomia Health&Safety Cade,Sections 5505,25533 and 25534.1 understand Nat if the NEW RESIDENTIAL MECH. SQ,F-E LL3 �' Q
building does not currently have a tenant.that it is my responsibility to notify the nucuprat r /J
aft ,,,,n¢whi�h usrbe met p' no iss..nce ofa Ceni&am fOccupuncy.
Owner or aml i. agent 3 )am TOTAL: ISSUED BY:
OFFICE