99090094APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY et A no, n n 9 4
OFFICE
CITY OF CUPERTINO BUILDING - ELECTRICAL
BUILDING DIVISION APPLICATIONIFERMIT PLUMBING - MECHANICAL.
IIUILDIN(IPROJECI'IDP.MI'IFICATION �• l
I I PERMI'N .
BUILDING ADDRESS:
�i _o Sb,v=I, rlc, 131 L,,4, CL„!� '�(�v L"� i- 6,,
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNtillE 'S NAME: PHONE:
M . , '1 100 +�=(
CO RACfOR'SNAME: LIC NOglik'.
c,TD f -37 3 3
NIC
❑
CONTROLa
RCHITEC'I'IENGIN ?R; LIC NO:
ADDRESS:
Ise cls 6•=�r t.
INTACT PHONE:
- - BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant (Initial)
B,L�D/G/ 1➢.ECI PLUMB MECH
L7J ❑ ❑ ❑
LICENSED CONTRACTOR'S DECLARATION'Q'FY.
Chapter 9 (comencing
I hereby short that lam ueenacd made,,owWofs of m
with Sxtinn]00(p of Uivisinn3of the Business and Pmfessinns Cale.andmylicarti<
in full tome and eRea
Liceme CL . Lia# 33 ) 7�3
Dam Crmra • •tea ��
-ELECTRIC PERMIT '. FEE . .
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JOB DESCRIPTION
RESIDENTIAL:
❑SFDWI. ❑KITCHEN REMODEL
[]ADDITION ❑PLUMBING RE -PIPE
CMULTI-UNIT []STRUCTURALti
MODIFICATION
PERAITI'ISSUANCE
APPLIANCES - HF,SIDENTIAL
ARCHITECTS DECLARATION
I understand my plans shall W used as public mens
PANIiLS
p
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Licensed Podcssioual
OW NER-BUILDER DECLARATION
1 hereby union that I am exempt from the Conua dor's License Law for the
fallowing reared. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, Improve. damrllsh, ar mmir any swclure
priarmits i,amewc,alsorequlres theapplicant for such penaino file asignWnammrnt
W P❑INTERIOR
I. fI ITA 1'S
1GNS ELECT! L
FCAA11 HIT
[I CHIMNEY REPAIR
IMPROVEMENT ❑ SWIMMING POOLS
ElBATH REMODEUREPAIR [IDEMOLITION
CI OTHER
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ySection
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that he is licensed pursuant m the provisions of the Contractor's License Law (Chapel-9�Q (commencingwith Section 7") of Dlvixam3 afthe Business and Pmfessinns Code)m
that he is exempt therefrom and the basis fur the alleged exemption. Any violation of
]031.5 by any applicant far a permit miniver, the itadiemu m a civil penalty of
not more than five hundred dollars ($500}
❑1, as owner ofthe property, or my employees with wages as their sole compensation,
will do thewnrk, and 16c almctam Is not intended oreff rel far sale IS.. ](W4, Business
E
COMMERCIAL:
El NEW BLDGIADDMON [IDEMOL TION
C TENANT 11 FOOD SERVIC17
IMPROVEMENT
❑ OTHRR
V
C O ICrl
F�
3 m
and Professions Calc: The Commemrs License Law des not apply m an owner of
props ny who builds or improves IIn mon, and who does such work himself (ir through
bi.a own employees, provided that inch improvemeau arc not intended or offered for
rade. IL howeve, the building or improvementTswld within me,or of completion,the
LETS -IH S-FIXTURI?S
OUTSWTC
NEW RESIDENTIAL ELECTR SQ PT.
S
SQ. FT, FLOOR AREA
S/SQ. IT.
er-builder will have the burden of Towing that he did not build or improve far pm-
p,sa of sale.).
I• as ower of the pte.704 nm with licensed coatmmorsm
TOT
Prmmeiins
Business
mmsWct the project (Ste. ]IM4, Boniness anJ Professions Crdep'll¢ Connectors Li-
censeWwdoes not apply m an owner of prnpeny who builds or improves thereon, it
QTY PLUMBING PERMIT FEE
who contracts for such projects with a contortions) licensed pursuant to the Committers
)
I PERMIT ISSUANCE
Liccnee Law.
❑ I am esion,omder See. , B he 1' C for thl.vrm.vrn
AI:IT:R - DRAIN & VEND '-WATER (EA)
Owner Da¢
VALUATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROTECT. DEVICE.
efolloing
I hereby atTum under penalty a[ perjury one of the following declarations:
DRAINS- FLOOR, ROOF. AREA, COND.
