99120049_ APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING-ELECTRICAL PF.RMI'1'NO,
BUILDING DIVISION APPLICATION/PERMIT PLUMBING-MECHANICAL
RUJI.DING PROJECTIDENTIFICATION
BUILDINGADDRESS SANITARY NO. APPLICAFION SUBMI'FI'AL DATE
OWN j 'S N E: PHONE: c C RACTOR'S NAME: L;;N�Ov
al. r R NIC CONTROL#
J HI'ICCT/IiNGINIi:H: 1,1C NO: ADDR:SS:W. ) n� B�•- I 1 ❑
FCONTAC PHONE: K>l BUILDING PERMIT INFO
-53`D6f ❑ Coneullnm Pees Paid By Applicznl(Initial) BLOCIiLF❑,CT PLUMB ML❑CH
LICENSED CONTRACTOR'S DECLARATION Yj Qqy ELECTRIC PBRMiT 1°EE 'L-aJeby affirm that 1 am licensed under provisions of Chirpier 9(atmmencing JOB DESCRIPTION
{SCD ]000)of Dlvisinn3oOhv llusincssand ProfessionsCnJe.andmylicenseis pF.RMIT ISSIIANCF. NIiSIDENTIAI.:F :md effect OSFDWL. O KITCHEN REMODEL
lUUs Lie.p ppP1JANCES—RE51D11 TIAL OADDITION BI sRE-PIPE
P.ZWConttamor
Fwai ARCHITECPS DECLARATION PANELS ❑MULTI-UNIT ❑STRUCTURAL.
'-Z 1 understand my plum shall be used as public retards MODIFICATION
oz- UP TO 200 AMPS OINTERIOR OCHIMNEY R17PAIR
,Cav'r4/hq"{ylLlCvnxeJ Pmfcssinnal 201-Into AMPS IMPROVEMENTOSWIMMING('001.5
C�zJ OWNER BUILDER UF.CLARAI'ION OVER Big)AMPS OI{ATH REMODE! REPAIR 0DEMOLITION
C 6 1 hereby affirm that I am exempt from the Commutm's License Law for the
°x-0aU fNlowing reason.(Section 7031.5.Business and professions Code:Any city or County SIGNS ELECTRICAL COTHER
ID 3 4I-" which requires a permit us con:wet,alter,improve,demolish,or repair any structure
E"0 poor In ilaiasamc,aleo mquimathe...licam fm,alh pamW.file.Maned statement SPECIAL CIRCUIT/MISC,
ythat he is licensed pursmtnt to the provisions of the Conlrncmr's License Law(Chapter 9
CCOm 0)
(commuting with Section 210of Division 3 ofthe Business and Pmes,ions CmC)or TEMP.ME'1'CR OR POLI!INST. COMMERCIAL:
C.,y m C Nat be is exempt therefrom and the basis for Ne allege!cumption.Any violation of ONE BLDG/ADDITION C1 DEMOLITION
4X1 m Section 7031.5 by myapplicam for u pennitxubjects the applicant no a civil penalty of POWER DEVICES ❑TE.NANT ❑FOOD SERVICE
1„> not marc than five hundred dollars(SSfN)).
pF6 R
It
TH
O I.anownero'fnepnspar,,or my employees with wngcs as thei...lecompensation, SWIM M INC,POOL ELEC TR IC LITIMPROVEMENT
A O will Jo the work,and the Swcmry is not incirded orotmi ed for sale(See91144,Business ❑ E
W"� and Professions Code rhe Contractor's License law docs not apply in an owner of OU FLITI:S—SWITCHES—FIX'IU J(EA)
(Y 3 property who builds or improves Ne eon,and who does such work himself or through
his own employees,provides]that such improvements art not intended m oRemd for NEW RESIDENTIAL CLECTR
sale.11'.however,the building or improvement issold wiihinoneyemofcomplction,the .FLOOR AREA S/SQ.14.
owner-huilder will have the bnNen m purving that he did not Saint or improve for put- �\
pose of sale.).
