94070084 APPLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY qqormoaq
CITY OF CUPERTINO BUILDING-ELECTRICAL PER
BUILDING DIVISION APPLICATIONlPFRMIT PLUMBING-MECHANICAL
MMM
BUILDING PROJECT IDENTIFICATION
BUILDING ADDRESS: SANITARY NO. APPLE LDATE
1 c - 3o , pF.
OWN;IeAllak N MF,' PHONE: CONTRAC,')k NA H: LIC NO:
r N� •f � 4 �J• Y i/ NIC CONI'kULp
iCHITECF/ENGINEER: LIC NO: KJ A R-'S: ! !_De J✓/aL�/�" ❑
CDfrrACT: PHONE: J T dUILU1NG PERMIT INFO
❑ Consultant Feu Paid by Applicant(Initial) BLDG ELECT PLUMB MECH
❑ ❑ ❑ Q�
LICENSED CONTRACTOR'S DECLARATION QTY, FI,ECTRIC PERMIT FEE
1 hereby Wfien 11m I.,it fianxed ender prodrsioos of Chapter v(votnmernue, JOB DESCRIPTION
QQO with Section 7f5glptf Division 3Ofthe Bd,fm,sand Prdesions Code,and mylicemc is PERMIT ISSUANCE RESIDENTIAL:
CWF nfolllora and a �L DSFDWL D KITCHEN REMODEL
QuU hiccnse Class Luc. APPLIANCES-RESIDENTIAL ❑ADDITION [I PLUMBING RE-PIPE
N Q W Date ContRClOr E fL
A 1HITECTSDECLA ATION DMULTI-UNIT ❑STRUCTURAL
F D oe PANELS MODIFICATION
Z O'N:4 I understand my plan.x shall he used as public records
OZ-D UP TO 200 AMPS (_1 INTERIOR D CHIMN17Y REPAIR
P54 in
Licen.,rd Professional 2014000AMPS IMPROVEMENT C]SWIMMING POOLS
OWNER-BUILDERDECLARA'I'ION OVER1000AMPS DBATH REMODEUREPAIR �DEMOLI'I'ION
ce C Q 1 fiemby ulfimt tint I am exempt from the Cnntnt d—License Luw for the
X 3 L FU- following reason.(Section]1131.5,Business and Prolesslnns Code:Any city or county SIGNS ELECTRICAL
D OTHER
W W y which requires a permit m amstmn,alter,improve.Demolish,m repair any swcture /
FN Z,I priono in izsuartce,also rx ims the applicant for such permiuo file a signed statement SPECIAL Cl RCUPUMISC
�§k ��5 . P, 12 -
f W y J that he is licensed pursuant to the prawki e,of the Cnntmcmr's License Law(Chapmr 9
�5p0 (commencing with Section 7000)of Division 3 Ofthe RusinesS and pmfexsimrx Cwle)or TEMP.METER OR VOLE(NST. R
Q. c W that he is exempt therefrom and the bases for the alleged exemption.Any violation of D NEW BLDG/ADDITION #fJQEMOLI1ION
' may
Section 7031.5byany applicant for a permit subjects the applicant to a civil penaltyef POWER DEVICES ❑TENANT ❑FOOD SERVICE
}y not nwrc than five hundred dolens($505). IMPROVEMENT
SSC ❑ L n,owner,of lie property,eon la with we. their,mc mm tion, SWIMMING POOL ELL'CI'RIC
yemP nde gcs as ,Bno El OTHER
F. will Proddo the wm,C d.,The on is rm'fol,Lndcd O Law doesmd out up,],.n ad wrier of
tail-� and I'mfensiom Calc:The Contramnr's License law Jsns nm apply m un owner of OUTLETS-SWITCHES-FI%TURES
a 3- pmpcny who build.,Or imp rmcx thereon,and who docs such work humsef m through
his own employee,,provided that such umprovements arc not intended or offered for NEW RESIDENTIAL ELECTR SQ Fr. ^--- t
sale.If.however,the building or improvement i,wild within one yeurofcompleion,the SQ. T. .00RA I-I LSO
LIowner-INulder will have the burden of proving that he did not build or improve for per- �` I•xl
s f sale. J
� TOTAL: I
1,as owner of the property,um exclusively contracting with licensed contractors to
mound the pntj,.(Sr,.944,Bexines,and Prufa,ein i,Codc)The Crnifir r'x Li-
seLaw doe.not apply In an owner of property who hoWsnrlmprovcxtherein,and QTY, 1'I,UMBINGPE�RMIT FEE JUL 3 0 999
who contracts for such pmjxetx with a eonaanons)hero ed pursuant to the Contntemr's
Liccnsc Law. PERMIT ISSUANCE
1 am exempt under Sec. .B&P C for this reason
ALTER-DRAIN&VENT-%ATER(EA) —VAEUATR3N
anerUate
WORKERS COMPENSATION DECLARATION BACK FLOW PROTECT.DEVICE.
