99070021APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPFRTINO - BUILDING - ELECTRICAL.
BUILDING DIVISION APPLICATIONMERMIT PLUMBING. -MECHANICAL
,rl/.rlh', BUILDING PROJECT IDEM''IF•ICATION/`.ldl. "1 '0
PERRMITIT.NO.O.- .�
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BUILDINGADDRESS:� �
SANITARY NO
APPLICATION SUBMI'TT'AL DATE
OWN PHONE.
CONTRACTOR'S NAME: LIC NO:
NIC
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ARCHITECT .INFER; LIC NO:
ADDRESS:
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CONTACT: PHONE,:
❑ Consultant Fees Paid by Applicant (Initial)
.';(,I(_"I ;IBUILDINr PERMIT INFOt. I"',�• r
IiI-L-�g1G/� FLFCT PLUMB MUCH
A ❑ ❑ ❑
LICENSED CONTRACTOR S DECLARATION
1 hereby sturdier I I adv provismnr of Chapter 9 (commencing
whh Sea n t7f0sbofDI x 3sftheNuaness and Pr,feavmdsCade and np license is
in full force and effect
License Class LEc a
Dule Contract
e 4
s s ,Ii 'R nit n .T srl; ,•::'If <rtlt'ss{)'-
QTY FLHCTRICPERMITI' t; t jNPCEf /.0
I =, n t I- rl O 1, - �I 11 I. rt O
JOB DESCRIPI']ON
RESIDENTIAL:
❑SFDWL ❑ KITCHEN REMODEL
❑ADDITION C1 PLUMBING RE PIPE
❑ MULTI -UNIT [I STRUCTURAL
MODIFICATION
El INTERIOR 0CHIMNEY REPAIR
IMPROVEMENT SWIMMING POOLS
El BATH RP,MODIi1JRFI'AIR DEMOLITION
❑OTHER
PERMIT ISSUANCIi
APPLIANCES-RLSIDFNTIAL
ARCHITECTS DECLARATION
I understand my plana shall he used as p,,hit, rccmde
PANfiLS
UP 10200 AMPS
Licensed Professional
D iCLARA'UON
1 hereby affirm that 1 am exempt from the Conlracmrs License Law for the
following reason (Section 9031 5, Business and Professions Cale: Any city or countyG
which requires a permit ,, commal, she,, improve, demolish, or repair any erchme
prior to its issuance, also requires the applicant for such Isnrurao file axigned statement
mathe ft Hcenstalfanti I to theprvisions of the Comacrors Licenm Law(Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Codd.r
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section7031.5byyapplicam lura permit sahjectsthca,plicunnoa civil pamhy,,f
a
not more than five hundred dollar
as owner ofihvpmpeny,ma,yempo,rv, with wages as thei... lecomper,clon,
will Jolhework.millia,miameisnot imendWnroRemdibrsale(Sec. 7044. Business
and Prnfes,ams Ode: the Cotnmctoe% License Law doer not apply to an owner of
property who builds ar improves thereon, and who due, mach work himself or through
his own employees, provided that such improvements arc not intended or offered for
sole. if, hswever, the building or improvement iewld within onc,,a, itriamletim the
er-builder will have the burden of proving that he did not build nr Improve far pun
Cue of soled.
❑ I, ns ower d Ice pmct . 70,1 ant exclusively Protesting with licensed v in
m¢e La shoes notapply.o an waterBusiess of property
xe Low Jas not apply to on ownerofpropenywho builds or improves iM1ereoq and
who or pro Contractors thereon,
who counsels for such project, with a amwaor(s) licensed po,omait the Concchm's
License Law.
ED I am exempt under Sen. , H & P C for this circuit
201-100AMPS
OVER JINNI AMPS
SINS ELECTRICAL
SPECIAL CIRCUIT/l,f
TEMP. METER OR POLEINST
COMMERCIAL:
❑ NEW BLDG/ADDITION ❑ DEMOLITION
P❑FOODSERVICE
MPRROVOV EMENT
IMPROVEMENT
❑OTHER
POWER DEVICES
SWIMMING POD1, ELECTRIC
OUTLETS -SWITCHES -FIXTURES
NEW RESIDENTIAL ELEC'1'R SQ IT.
SQ. Fr. FLOOR AREA
'
"
$/SQ. ITC.
TOTAL:
-,�i, • y, ., q (It. YL' it i.'i'rr'•`I
QTy,t PI,UMR7NG PERMIT;s�'�0 "(FEF1(�"•
PERMIT ISSUANCE -
ALTER - DRAT VENT -WATER (BA) 00VALUATION
Owner Data
WORKER'S COMPENS A'INN DECLARA'1'I ON
I hereby alarm under penalty of perjuryane of the following declarations:
❑ I have and will maintain a Certificate of Conwatto salf-insure for Warker'x Compete
sauna, as provided for by Seel i 3700 elthe Labor Codeth
, for e pal'ormance of the
,,,,it for which his pemtil is issued.
