99090069 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY t7 OOH,
CITY OF CUPERTINO -N BUILDING-ELECTRICAL PERMIT NU.
BUILDING DIVISION APPLICATION/PERMITPLUMBING-MECHANICAL
B1111.DING PROJECT IDEN'riv[CATION.
BUILDING ADDRESS: SANITARY NO. APPLICA'I ION SUBMITTAL DATE
Zo vo G ee &.VP, 9-Z,?
WNER'S NAME: PHONE: CONTRACTOR'S NAME: LIC NO'.
LESS G L Nrc ///��� COO7NrROLx
CHlll, TUF,NGINEER: LIC NO: ADDRESS: ❑ L-1 /
RR oN to LA 6R1�3 174 GL
C NTACI: PHONE: - BUILDING PE
ARMIT(NFO
pt, D65/GN, wc-
❑ Consultant Fees Paid by Applicant(initial)(initial) nLDG f:LEC9' PLUMB
LFOAI D Ori/ 8 p 1 E�— ❑ L
LICENSED CON DIACTOR S DECLARATION QTY ELIEC'FRIC PERMIT _FEE
I hereby affirm th,I h<e scJ u a pro i n. fCh pter9 fcommencing _ - JOB DESCRIPTION
OZZ th$«don 70(NII aCD,Ann d,f,he ens' exit)Pn e:on' a andmy Tcenscis.
1- - wt vENMIT n$uANce RESIDENTIAL:
1-w_ ,n fat rnreea rcect.
aUzU Ltccns lues Lic.M � � ❑SFDWI. C1 KITCHEN REMODEL
HQL Datc�Cn aacmr APPLIANCI3S-kESIDIiNT1AI. El ADDITION ❑PLUMBING RE-PIPE
F'>q> ARCHITECT'SDECI R TION PANELS ED MULTI ❑ST RAL
z O'sn❑ 1 understand my plans shall be used as public records TION
CZ-0 UP'1'0 2041 AMPS
{-�' RID I e REPAIR
H4.F-,B: License)lkufessiowl 2111-IfgOAMPS �1 1 PIROV NI� I 1 GPOOfS
OWNER BUILDER 1l13CLA12A1'ION OVER 104g1AMl'S TFI'RPDIiI✓REPAIR ❑DF.M ON
:C a Q 1 hereby n!f tat that I am exempt from,he Cnmtazmr'z License law for,he
CFF following reason.(Section 7031.5.Business and Professions Cote Any city or county SIGNS ELECTRICAL ERal; �)
1x10.a m which regnbes a permit to construct,alter,improve,demolish,or repair any,wesure N
WEpp-- cQ prior to its issuance,also requires the applicant for such Permit to file a signed statement SPECIAL CIRCUIT/M ISC.
IlEppppEE----�}'1 thin he,,licensed cursors,10 maprovivons"ftbm Cmnammr's license l,nw Urtpter9
tYq� (commencing with Section 7")of Division 3 afire Business and Prefessioms CrAr)nr TEMP.METE I ST. _1)
0.55-
a that he is exempt therefrom and the basis for the alleged exemption.Any violation of BF, QI7170N
iC Semlon 91131.5 by any vpplicam fora permit subjects the opplinmt m a civil pe,ndty nl' POWER DEVTal mFOOD SERVICE
} not more than five hundred dollars($500). 4,§DI:T�ION
� CdO D 1,as owner of lhm pmpany,or my employees wdh wages as tucf sole compensation, SWIMMING POOL. P.CfR
F will do the work,anJ lheswnure atom amended or mtl'ered for sele(Sea V011.lness
13 m and Potassium,Code:The Contractors License law does not apply to an toner Of OIITLEI'S-SWIT -FI 'l
prof a ty who builds or improves theref,and who dies such work himself nr,M1rough
his own employees,provided That such imp..samems art ren amended or offered for NEW RE.SIDI3N'HAL ELECTS SQ FT.
ownef,hnweveasheveth boder of proving
issoldhe withinone
prove fogthe �Q�OORARTA $/SQ.R.