I hereby affirm under penalty of perjury one of the following declarations:
Ihuveandwill mainmina Certificate of Consent to seltin,urc for Worker's Cumpen- DRAINS-FLOOR,ROOF,AREA,COND. STORIEK TYPT CONSTRUCTION
"deu ns provided for by Seen 1 3700 of the Ubus,Cod,,for the esiformm¢c of the
work f or which this pmmit h i,xsued. IIXTUS ES-Plik TRAP
1 have and will maintain Workers Compensation Insurance,m required by Senior
ofthe Labor Cole,for the performance of the wrnk for which this permit is issued. GAS-EA.SYSTEM-]INC.4 OUTLETS OCC.GROUP 3z N-�
My N'orkph C�mg^smiun InsuT4^M1?A°Pol cY Nn.Y numbC,aL=- GAS-CA.SYSTEM-OVER 4(EA) •J
C:anee Ll F C
'ERI'11IGCOMPE S ON INN FROM E KERS' GREASE%INDUSTRL WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION EYES
(Thissection need not becompletedifthepermit isforonehundreddollao SIM) GREASE TRAP
or les,.) PLANCHF.CK FEE
I certify that in the perlorntance ofthc work En wh,,h,hi,peonin,issued.I,ha1l SEWER-SANI'T'ARY-STORM IEA.200 IT.
not employ any person in any nmnncr so as to become,uhjeet to the WorkersCompen- ENERGY FEE
OZ ,firm Laws of Cnlifnmiu.Date WATER BEATER WNENT/ELECTR GRADING FEE
Z 2 Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should WATER SYS'ITWOREATINC
F (G become,subject to the Workcr',Compensation prookions of the labor Code,you most SOILS FEE
Wforthwith comply with such provisions or this femur shall be deemed revoked. WATER SERVICE
Q
CONS'I'RUCFION LF,NDINGAGENCY NEW RESIDENTIAL PLMB. SQ.FT PAID
U O 1 lerehynffinotnnuherc ixaennsnme, ilending ugxrocy for the pr&....tn",of [)are Receipt#
IL F' the work for which dui,tomtit is Issued(Sec.9007.Go.C.) TOTAL:
O Inmder's Name
1<ndcr's Address TOTAL:
(J] 1 certify that 1 have read this appllcmlon and are the.the above information i, BUILDING FEE
a
U Z cotmetlagree mcomply
and with
yaucity hor representatives of
and sendlawsntruping m QTY. MECHANICAL PERMIT FEE
U Z building construction,and hereby authome mpresemmivc5 of this city mentor upon the SEISMIC FEE
above mentioned pro,cr y for inspection purposes PERMIT ISSUANCE
(We,)agreed,oec.Indemnify and keep harmleo the City of Cupertino ageimt ELECTRIC FEE
IlnMliticx,judgmcnu,co,a nnJ cxpcnxx wn6may in any way accmeagalmt,aid City AMER OR ADUTOMGCH.
PLUMBING PIES
mICAN ee of the grunting of unix penult.
APPLICANT UNUERSI'ANDS AND WILL COMPLY WITH ALL NON-POINT AIR HANDLING UNIT(TO 111,1551 CPM) MECHANICALPF.P,
SOURCE REGULATIONS.
17/ / AIR HANDLING UNIT(OVER IB,(N10CFM) CONSTRUCTION TAX
.ignnerc of
"Co. acmr me EXHAUST HOOD(W/DUCT) HOUSING MITIGATION FEE
HAiiA
f{Ap,ARDOUS MATERIALS USURE
Will the applicant or future building occupant store
nnre or handlehmaNnus murenul HEATING GNII'TTQ 100,0011 BTU)
an defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cole,Section 25532(n)'I HEATINO ONI'F(OVER 100,tk5)BTU)
D Ycs DNo VFN'1'ILAI'ION PAN(SINGLE RESID) PAID Date, Receipt#
Will We applicant or future huilding accup:mt use equipment or devices which BOILER-COME'(3HP OR 100,gN)B'1 U)
.tit harardous air contaminants as defined by the Bay Area Air Quality Management TOTAL'
)mnmt BOILER-COMP(OVER HBO,"BTU)
E3 Via, DNO
1 have read the harallom materials rcpiremems under Chapter fi 95 of the Cull- AIR CONDITIONER ISSUANCE DATE
hum.Heahh&Surety Code.Sections 25505,25533 and 25534.1 understand than If the NEW RESIDENTIAL MECH. SQ.FT.
I WingJnr,in nn'rendyhave ntenain,thath is myrcTom,ibility to notify the oceupont
xftI ymreuenI whidtnm- be met pnor eo,ouuncenl'1.Cenifiune of tkcnpetcy.
i_�g 1/4- 7/4,/9 a �- 3 a gF
Meer or aathoriecd agent forec e-T TOTAL: ISSUED BY:
OFFICE