ID I hove and will maintain Worker, Compensation Lamar-, us require) by Section
37N) of the labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
Currier. Policy Nn.;
CERTIFICATE. OF EXEMPTION FROM WORKERS'
CUM III" NSA I'(ON INSURANCE
(Thlssectir i need not he emn,axed if the permit is forone hundred dollars ($10)
lar)
certify fif in the part ..raerofthe work for which this Founds issued, is hull
not employ any person in any manner so as to become subject to the Workers'Comped-
cation Luwrof Cali forma. Date
Applicant
BACK FLOW P OT .DEVICE
DRAINS - FL, ROOT. AREA, COND.
STORIES
UCC GROUP/
TYPE CONST RUCTION
� Pbk
(O I"
O
FIX 'I ORES - PER'1'R
GAS- EA. SYSTEM. I INC. ] \
GAS -EA SYSTEM OVER 4 (EA)
GREASE/INDUS'IRL WASTE 1 CC N
-
BUILDING DIVISION FEESur
GRI?ASE TRAP
PLANCHECK NIJ?
SEWER - SAND ABY -STORM EA. 200 FT.
ENIeRGY PEE
WATER HEATER WNENINELF,CTR
GRADING ME
NOTICE ID APPLICANT: IL oiler making this Certificate of Exemption, no should
Iwoome Ojcet In the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provkioasnr this permit shall be deemed rovoked.
CONSTRUCTION LENDING AGENCY
I herebyal can thin there is onmsuvaien leadingagin,y loathe pertommuce of
the work for which this Permit In issued (Sec. 3097. Civ. C7
Lender's Name
WXIER SYSTEM/TREATING
SOILS Felt
WATER SERVICE
PAID on
Date cjW OF
NEW RESIDENTIAL PI,MB. SQ, IT.
'TOTAL:
facarder, Address
TOTAL:
BUILDING FEE
I certity unit I aLvc realll . pplcat d state that the h f me . '
coned 1 agree to c niply an II ly ndtrial,ordinancesn d tat 1 clod g1
building authorizesction, and hereby authorize representatives ofthi. city) enter un the
above mentioned pmperry for inspection purposes.
(We) agree In save, indemnify and keep hamdess the City of Cupertino against
l lahilities. judgments, casts and expenees which may in anyway accrue against said City
sequence nl the graining of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULATIONS.
t i .... ,• s ,i.. I - t j )a
.QTY.' MECHANICAL' LERM I'r I star :i,('PFr
r t ' �t
SEISMIC PER
P17RMIIISSUANCE
ELECTRIC FEE
AITERORADDTOMHCH.
PLUMBING FEE
AIR HANDLING UNIT (TO 10.000 CFM)
MECHANICAL FINE
AIR HANDLING UNIT (OVER 10.000 CIM)
CONSTRUCTION TAX
Signctie of A,,hr.m/Comosta, Dec
HAZARDOUS MATERIALS DISCLOSURE
Will the upplicnm nr Tamm building accopenl store or handle hartadnus material
;is defined by the Condition Municipal Code, Chapter 9.12, and the Headland Safety
Code. Section 2553260?
❑Yes E:1 No
" Will the applicant or (more building occupant use equipment or devices which
emit han,rdous air continuum, ax Jefrred by the Bay Are, Air Quality Munagemcm
Di dn"?
F-1 Yr, F7 No
I have read the hmmlous materials requirements under Chapter 6.95 of the Cal i-
larnia Health & Safety Code, Sections 25505, 25533 and 25534, 1 mde,dadd than il'the .. rmet
building does not currently have a lenanl, that it is my responsibility to notify the acup,m
ofthe....enunt, which must be prior m i...aceofo Cenificaleof Occupancy.
EXHAUST HOOD(W/DUCT)
HOUSING MITIGATION FEE
HEATING UNTI'(TO 100,000 BTU)
HEATING UNIT (OVER 100,010 BTU)
PAID
Dam Receipt If
VIESED LATION AN I NGLE RESI Of
BpILF.R - COMP (3HP OR Ifl(1,000 B'fU)
TOTAL:
BOILER - COMM' (OVER IOO.(NN) BTU)
AIR CONDITION ER
ISSUANCE DATE
^
`/ �7(j 1Yy
, �.}.-�
ISSUED BY: a l_)
NEW RESIDP,N'IIAL MEiCH, , FT.
SQ
TOTAL'
Ownernrautboriardagenl Date
OFFICE