iter-budder complain.,
incur
pose of sale.). '
❑ 1,as owner of the property,ren exclusively muton sinir with licensed contractors of
answer the project(See.7041,Business and Professions Gare:)The Cnwmemr's Li. - .cense Law does not apply to at owner of property who builds or impsrovc,hemon,and QTY.- PLUMBING PERMIT FEE
who contracts for such project,with a conirwoork)licensed pursuant to no Conuamars -
License law. PERMIT ISSUANCE
1 am exempt under See ,B&P C for this mason
Date
ALL ER-DRAIN&VE .R(EA) VALUA N S
/u
WORKER'S COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE
1 hereby uffitm under penalty of perjury one of the following declarations:
[:]nIbave and will maintain a Certificate ofConwnt mself-insure for Worker's Compen- to DRAINS-FLOOR, OOP,ARW,C N STORIES TYPE CONSTRUCTIONsation,as provided for by Sectio 37M of she Labor Gare,for the performance of arc
work for which this permit is issued. FIXTURES-PER
❑ 1 have and will maintain Worker's Compensation Insurance,as required by Section
37I0o17she Labor Code,forte Performance of the work for which this permit is issued, GAS-EA.SYSII'd,! C O TLE'1'. UCC.GROUP
My W" rs Com ouionl sum,,c canter and Policy number are: ll
Carie. sq�_Policy Nu: 4491459 GAS-EA.SYSTEM-OVE sA)
CERTIFICATE OIr ESEMPT10N FROM WORKERS'
COMPENSATION INSURANCE GREASEANDUSTRL WA .1 C+MR
(P
' war
his scram; rant becompleted Robe patten is fomite hundred dollas($100) - BUILDING DIVISION FEES
or less.) GREASETRAP PLANCHECK FEE
I canify that in the performance of the work for which this penult is issued,I shall SEWER-SANITARY-STORM FA,200FT. V
not employ any person in any manner so as to become subject m she Workers'Compen- ENERGY FEE
,Z cation Laws of Codiremia.Data WATER HEATER WNENT/ELECTR C _
Ogg
z0 Applicant ` GRADING FEB If
h
NOTICE'1 O APPLICANT:If,after making this Certificate of Exemption,you should WATER SYSTEM/IRFA'1'ING SOBS FEI3
a bcc ow s.hj,c,to the Wnrkeds Cnwpenmtion provisions of the lahor Code,you most
fnflowith comply with.such provisions or this permit shut[be deemed rooked. WATER SERVICE
Q
UV CONS I'RUCTIGN LENDING AGENCY NEW RESIDENTIAL TI.MB. SQ.PT. PAID
I hereby willow that hem is a construction lending agency for the performance of Dale eceiptis
fL p-t she work for which Ihix permit is issued(Sec.30197.Civ.C.)
Q U Lender's Name TOTAL:
� 1'--)s Lenders Address TOTAL:
I canify,hat 1 have d,his application and state thin the have information is - BUILDING
Y4 `Q1
UF Z) comet.l agree to comply with all city and county ordinances and some laws relating in QTY. MECHANICAL PERMIT - FEF,
,Z building construction,and hereby authorize representatives ofmis city to emer upstarts, SEISMIC FEE
uhi ve-coral oned property for atop«,ion parpor,,
(%'a)agree to save.indemnify and keep hamlets the City of Cupertino again; PERMIT ISSUANCE. ELECI'I2IC EEE
Iiahilitic.s,judgmcros,costs and expenses which may in anyway accrue against said City AUERORADD'IGMECH.
in asequence of the gmmim,of this permil. PLUMBING
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
AIR HANDLING UNIT(TO 10,00)CEM)
SOURCB F,I1I.ATIC //'sem �,{�J f'') MECHANICA E
');"a
AIR HANDLING ON]](OVER 111.000 CFM) CONSTRUCTION X
nature of ApplicardContracmr D."a EXHAUST HOOD(WIDUCT)
HAZARDOUS MATERIALS DISCI-41113 HOUSING MITIGA'HON PEE
Will the applicant or future bnllaing Occupant wont or handle heran)eus material FIEATING UNIT(TO 100,11110 BTU)
as retuned by the Cupertim Municipal Gare,Chapter 9.12,: the Heahh and Safety
Cody Section 25532(x)? HEATING UNIT(OVER 100,000 BTU)
❑Yea [3 No PAID
VENTILATION PAN(SINGLE RESIU) Dare Receipt is
Willthe upplicum or future building occupant use equipment or devims which
ROLLER-COMP(3HP OR IOC
moat haurJous air cnmaminams as Jc1inW by the Buy Ares Air Quality Mnnugane100.000 BTU)
K�.V
District? TOTA J
❑Yes 7N BOILER-COMP(OVER 100,000 BTU)
I have read the hazardous materials requirements under Chapter 6.95 of the Cali- AIR CONDITIONER ,-s/ ISSUANCE DATE
tondo Health&Safety Code,Sections 25505,25533 and 25534.1 understand that If the NEW RESIDENTIAL MECH. SQ.FT. ( / Z
building does not currently have a tenant,that it is my expomsibility m notify the«cupant 7
amu, met prion"Issmnce of a C�'Ic of vncy -
0%net n a razed cot I- Dijoa TOTAL: I ISSUED BY:
OFFICE