99080224APPLICANT TO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY A,- (Q og_ adswomaq -01
NO BUILD NG-MECII N
CITY DI C DIVISION
BUILDING DIVISION APPLICATION/PERMIT PINGPROO-MRCH9NIFIC
. BUILDING PROJECT IURNTIFICATION
BUILDING AD ^
wqm
SANITARY NO.
APPLICATION SUBMITTAL DATE
OWNI°'S A E:
1 E:
CO R UR:S NAME: LIC NO:
NIC
CON
L
❑
�RO/L#
157 (p
/
.HIT Cr/ENGINEER: L 0'
Aish r
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'Ac ':1 PHON ..
J &O1wer y�
❑Consultant Feu Paid by Applicant (Initial)
,.' (BUILDING PERMIT INFO
M2
a ELECT PLUMB MECty
v /
V
CrJ•r
LICENSED ONTRACfOR'S DECLARATION
1 hereby affirm mm 1 am licenced order provisions of Chapter (Commencing_
QTY .ELECTRIC PF;RMIT I:EE '
1
JOB DESCRIPTION
PERMIT ISSUANCE
with$ecninn 9)Od)a[Divlsinn3nfrM1e Businres and Profeaxiors Cudeamd my license is
in mB unro and effect.
RESIDENTIAL:
❑ SFDWI. ❑ KITCHEN REMODEL
APPLIANCES-RESIDliNI'I AL
I.iccnxc Class Lic.#
Dae Comacmr
❑ADDITION ❑PLUMBING RP . -PIPE
❑MULTI -UNIT El STRUCTURAL
MODIFICATION
❑INTERIOR - C3 CHIMNEY REPAIR
IMPROVEMENT EJSWIMMINGP0OIS
A HI ECCS DECLARATION
em# m In ha beusMaspoblicrecurds
j
PANELS
Oil TO 200 AMPS
L cath fessrona
201-1000AMPS
OWNER UILDER DECLARATION
1 hereby affirre that 1 am exempt from the Commerce', License Law for the
following reason. (Section 703 1.5, Business and Professions Coact Any city or county
C3 BATH REMODF.IIREPAIR ❑DEMOLITION
❑ OTHER
OVER 1000 AMPS
SIGNS ELECTRICAL
which requires a permit to construct, alter, improve, demolish, or repair any structure
SPEC I AL CIRCUIT/M ISC.
priorto its Issuance, also captions (he upplicant for such paninn file a. signed statement
IM( he is li ,awal pufauont In the provisions of the Contractor's License Law (Chapter 9
(em.meming with Section 7000) of IN vision 3 of NC Business and Professions Code)or
TIiM P. METER OR POLE INS' I'.
COMMERCIAL:
Thal he is exempt thcrefmm and me basis for the alleged exe.ption. Any violation of
❑ NEW BLDG/ADDITION ❑ DEMOLITION
POWER DEVICES
Section 7031.5 byanyap homy fora permitmbjects lhenpplicamma civil pcarlty,if
not more man five hundred dollars ($500).
rj 1, as owner of the property, at my employees with wages as their.wle compensation.
will do the work, and the Scam.. re is not intended urodered for sale (Sce.'l014, Business
TENANT ❑ FOOD SERVICE
IMPROVEMENT
❑ OTHER
SWIMMING POOL ELECTRIC
OUTLETS - SWITCHES -FIXTURIS
and Professions Code: The Contractors License Law does nm apply to an owner ofle
property who builds or improves thereon, and who does such work himself or through
his own employees, provided that such improvements ate not intended or offered for
sale, If, howeve,hebanking or inlprovemmrt is sold within one yearaf completion, the
NEW RESIDENTIAL ELECTR SQ
SQ. Fr. FLOOR AREA
S/SQ. IT.
tho-hander will have the h ndca of proving that he did not built]built]or Improve for poo-
pif taim).
1, es owner of the property, tam exclusively cramming with licensed conlmcmrs 1.
Y/'� 6 �•�(�
......tract the project (Sec. 9044, Business and Profession Cnde:) The Carnation's Li-
an ownerofppcny who build.. or infprovesmemon,and
Lswdoesnotapplyom
wmho
QTY. PLUMBING PF-RMIT FEE
c mermis for such projects wilh a comractor(s) licensed purs...uo the Cnnhactor's
PERMIT ISSUANCE
License Law.
c
]am exempt oderc , li & P C far th'x reason
Owner Dom
WORK IRS • MI W ION DF.CLARgI'ION
A:1 ER- DRAIN & VENT - WAG 'ER(EA)
VALUATION
RACK Ir1,UW PROTF;CT. DEVICE
I hereby alRem under penally.. perjury, one of rhe following Jcaaations:
DRAINS- FLOOR, ROOF, AREA, COND.