(have end will mainmina Cenifi<me of Cnn.ttnuo self -insure for Workers Comped-
ion, as provided for by Section 37W of the Labra Code, for the Performance of the
STORIES
TYPECONSTRUCION
ark far which this lwnnit is issncJ.
FIXTU14ES-PER TRAP
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
37W ofthe labor Cale, for the performance of the work far which this permit is issued.
GAS -EA. SYSTHM-I INC. 4 OUTLETS
OCC. GROUP
APS
My Worker's Compensation Insurance cancer and Policy number arc:
Carrier: Policy No.:
GAS - EA. SYSTEM -OVER 4 (EA)
GRFASEIINDUSTRL WASTE INTERCEPTOR
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissxtinn need not hett,mpletal if the permit is forone hundrcddellars ($100)
nr lees)
BUILDING DIVISION FEES
GRI!ASE TkAI'
PLANCI{f!CK PEP.
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.A
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lminify that in the any Performance ofthe work for which this the issued, I
of employ any person in any inn m subjecnr the workers Cmnpcn-
smarm Laws of alitcQor Dae nam q s' Jycyrgp
Applicant �i, - 3JYIt
SEWER -SANITARY- S'I ORM EA. 211(1 FT
ENERGY FEE
grppiR HEATEH WNEMI'/F,LECfH
GRADING FEE
NOTICE TO APPLICANT: If, after making this Cenifieme of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Cak, you must
fanhwith comply with such provisions in, this permit shnll be deemed revoked.
WATER SYSTEMOREATING
SOILS FEE
WATER SERVICE
NEW RESIDENTIAL P1.M0. SQ. PI'.
z
Q
•U
ULender's
� L
CONSTRUCTIONLENDINGlNG AGENCY
I far
rwhich mtthauhere isaed(Seeconstruction3097, Cin. agency for the Performance of
the work for which this permit is issued (Sec. 309]. Civ. CJ
Name
PAID
Date kecciptp
1F -���--
r, s TOTAL:
Isndcrs Address
TOTAL:
(1 ILDINF Is -�
1 scatty that 1 have read this application and stain that Be e6we information is
1 y
) Z
correct 1 agree to comply vo h all city sad ammy ordln:mces ane rete laws miming m
huilJingmmtoctinn, and hereby authonu represenladvus aRhis c'ny to enter upoa the
QTY. MECHANICAL'PERMIT FEE
+
SEISMIC FEE I �
PERMIT ISSUANCE
••..
ELE 4PEEj U 1 "
abrvcancmioaed prnpeny far inspection purrysses'
(We) agree m save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs anJ expenses which may in any way accrue against said Cityf+
in consequence ofthe grunting rl' this permit
AL'fI:H OR ADD TO MI!CH.
IJ
PLUMBING PEE Ji
11
AIR HANDLING UNIT (TO IT" CENT)jMECHANICAL
FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
AIR HANDLING UNIT (OVER 10,010 CFM)
CUNSTRUCTION'TA%,�
�]/-�•
/>� C
T
Signature ofApplicadmCoamamor Dam
HAZARDOUS MATERIALS DISCLOSURE
M HAUSTHOOD(WMUCO
HOUSING MITIGATION FEE
1
HEATING UNIT (TO 100,000 BTU)
Will the applicant or future building occupamsterc or handle bmardous material
-
m duffed by the Cupertino Municipal Code, Chapter 9.12, and the Heahh and Safety
Code, Section 2553200?
E3 Yes cko
Will the a licam or future buildin • occupant use equipment or devices which
pp 6 pan
it hazardous air contaminants as defined by the Bay Arca Air Quality ManagementBOILER-
� Yes ` 11
HEATING UNIT (OVER 100.000 BTU)
PAID
Date Receipt#
VENTILATION FAN (SINGLE RESID)
COMP QHP OR I03,00O BTU)
TOTAL
BOILER -COMP (OVER 100.000 PTU)
AIR CONDITIONER
d'smatcrials eFiremcn¢ under Chapter 6.95 ofthe Cali
1 have mad he hdzuw
ISSUANCE DAT13
NEW RESIDENTIAL. h1ECH. SQ. ET.
fomia Health & Safety Code, Seetions 25505. 25533 and 25514. 1 m onstan l that if the
building docs not cormally have a mount that II is my reslanoibilay in notify the aecuprat
/
of ust lberst priormissuance rfa Cenifcar f cup c
1
-'a`.,\_
.waw or awhomed agent Dote
TOTAL:
ISSUED BY: !` V
OFFICE