1,as owner of the property,am exclusively contracting with licensed conumcom m
construct the project(Sec.9W4,Business and Pmfersions Con:)The Contractors Li- ['((llc wLawdoesnotapplytoanownerofpuspettywhobuildsorimprovesthereon.and QTY. PLUMBING PERMIDLA/ 71999
whoComruets forsuch pmjedc withaenmmano(s)Ii.owd pamus.I,,the ContractorsLicense Low. PERMIT'ISSUANCE
O IamexemtunderSec. .B&F'Cforthis reasonOwner Dute ALTER—DRAIN&VENT—WATEWORKER'S COMPENSATION DECLARATION BACK FLOW PROTEC'.DI?VICE ——1 hereby affirm under penaltyofperjnry one of the Following declarations:lei❑ I have and will mainNin a Ceniicate of Consent to sell-insure forWorkers Compe - DRAINS—FLOOR,ROOF.AREA,CSTORIES 'I'VPE CONS'I'RIIC'FION
sation,as provided for by Section 3700 of Ne Labor Ctsle•for the performance of the
work far which Nis permit is issued. FIXTURES—PER TRAP
el-rMmmotwill maintain Workers Compensation Imamate,as required by Section
37M of the Labor Code.for the performance of Ne work for which this permit is issued GAS—EA.SYSTEM-I INC.40I1TLF1'S DGG.GRGGI'
MyComcnsati eu IPolicyjj'! gfq,leiz sB GAS—HA.SY -OVER 4(1'A) J F
Car ri x O� Pnlicy No.. l J 1
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPF:NSAION INSURANCE GREASE I NDUSTRI.WASTE INTERCEPTOR
BUILDING DIVISION FEES
(This section need not be completed if the permit is for one hurldrtddnllnrs(EIO(p GREASE TRAP
or less.) I'LANCHF.CK PEE
Iecrtifythm in the priforranecal'the wnrkto,wh'whthis permit is 1....d,lshall SEWER—SANITARY—S ORM F.A.200 FI'.
not employ any person in any manner so ax to became subject to the Wormrd Compen- I!NI!RGY FEE
z anion Laws of California.Dam WATER HEATER W/VENPHLECfR
Z Applieunt I GRADING FEE
NOTICE TO APPLICANT:If,after making this Cenifictne of Exemption,you should WATER S YSTEM/fREA'I'ING
a ^ became subject to the Worker's Compensation provisinre of the Labor Gale,you must I SOILS FEE
G forthwith Comply with such pmehium,n,this pennit shall he Jcemedw,oked. WATER SERVICE
0. Q
5z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL FILMS SO,FT. PAID
L) 0 Ihetxhy affirm that here isaconstruction lending agency for performance of Data Recciptp
P the work for which this amnia is issued(Sec.3097,Civ.C.)
C")
L Lender's NameTOTAL:
WLenders Address 'I OTAL:
y I certify that I have mad Nis application and swat that the above mormation is BUILDING THE
LA Correct,l agree m comply with all city and county ordinances and state laws Whiting to QTY. .MECHANICAL PERMIT FEE
V Z building Construction.and hereby embonze represenmtives ofthis city mernerupon the SEISMIC FEE
above-mentioned property for inspection purposes. PERMITISSUANCE
(We)agree ua xnvv,indemnify and keep ha plell Pat City of Cupertino against ELECTRIC FEL!
Iiahilitics,judgments.costs and expenses which may in any way accrucagoinst said City ALTERORAUUTOMIiCIi.
in consequence mthe granting of this per PLUMBING Fido
APPLICANT UNDERSTANL4 AN W L COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 10.000 CFM) MECHANICAL ITT
SOURCEREGUL9 ON
/'_>
G)- ,�7T 5'
? AIR HANDLING UNIT(OVER I10.00()CI'M) CONSTRUCTION'I'AX
Signemmt' mm/Cnntrvcmr
Data EXHAUSTHOOD(W/OUC'I)
{DOSING MITIGATION ITE
HAZARDOUS MATERIALS
me pi DISCLOSURE
Will the applirmnrfuwre building sccupam atnrc or handle humNnus material HEATING UNIT(TO 11N1.110NI BTU)
as deinssf by the Cupertino Municipal Gale.Chapter 9,12.and the Heahh and Safety
Code,Section 25532(a)'i HEATING UNIT(OVER 100,000 BTU)
yes No
VENTILATION PAN(SINGLE RES]D) LAID One Receipt#
Will the applicant or future building..pam use equipment or devices which BOILER—COMP(3HP OR 100,060 BN)
emit hazardous air contaminants as defined by the Bay Area Air Quality Management TOTAL: ,
District! BOILER—COMP(OVER 110,(X1)B'1 U)
❑Yes ❑No
I hove mad the havmdous materials rcquiremcros under Chapter 6.95 of the Cali- AIR CONDITIONER ISSUANCE DATE
Runic HuIN&Safety Gs1c,Sxtions 255115.25533 unJ 25511.1 understand rhes if the NEW RFSEDENTIAL MT:CIL SQ.ET
building does not currently have a anent,that it is my responsibility,to notify the pecupam
of the requirements which must be met prior to issuance of a Certificam of Occupancy.
Owner nr authorized agent Data TOTAL ISSUED BY:
OFFICE