I have and willmainminu ComilicmConsent c of Conseno self-imearc l'or Worker's Camper-
as provided for by Section 3700 of the Labor Cars, for the performance of the
STORIES
TYPE CONSTRUCTION
1, for which this .it is issued.
FIXTURES - PER TRAP
❑ I have and will maintain Worker's Compensation Insurance. as acquired by Section
3700 of the labor Cade, for pcAonnance of the work for which this permit is issued.
My Works,'s Compensation Insurance carrier and Policy number am:
Cartier: Policy Na.:
GAS -EA. SYSTEM -1 INC.4 OUTLETS
OCC.GROUP
�/ APN 1
/ /
GAS - EA. SYSTEM OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GREASFANDUSTRL WASTE INTERCEPTOR
r w BUILDING DIVISIONFEES
('(Tis section need not hewmplcted if the permit is Income hundred colors ($l00)
or loss.)
GREASE TRAP
•PLANCHECK FEE
I comfy that in the l.;,It rnanccoftmwmkfor whichthispermit ixissucd,Isbell
no employ any person In any manner so as to became svbject Io the Wokei Compen-
SEWER -SANITARY -STORM I?A. 2101 IT.
ENERGY FEE
WATER HEATER WNE Uf f:LEC'IR
scion Lows of Cilifomia. Date
Applicant
GRADING FEE
NOTICE. TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation Provisions of the Labor Code, you must
WATER SYSTENUMEA'1'ING
SOILS FEE
forthwith comply with such provisions or this repair shall be deemed rcvnked.
WATIiR SERVICE
CONS1' RUCTION LENDING AGENCY
Ihereb than that there is a construction lemdin for performance of
hereby gag.mcy p
It,. work for which this lunnin is Ixaued (Sec 3097, Civ. CJ
Lender's Name
NEW RESIDENTIAL PLMB. SQ. ET.
PAID
Doe Rs,cs,ipt#
r''_.-........�._.
f
kjr•� i �Is�TOTAL:
LenderAdd
's Address
TOTAL:
^ I
BUILDINC� liE h JI 1
I comfy that 1 have read this application and state that the above information is
�
concert. l agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby anthome representatives of this city to enter upon the
QTY. MECHANICAL. PERMIT 'FEEfR(
n
!^�
SEISMIC FEE ,i it q 1
PERMIT ISSUANCE_
sat I
ELECTRIC FF.Ein
above-mentioned property for inspection purposes.
(We) agree m save, indemnify and keep factories, the Cq of Cupertino against
Iiahilities,judgments, costs and expenses which may in any way tactics, againstsaid City
in consequence of me gaming of this permit.
ACI ER OR ADD TO MECH.
PLUMBING FBI. ✓'
AIR HANDLING UN1'r LTO ftfoo 1 CPM)
MECHANICAL d,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU CF, RE ULATIO g.
Alit HANDLING UNIT (OVER 111,1100 CFM)
CONSTRU 1 N X
'
=21
Signa re ofA plica. Con uor Uare
HALA DIIS MATERIALS DISCLOSURE
EXHAUSTHOOD(WMUCD
HOUSING TION FEE
BEATING UNIT (TO 100.000 BTU)
Will the applicant orfrme building occupant stucco, handle haaalloas material
we definel by the Cupertino Municipal Cade, Chapter 9.12. and the Health and Safety
Code, Section 8532(al"
E] Yes AN.
I HEATING UNIT (OVER HMNM1 BTU)
PAID
Date Receipt#
VENTILATION PAN (SINGI.Ii RES ID)
BOILER- COMP(3HP OR 1110,000 BTU)
Will the car Onerant ofroom building occupby Quaor itdeviceswhich
nt Bay At.
Ma baeaNnus air commndnnnns nx defined M1y rhe Bay Areu Air Quality Management
I)inrim,l
❑Yes )kNo
I have read me harmonies materials ants under.looChapter b.95..Tote Cali-
TOTAL:
BOILER- COMP (OVER 1 f010IM) it HE
at
AIR CONDITIONER
ISSUANCE D T�
NEW RESIDENTIAL MECH. SQ. FT.
fnmiv Health & Saftiy Cale, Sections 8504 25533 and 25531. 1 undcrsnand that if the
5, ii., 5, 2553
buildingdossnotembentlyhave •nand meritkmy responsibilitymnonify the rccupant
`/ /
t
I vire ren hi It oust act prion issuance ofd Cour, t of Oct Y.
_
ISSUED BY:
O r or aurarized agenr Dam
TOTAL:
OFFICE